Approximately 5% to 10% of hospitalized patients may develop ventricular tachycardia (VT)/ventricular fibrillation (VF), usually within 48 hours of presentation.574 The incidence of VF in otherwise uncomplicated AMI appears to have decreased within the past few years from >4% to <2%, of which 59% of patients had non Q-wave MI.574 A study of 277 consecutive patients with NSTE-ACS who under- went cardiac catheterization within 48 hours found VT/VF occurring in 7.6% of patients, 60% of which developed within 48 hours after admission.575 Risk factors for VT/VF include HF, hypotension, tachycardia, shock, and low TIMI flow grade. Treatment consists of immediate defibrillation or Table 11. Summary of Recommendations for Special Patient Groups Recommendations COR LOE References NSTE-ACS in older patients Treat older patients ( 75 y of age) with GDMT, early invasive strategy, and revascularization as appropriate I A 515 519 Individualize pharmacotherapy in older patients, with dose adjusted by weight and/or CrCl to reduce adverse events caused by age-related changes in pharmacokinetics/dynamics, volume of distribution, comorbidity, drug interactions, and increased drug sensitivity Undertake patient-centered management for older patients, considering patient preferences/goals, comorbidities, functional and cognitive status, and life expectancy Bivalirudin rather than GP IIb/IIIa inhibitor plus UFH is reasonable for older patients ( 75 y of age), given similar efficacy but less bleeding risk It is reasonable to choose CABG over PCI in older patients, particularly those with DM or multivessel disease, because of the potential for improved survival and reduced CVD events IIa B 529 534 HF Treat patients with a history of HF according to the same risk stratification guidelines and recommendations for patients without HF Select a revascularization strategy based on the extent of CAD, associated cardiac lesions, LV dysfunction, and prior revascularization Cardiogenic shock Recommend early revascularization for cardiogenic shock due to cardiac pump failure I B 560, 588, 589 DM Recommend medical treatment and decisions for testing and revascularization similar to those for patients without DM Post CABG Recommend GDMT antiplatelet and anticoagulant therapy and early invasive strategy because of increased risk with prior CABG Perioperative NSTE-ACS Administer GDMT to perioperative patients with limitations imposed by noncardiac surgery I C 626, 627 Direct management at underlying cause of perioperative NSTE-ACS I C 21, 626 634 CKD Estimate CrCl and adjust doses of renally cleared medications according to pharmacokinetic data Administer adequate hydration to patients undergoing coronary and LV angiography I C N/A Invasive strategy is reasonable in patients with mild (stage 2) and moderate (stage 3) CKD IIa B 649 652 Women Manage women with the same pharmacological therapy as that for men for acute care and secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding risk I B 669 673 Early invasive strategy is recommended in women with NSTE-ACS and high-risk features (troponin positive) Myocardial revascularization is reasonable for pregnant women if ischemia-guided strategy is ineffective for management of life-threatening complications IIa C 674 Women with low-risk features (Section 3.3.1) should not undergo early invasive treatment because of lack of benefit and the possibility of harm Anemia, bleeding, and transfusion Evaluate all patients for risk of bleeding I C N/A Recommend that anticoagulant and antiplatelet therapy be weight-based where appropriate and adjusted for CKD to decrease the risk of bleeding There is no benefit of routine blood transfusion in hemodynamically stable patients with hemoglobin levels >8 g/dL III: No Benefit B 699 703 Cocaine and methamphetamine users Manage patients with recent cocaine or methamphetamine use similarly to those without cocaine- or methamphetamine-related NSTE-ACS. 