Unstable angina/ NSTEMI resident survival guide: Difference between revisions

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==Do´s==
==Do´s==
* Administer 300 mg of clopidogrel as initial treatment instead of aspirin in case of gastrointestinal intolerance of hypersensitivity reaction.
* Oxygen must be administered in patients with arteria saturation less than 90% or in respiratory distress <ref> "pmid23554440">{{cite journal| author=Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S et al.| title=Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 22 | pages= 1630-5 | pmid=23554440 | doi=10.1093/eurheartj/eht110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi? </ref>


==Don´ts==
==Don´ts==

Revision as of 18:08, 27 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Definition

Unstable angina is an unexpected chest pain while resting or sleeping,that could get worse with time lasting at least 20 minutes up to 30 minutes. It is caused by a temporary reduced blood flow, resulting in a decreased oxygen supply to the myocardial tissue.

Causes

Life Threatening Causes

  • Reduced myocardial perfussion
  • Mycordial infarction
  • Cocaine-associated mycoardial infarction

Common Causes

  • Atherosclerosis
  • Non-occlusive thrombus

Management

Diagnosis

CHARACTERIZE THE SYMPTOMS
❑ Chest pain or discomfort while resting

❑ The pain is longer than 20 minutes
❑ It started without physical exertion
❑ Rest doesn´t help to relieve it

❑ Gets worse with time
 
 
 
 
 
PERSONAL HISTORY

❑ Age
❑ Previous MI

❑ Previous PCI or CABG
 
 
 
 
 
PHYSICAL EXAMINATION

❑ Measure blood pressure
❑ Measure heart rate
❑ Auscultation of murmurs

❑ CHF
 
 
 
 
 
LABS & TESTS

❑ EKG
❑ Troponin I and T
❑ CK-MB
❑ Creatinine
❑ Glucose

❑ Hemoglobin

Treatment

 
 
 
 
 
 
 
 
❑ Administer 300mg Aspirin immediately after hospital admission

❑ Administer oxygen in patients with saturation <90%
❑ Administer nitroglycerine sub-lingual ADD DOSES
❑ Administer morphine IV initial dose 2-4mg with increments of 2-8mg every 5 to 15 minutes
❑ Administer beta-blockers to all patients without contraindications
❑ Administer statins, atorvastatine 80mg

❑ Initiate anti thrombotic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine Risk of adverse coronary event (TIMI)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LOW RISK
Initial conservative strategy
 
 
 
 
 
HIGH RISK
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer 300mg of copidogrel
❑ Administer fondoparinaux or UFH in case of renal failure
 
 
 
 
 
❑ Administer IV GP IIb/IIIa inhibitors (eptifibatide or tirofiban)
OR
❑ Administer Bivalirudin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a Stress test
 
 
 
 
 
Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
LOW RISK
 
HIGH RISK
 
NEGATIVE
 
POSITIVE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent symptoms?
 
 
 
 
 
 
❑ Continue Aspirin
❑ Continue with clopidrogel or ticagelor for 12 months
❑ Discontinue with GP inhibitors
❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
❑ heart faillure
❑ serious arrhythmias
❑ subsequent isquemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue Aspirin
❑ Continue with clopidrogel or ticagelor for 12 months
❑ Discontinue with GP inhibitors
❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas
 
 
 
 
 
 
 
 
 
 
 
PCI

❑ Administer clopidogrel 24 hrs before
❑ As as possible in no bleeding risk patients who are unstable or with high risk of isquemia

❑ Administer UFH (50-100 units/kg)
 
CABG

❑ Continue aspirin + UFH
❑ Discontinue clopidogel 5 days before
❑ Discontinue enoxiparin and fondoparinaux 12-24 hrs before
❑ Discontinue IV GP inhibitors 4 hrs bfore

❑ Discontinue bivalirudin 3 hrs before
 
 
 
 
 
 
 
INTENSIVE STRATEGY - ANGIOGRAPHY
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NEGATIVE
 
 
 
POSITIVE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue Aspirin
❑ Continue with clopidrogel or ticagelor for 12 months
❑ Discontinue with GP inhibitors
❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas)
 
PCI

❑ Administer clopidogrel 24 hrs before
❑ As as possible in no bleeding risk patients who are unstable or with high risk of isquemia

❑ Administer UFH (50-100 units/kg)
 
CABG

❑ Continue aspirin + UFH
❑ Discontinue clopidogel 5 days before
❑ Discontinue enoxiparin and fondoparinaux 12-24 hrs before
❑ Discontinue IV GP inhibitors 4 hrs bfore

❑ Discontinue bivalirudin 3 hrs before
 
 


Do´s

  • Administer 300 mg of clopidogrel as initial treatment instead of aspirin in case of gastrointestinal intolerance of hypersensitivity reaction.
  • Oxygen must be administered in patients with arteria saturation less than 90% or in respiratory distress [1]

Don´ts

References

  1. "pmid23554440">{{cite journal| author=Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S et al.| title=Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 22 | pages= 1630-5 | pmid=23554440 | doi=10.1093/eurheartj/eht110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?


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