Unstable angina/ NSTEMI resident survival guide: Difference between revisions

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==Thrombolysis in Myocardial Infarction (TIMI) Risk Score<ref name="pmid16365321">{{cite journal| author=Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE| title=Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. | journal=Acad Emerg Med | year= 2006 | volume= 13 | issue= 1 | pages= 13-8 | pmid=16365321 | doi=10.1197/j.aem.2005.06.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16365321  }} </ref>==
==Risk Scores==
===Thrombolysis in Myocardial Infarction (TIMI) Risk Score<ref name="pmid16365321">{{cite journal| author=Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE| title=Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population. | journal=Acad Emerg Med | year= 2006 | volume= 13 | issue= 1 | pages= 13-8 | pmid=16365321 | doi=10.1197/j.aem.2005.06.031 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16365321  }} </ref>===


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==HEART Risk Score<ref name="pmid10704160">{{cite journal| author=Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P et al.| title=Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty. | journal=Circulation | year= 2000 | volume= 101 | issue= 9 | pages= 955-61 | pmid=10704160 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10704160  }} </ref>==
===HEART Risk Score<ref name="pmid10704160">{{cite journal| author=Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P et al.| title=Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty. | journal=Circulation | year= 2000 | volume= 101 | issue= 9 | pages= 955-61 | pmid=10704160 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10704160  }} </ref>===


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===GRACE Risk Score<ref name="pmid15764619">{{cite journal| author=de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R| title=TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. | journal=Eur Heart J | year= 2005 | volume= 26 | issue= 9 | pages= 865-72 | pmid=15764619 | doi=10.1093/eurheartj/ehi187 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15764619  }} </ref>==
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
==GRACE Risk Score<ref name="pmid15764619">{{cite journal| author=de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R| title=TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. | journal=Eur Heart J | year= 2005 | volume= 26 | issue= 9 | pages= 865-72 | pmid=15764619 | doi=10.1093/eurheartj/ehi187 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15764619  }} </ref>==
   
   
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==Do´s==
==Do´s==

Revision as of 14:32, 31 January 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]; Rim Halaby, M.D. [3]

Definition

Unstable angina is an unexpected chest pain that starts on minimal exertion, rest or sleep, lasts at least 20 minutes up to half an hour and is not relieved by medications or rest. Unstable angina and non ST elevation myocardial infarction (NSTEMI) belong to two different ends of the spectrum of acute coronary syndrome. Unstable angina is differentiated from NSTEMI by the absence of elevated cardiac biomarkers.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to unstable angina and NSTEMI based on the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction.[2]

Characterize the symptoms:

Chest pain

❑ Absence of physical exertion
❑ Duration> 20 minutes
❑ Radiation to the jaw or left arm
❑ No relief with medications
❑ No relief with rest
❑ Worse with time

Nausea
❑ Vomiting

❑ Sweating
 
 
 
 
 
Obtain a detailed history:

❑ Age
❑ Previous MI
❑ Previous PCI or CABG
❑ Cardiac risk factors:

Hypertension
Diabetes
Hypercholesterolemia
❑ Tobacco use
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Auscultate the heart searching for murmurs
❑ Search for signs of CHF

❑ Decreased air entry in the lungs
❑ Edema in the extremities
 
 
 
 
 
Order labs and tests:

EKG
❑ Biomarkers

❑ Troponin I
❑ CK-MB

Creatinine
Glucose

Hemoglobin

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to unstable angina and NSTEMI based on the 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction.[2]

 
 
 
 
 
 
Initial Treatment
❑ Administer 300mg aspirin[3]

❑ Administer oxygen in patients with saturation <90%
❑ Administer sub-lingual nitroglycerine, (0.4-0.8mg)[4]
❑ Administer morphine IV (initial dose 2-4mg with increments of 2-8mg every 5 to 15 minutes)
❑ Administer beta-blockers (unless contraindicated)
❑ Administer statins (atorvastatin, 80mg)
❑ Administer antithrombotic treatment

Fondaparinux, or
UFH in case of renal failure[5]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the risk of adverse coronary event:

TIMI Score, or
HEART Risk Score, or

GRACE Risk Score
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk
Initial conservative strategy
 
 
 
 
 
High risk
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer one of the following antiplatelet agents:

Clopidogrel

❑ Loading dose
❑ Maintenance dose for up to 12 months

Ticagrelor

❑ Loading dose
❑ Maintenance dose for up to 12 months
 
 
 
 
 

Administer one of the following antiplatelet agents:
Before PCI
P2Y12 receptor inhibitors

Clopidogrel (300mg), or
Ticagrelor (180mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide, or
Tirofiban

At the time of PCI
P2Y12 receptor inhibitors

Clopidogrel (300mg), or
Ticagrelor (180mg), or
❑ Prasugrel

❑ IV GP IIb/IIIa inhibitors

Eptifibatide, or
Tirofiban
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent or worsening symptoms?
 
 
 
 
 
❑ Perform an angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Recurrence of symptoms
Heart failure
❑ Serious arrhythmia
❑ Subsequent ischemia
 
No recurrent symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an angiography
❑ Administer upstream antiplatelet agent:
P2Y12 receptor inhibitors
Clopidogrel (300mg), or
Ticagrelor (180mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide, or
Tirofiban
 
❑ Perform a stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low Risk
 
High Risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue aspirin for life
❑ Continue P2Y12 receptor inhibitors up to 12 months
Clopidogrel (75mg once a day), or
Ticagrelor (90mg twice a day)

❑ Discontinue GP IIb/IIIa inhibitors
❑ Continue antithrombotic therapy:

UFH for 48 hours, or
Enoxaparin for up to 8 days, or
Fondaparinux for up to 8 days
 
 
 
 
 
 


Management Following Angiography

 
 
 
 
 
Findings on Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PCI
 
CABG
 
Medical treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue Aspirin for life
❑ Continue P2Y12 receptor inhibitors (for 12 months)
Clopidogrel (75mg once a day)
Ticagrelor (90mg twice a day)
Prasugrel (10mg once a day)

❑ Discontinue GP IIb/IIIa inhibitors
❑ Continue Antithrombotic therapy

UFH(for 48hrs)
Enoxaparin
Fondaparinux (up to 8 days)
 
❑ Administer aspirin for life

❑ Administer P2Y12 receptor inhibitor (if not initially started)

Clopidogrel (75mg once a day)
Ticagrelor (90mg twice a day)
Prasugrel (10mg once a day)

❑ Discontinue anticoagulant in uncomplicated cases
 

❑ Continue aspirin
❑ Discontinue IV GP IIb/IIIa inhibitors (4 hours before CABG)
❑ Manage the P2Y12 receptor inhibitor therapy (if CABG can be delayed)

❑ Discontinue clopidogrel (5 days prior to CABG)
❑ Discontinue ticagrelor (5 days prior to CABG)
❑ Discontinue prasugrel (7 days prior to CABG)

❑ Manage the antithrombotic therapy

❑ Continue UFH
❑ Discontinue enoxaparin (12-24 hours prior to CABG)
❑ Discontinue fondaparinux (24 hours prior to CABG)
❑ Discontinue bivalirudin (3 hours prior to CABG)
 
❑ Continue aspirin

❑ Administer a loading dose of P2Y12 receptor inhibitors (if not given before angiography)

Clopidogrel (600mg), or
Prasugrel (60mg)

❑ Discontinue IV GP IIb/IIIa inhibitors if started
❑ Manage antithrombotic therapy if given before angiography:

❑ Continue IV UFH for 48 hours or until discharge
❑ Continue enoxaparin for entire hospital stay, up to 8 days
❑ Continue fondaparinux for entire hospital stay, up to 8 days
❑ Discontinue bivalirudin or continue, 0.25mg/kg/hour for up to 72 hours
 
 
 

Risk Scores

Thrombolysis in Myocardial Infarction (TIMI) Risk Score[6]

 
 
 
 
 
Adults 65 years and older

Previous coronary artery stenosis > 50%

  • Cardiac catherterization
  • Angioplasty or stent
  • Bypass
  • Myocardial infraction

Cardiac risk factors - three or more

  • Hypertension
  • Diabetes
  • High cholesterol
  • MI in family history
  • Tobacco history

Use of aspirin the previous week


Anginal events (two or more) in the previous day


ST segment alteration (>1mm elevation or depression)


Cardio bio-markers elevated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

HEART Risk Score[4]

Factors Degree Score
History Highly suspicious

Moderately suspicious


Slightly suspicious

2

1


0

EGC Significant ST depression

Non-specific repolarisation disturbance


Normal

2

1


0

Age >65 years

45-65 years


<45 years

2

1


0

Risk Factors > 3 risk factors or history of atherosclerotic disease

1 or 2 risk factors


No risk factors

2

1


0

Troponin >3x the normal limit

1-3x the normal limit


< the normal limit

2

1


0

TOTAL

=GRACE Risk Score[7]

Factor Categories Score
Age (years) <40

40-49


50-59


60-69


70-79


>80

0

18


36


55


73


91

Heart Rate (bpm) <70

70-89


90-109


110-149


150-199


>200

0

7


13


23


36


46

Systolic Blood Pressure (mmHg) <80

80-99


100-119


120-139


140-159


160-199


>200

63

58


47


37


26


11


0

Creatinine (mg/dL) 0-0.39

0.4-0.79


0.8-1.19


1.2-1.59


1.6-1.99


2-3.99


>4

2

5


8


11


14


23


31

Killip Class Class I

Class II


Class III


Class IV

0

21


43


64


Cardiac arrest at admission 43
Elevated Cardiac Bio-markers 15
ST-segment deviation 30

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 [8]
  • Administer sublingual nitroglycerin in patients with ischemic chest pain. IV should be administer in patients with persistent chest pain after three sublingual nitroglycerins. [9]
  • Nitroglycerin should be administer to all patients with hypertension or heart failure.
  • Beta-bloquers should be administer to all patients with hypertension, tachycardia or ongoing chest pain. [10] [11]
  • Statins should be administer to all patients with unstable angina. The recommendation is atorvastatin 80mg/day [12] [13]
  • Non-steroidal anti-inflamatory drugs should be discontinued immediately. [14] [15]
  • Patients 75 years and older have an increased risk of bleeding the administration of anti-platelet therapy should be cautions, except in high risk situations such as diabetes and prior myocardial infarction.
  • P2Y12 platelet inhibitor therapy should be continued for 12 months with a maintenance dose of either: [3]
    • Clopidogrel - 75mg per day
    • Prasogrel - 10mg per day
    • Ticagrelor - 90mg twice a day

Don'ts

  • Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding, already with aspirin and P2Y12 receptor inhibitors therapy.
  • Prasugrel is potentially harmful as part of a due anti-platelet therapy in patients who are planned for PCI, with prior history of strokes o TIAs.
  • IV beta-blockers should not be administer to hemodynamically unstable patients.
  • Patients under 60kg (132lbs) should not receive a complete dose of prasugrel (10mg), due to high exposure to the active metabolite. They should receive half the dose (5mg) although it has not be proved to be as effective as a complete dose.
  • Do not administer fibrinolytic therapy to patients with unstable angina, as it is not beneficial.[16]
  • Abciximab should not be administer to patients not programmed for PCI. [2]

References

  1. McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P; et al. (2008). "Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology". Circulation. 117 (14): 1897–907. doi:10.1161/CIRCULATIONAHA.107.188950. PMID 18347214.
  2. 2.0 2.1 2.2 Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.
  3. 3.0 3.1 Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ; et al. (2008). "Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 670S–707S. doi:10.1378/chest.08-0691. PMID 18574276.
  4. 4.0 4.1 Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P; et al. (2000). "Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty". Circulation. 101 (9): 955–61. PMID 10704160.
  5. Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J; et al. (2006). "Comparison of fondaparinux and enoxaparin in acute coronary syndromes". N Engl J Med. 354 (14): 1464–76. doi:10.1056/NEJMoa055443. PMID 16537663. Review in: ACP J Club. 2006 Sep-Oct;145(2):30-1
  6. Pollack CV, Sites FD, Shofer FS, Sease KL, Hollander JE (2006). "Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population". Acad Emerg Med. 13 (1): 13–8. doi:10.1197/j.aem.2005.06.031. PMID 16365321.
  7. de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R (2005). "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS". Eur Heart J. 26 (9): 865–72. doi:10.1093/eurheartj/ehi187. PMID 15764619.
  8. name="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?
  9. Kaplan K, Davison R, Parker M, Przybylek J, Teagarden JR, Lesch M (1983). "Intravenous nitroglycerin for the treatment of angina at rest unresponsive to standard nitrate therapy". Am J Cardiol. 51 (5): 694–8. PMID 6402912.
  10. Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL; et al. (2007). "Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention". Circulation. 115 (21): 2761–88. doi:10.1161/CIRCULATIONAHA.107.183885. PMID 17502569.
  11. López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H; et al. (2004). "Expert consensus document on beta-adrenergic receptor blockers". Eur Heart J. 25 (15): 1341–62. doi:10.1016/j.ehj.2004.06.002. PMID 15288162.
  12. Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R; et al. (2004). "Intensive versus moderate lipid lowering with statins after acute coronary syndromes". N Engl J Med. 350 (15): 1495–504. doi:10.1056/NEJMoa040583. PMID 15007110. Review in: ACP J Club. 2004 Sep-Oct;141(2):33
  13. Schwartz GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D; et al. (2001). "Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial". JAMA. 285 (13): 1711–8. PMID 11277825.
  14. Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM; et al. (2011). "Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis". BMJ. 342: c7086. doi:10.1136/bmj.c7086. PMC 3019238. PMID 21224324. Review in: Evid Based Med. 2011 Oct;16(5):142-3
  15. Coxib and traditional NSAID Trialists' (CNT) Collaboration. Bhala N, Emberson J, Merhi A, Abramson S, Arber N; et al. (2013). "Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials". Lancet. 382 (9894): 769–79. doi:10.1016/S0140-6736(13)60900-9. PMC 3778977. PMID 23726390. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC12
  16. Anderson HV (1995). "Intravenous thrombolysis in refractory unstable angina pectoris". Lancet. 346 (8983): 1113–4. PMID 7475596.


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