Unstable angina/ NSTEMI resident survival guide

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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]
  • Administer sublingual nitroglycerin in patients with ischemic chest pain. IV should be administer in patients with persistent chest pain after three sublingual nitroglycerins. [2]
  • 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. [3] [4]
  • Statins should be administer to all patients with unstable angina. The recommendation is atorvastatin 80mg/day [5] [6]
  • Non-steroidal anti-inflamatory drugs should be discontinued immediately. [7]
  • P2Y12 platelet inhibitor therapy should be continued for 12 months with a maintenance dose of either
    • Clopidogrel - 75mg per day
    • Prasogrel 10mg per day
    • Ticagrelor 90mg twice a day

Don´ts

References

  1. 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?
  2. 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.
  3. 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.
  4. 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.
  5. 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
  6. 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.
  7. 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


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