Unstable angina/ NSTEMI resident survival guide

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 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