Unstable angina non ST elevation myocardial infarction immediate management
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Resident Survival Guide |
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Special Groups |
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Diagnosis |
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Laboratory Findings |
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Treatment |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Mechanical Reperfusion |
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Discharge Care |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.; Neil Gheewala, M.D. [3]
Overview
The initial management of acute coronary syndrome (ACS) begins with differentiation within the spectrum of ACS which includes; STEMI, unstable angina and non-ST elevation myocardial infarction. As the symptoms for all these syndromes can be similar, a medical evaluation is necessary as mentioned in earlier sections (see UA / NSTEMI prehospital care and Unstable angina / non ST elevation myocardial infarction initial therapy). Information from the history, physical examination, 12-lead ECG, and initial cardiac biomarker studies can help in differentiating between the above three categories as well as categorize the patient into probable or definite ACS, chronic stable angina or non-cardiac cause of chest pain. Patients with STEMI must be evaluated for immediate reperfusion therapy (see ST Elevation Myocardial Infarction Reperfusion Therapy). Patients with unstable angina/NSTEMI, recurrent symptoms suggestive of ACS and/or electrocardiogram, ST-segment deviations, or positive cardiac biomarkers, who are hemodynamically stable, should be admitted to an inpatient unit for bed rest with continuous rhythm monitoring and careful observation for recurrent ischemia. These patients should be managed with either an invasive or conservative strategy (see Unstable angina / non ST elevation myocardial infarction initial conservative versus initial invasive strategies).
Risk Stratification
Risk stratification and prognosis early in the course of admission is important, so that patients who are classified as intermediate to high risk, including those with ongoing ischemia and evidence of hemodynamic instability, can be immediately transferred to a critical care unit.
Once a patient with documented high-risk ACS is admitted, standard medical therapy is indicated which includes oxygen, ASA, beta blockers, anticoagulant therapy, antiplatelet therapy with a GP IIb/IIIa inhibitor, and a thienopyridine (for example clopidogrel), unless contraindicated.
You can read about each of the therapies specifically in relation to treatment in unstable angina or NSTEMI, by clicking on the link for that therapy below:
- Oxygen
- Nitrates
- Analgesics
- Beta-blockers
- Calcium channel blockers
- Renin-angiotensin-aldosterone inhibitors
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [1]
ED or Outpatient Facility Presentation
| Class I |
| "1. Patients with suspected ACS and high-risk features such as continuing chest pain, severe dyspnea, syncope/presyncope, or palpitations should be referred immediately to the ED and transported by emergency medical services when available. (Level of Evidence: C)" |
| Class IIb |
| "1. Patients with less severe symptoms may be considered for referral to the ED, a chest pain unit, or a facility capable of performing adequate evaluation depending on clinical circumstances. (Level of Evidence: C)" |
Immediate Management
Discharge From the ED or Chest Pain Unit
| Class IIa |
| "1. It is reasonable to observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (nonischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals. (Level of Evidence: B)" |
| "2. It is reasonable for patients with possible ACS who have normal serial ECGs and cardiac troponins to have a treadmill ECG before discharge or within 72 hours after discharge. (Level of Evidence: A)" |
| "3. It is reasonable for patients with possible ACS who have normal serial ECGs and cardiac troponins to have a stress myocardial perfusion imaging , or stress echocardiography before discharge or within 72 hours after discharge. (Level of Evidence: B)" |
| "4. In patients with possible ACS and a normal ECG, normal cardiac troponins, and no history of CAD, it is reasonable to initially perform (without serial ECGs and troponins) coronary CT angiography to assess coronary artery anatomy. (Level of Evidence: A)" |
| "5. In patients with possible ACS and a normal ECG, normal cardiac troponins, and no history of CAD, it is reasonable to initially perform rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude myocardial ischemia. (Level of Evidence: B)" |
| "6. It is reasonable to give low-risk patients who are referred for outpatient testing daily aspirin, short-acting nitroglycerin, and other medication if appropriate (e.g., beta blockers), with instructions about activity level and clinician follow-up. (Level of Evidence: C)" |
2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[2][3][4]
Immediate Management (DO NOT EDIT)[2]
| Class I |
| "1. The history, physical examination, 12-lead ECG, and initial cardiac biomarker tests should be integrated to assign patients with chest pain into 1 of 4 categories: a noncardiac diagnosis, chronic stable angina, possible ACS, and definite ACS. (Level of Evidence: C)" |
| "2. Patients with probable or possible ACS but whose initial 12-lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring (e.g., chest pain unit or hospital telemetry ward), and repeat ECG (or continuous 12-lead ECG monitoring) and repeat cardiac biomarker measurement(s) should be obtained at predetermined, specified time intervals. (Level of Evidence: B)" |
| "3. In patients with suspected ACS in whom ischemic heart disease is present or suspected, if the follow-up 12-lead ECG and cardiac biomarkers measurements are normal, a stress test (exercise or pharmacological) to provoke ischemia should be performed in the ED, in a chest pain unit, or on an outpatient basis in a timely fashion (within 72 h) as an alternative to inpatient admission. Low-risk patients with a negative diagnostic test can be managed as outpatients. (Level of Evidence: C)" |
| "4. In low-risk patients who are referred for outpatient stress testing (see above), precautionary appropriate pharmacotherapy (e.g., ASA, sublingual NTG, and/or beta blockers) should be given while awaiting results of the stress test. (Level of Evidence: C)" |
| "5. Patients with definite ACS and ongoing ischemic symptoms, positive cardiac biomarkers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management. Admission to the critical care unit is recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability. Otherwise, a telemetry step-down unit is reasonable. (Level of Evidence: C)" |
| "6. Patients with possible ACS and negative cardiac biomarkers who are unable to exercise or who have an abnormal resting ECG should undergo a pharmacological stress test. (Level of Evidence: B)" |
| "7. Patients with definite ACS and ST-segment elevation in leads V7 to V9 due to left circumflex occlusion should be evaluated for immediate reperfusion therapy. (Level of Evidence: A)" |
| "8. Patients discharged from the ED or chest pain unit should be given specific instructions for activity, medications, additional testing, and follow-up with a personal physician. (Level of Evidence: C)" |
| Class IIa |
| "1. In patients with suspected ACS with a low or intermediate probability of CAD, in whom the follow-up 12-lead ECG and cardiac biomarkers measurements are normal, performance of a noninvasive coronary imaging test (i.e., CCTA) is reasonable as an alternative to stress testing. (Level of Evidence: B)" |
Anti-Ischemic Therapy (DO NOT EDIT)[3]
| Class I |
| "1. Bed/chair rest with continuous ECG monitoring is recommended for all UA/NSTEMI patients during the early hospital phase. (Level of Evidence: C)" |
| Class IIa |
| "1. Intra-aortic balloon pump (IABP) counterpulsation is reasonable in UA/NSTEMI patients for severe ischemia that is continuing or recurs frequently despite intensive medical therapy, for hemodynamic instability in patients before or after coronary angiography, and for mechanical complications of MI. (Level of Evidence: C)" |
References
- ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.
- ↑ 3.0 3.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-11. Unknown parameter
|month=ignored (help) - ↑ Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM; et al. (2011). "2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons". J Am Coll Cardiol. 57 (19): e215–367. doi:10.1016/j.jacc.2011.02.011. PMID 21545940.