Unstable angina non ST elevation myocardial infarction immediate management: Difference between revisions

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{{WikiDoc Cardiology Network Infobox}}
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{{CMG}}
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| [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br>
| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
{{Unstable angina / NSTEMI}}
{{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.;  Smita Kohli, M.D.;  {{NMG}}


{{Editor Join}}
==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 [[Unstable angina / NSTEMI ECG|electrocardiogram]], ST-segment deviations, or positive cardiac [[Unstable angina / NSTEMI bio markers|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]]).


==Overview of Immediate Management in UA / NSTEMI==
==Risk Stratification==
Initial management of [[ACS]] begins with differentiating between the spectrum of [[ACS]] which includes [[unstable angina]], [[NSTEMI]] and [[STEMI]]. Because the symptoms for all these can be similar, a medical evaluation is necessary as mentioned in earlier section. Information from the history, physical examination, 12-lead ECG, and initial cardiac biomarker tests 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. Patients with [[UA]]/[[NSTEMI]], recurrent symptoms suggestive of [[ACS]] and/or [[ECG]] ST-segment deviations, or positive
[[Unstable angina risk stratification and prognosis| 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]].
cardiac biomarkers who are stable hemodynamically should be admitted to an inpatient unit for bed rest with continuous rhythm monitoring and careful observation for recurrent ischemia and managed with either an invasive or conservative strategy(see [[Unstable angina / non ST elevation myocardial infarction initial conservative versus initial invasive strategies|Initial conservative versus initial invasive strategies)]]. Once a patient with documented high-risk [[ACS]] is admitted, standard medical therapy is indicated which includes [[supplemental oxygen]], [[ASA]], [[beta blocker]], anticoagulant therapy, a [[GP IIb/IIIa inhibitor]], and a [[thienopyridine]](for example [[clopidogrel]]), unless contraindicated.


==Supplemental oxygen==
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.
In general oxygen is administered via nasal canula or face mask to patients with an uncomplicated course to maintain an oxygen saturation greater than 90%. However, endotracheal intubation may be required in those patients with a clinical course complicated by severe pulmonary edema, cardiogenic shock or mechanical complications (e.g. papillary muscle rupture, free wall rupture, or acquired ventricular septal defect). Finger pulse oximetry is useful for the continuous monitoring of SaO2 but is not mandatory in patients who do not appear to be at risk of hypoxemia. There is no evidence to support the administration of oxygen to all patients with ACS in the absence of signs of respiratory distress or arterial hypoxemia.


==Antiischemic and analgesic therapy==
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:
===Nitrates===
*[[Unstable angina / NSTEMI oxygen therapy |Oxygen]]
[[Nitroglycerin]], an endothelium-independent vasodilator, has both peripheral and coronary vascular effects. By venodilation, it decreases the myocardial preload, ultimately, decreasing the myocardial oxygen demand. It also dilates the coronary arteries, thus, decreasing the amount of stenosis and relieves pain. In addition, it promotes collateral flow and redistribution of coronary blood flow to ischemic regions. If three sublingual 0.4mg tablets of [[NTG]] fail to relieve the pain, intravenous [[NTG]] may be initiated along with oral or intravenous beta blocker. It will also be helpful in patients with heart failure and hypertension.
*[[Unstable angina/NSTEMI nitrate therapy |Nitrates]]
*[[Unstable angina/NSTEMI analgesics | Analgesics]]  
*[[Unstable angina/NSTEMI beta blockers | Beta-blockers]]
*[[Unstable angina / NSTEMI CCB therapy | Calcium channel blockers]]
*[[UA/NSTEMI inhibitors of RAS | Renin-angiotensin-aldosterone inhibitors]]'''


===Morphine===
==2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) <ref name=Guidelines> 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) </ref>==
[[Morphine sulfate]] is reasonable for patients whose symptoms are not relieved despite NTG (e.g., after3 serial sublingual [[NTG]] tablets) or whose symptoms recur despite adequate anti-ischemic therapy. Morphine sulfate has potent analgesic and anxiolytic
effects, as well as hemodynamic effects, that are potentially beneficial in [[UA]]/[[NSTEMI]]. [[Morphine]] causes venodilation and can produce modest reductions in heart rate (through increased vagal tone) and systolic blood pressure to further reduce myocardial oxygen demand<ref name="pmid17692738"/>.


===Beta blockers===
===ED or Outpatient Facility Presentation===
In [[UA]]/[[NSTEMI]], the primary benefits of [[beta blockers]] are due to inhibition of beta-1 adrenergic receptors, which results in a decrease in cardiac work and myocardial oxygen demand. Slowing of the heart rate also has a favorable effect, acting not only to reduce myocardial oxygen demand(MVO2) but also to increase the duration of diastole and diastolic pressure-time, a determinant of forward coronary flow and collateral flow<ref name="pmid17692738"/>. In the absence of contraindication(especially hypotension, heart failure and hemodyanamic instability), beta blockers should be initiated either orally or intravenously within first 24 h. Patients with marked first-degree AV block (i.e., ECG PR interval greater than 0.24 s), any form of second- or third-degree AV block in the absence of a functioning implanted pacemaker, a history of asthma, severe LV dysfunction or HF (e.g., rales or S3 gallop) or at high risk for shock (see above) should not receive beta blockers on an acute basis. Two recent studies(GUSTO-I and COMMIT) have revealed that early aggressive beta blockade poses a substantial net hazard in ''hemodynamically unstable patients'' and should be avoided. In the COMMIT study<ref>Early intravenous then oral metoprolol in 45,852 patients with acute myocardial infarction: randomised placebo-controlled trial.
{|class="wikitable"
Chen ZM, Pan HC, Chen YP, Peto R, Collins R, Jiang LX, Xie JX, Liu LS; COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group.
|-
Lancet. 2005 Nov 5;366(9497):1622-32.
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
PMID: 16271643</ref>, the utility of early intravenous followed by oral beta blockade (metoprolol) was tested in 45,852 patients with MI (93% had STEMI, 7% had NSTEMI) which showed that neither the composite of death, reinfarction, or
|-
cardiac arrest nor death alone was reduced for up to 28 d in the hospital. Overall, a modest reduction in reinfarction and
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
ventricular fibrillation (which was seen after day 1) was counterbalanced by an increase in cardiogenic shock, which occurred early (first day) and primarily in those who were hemodynamically compromised or in HF or who were  stable but at high risk of development of shock. Risk factors for shock were older age, female sex, time delay, higher Killip class, lower blood pressure, higher heart rate, [[ECG]] abnormality, and previous hypertension. In GUSTO-I retrospective analyses<ref name="pmid9741504">{{cite journal |author=Pfisterer M, Cox JL, Granger CB, ''et al'' |title=Atenolol use and clinical outcomes after thrombolysis for acute myocardial infarction: the GUSTO-I experience. Global Utilization of Streptokinase and TPA (alteplase) for Occluded Coronary Arteries |journal=J. Am. Coll. Cardiol. |volume=32 |issue=3 |pages=634–40 |year=1998 |month=September |pmid=9741504 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109798002794}}</ref> , the administration of intravenous atenolol combined with late oral administration was associated with higher mortality than late oral administration alone. The authors concluded that late oral administration of atenolol might be sufficient and may offer just as good of outcomes as that coupled with early IV administration. Overall, the rationale for beta-blocker use in all forms of [[CAD]], including [[UA]], is generally favorable, with the exception of initial heart failure.
|-
|}


===Calcium channel blockers===
{|class="wikitable"
Calcium channel blockers(CCBs) consist of three subclasses:
|-
*Dihydropyridines (e.g., nifedipine, amlodipine),
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
*Phenylalkylamines (e.g., verapamil), and
|-
*Benzothiazepines (e.g., diltiazem).
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


CCBs inhibit both myocardial and vascular smooth muscle contraction. They also cause AV block and sinus node slowing. The degree of these effects varies amongst the three classes with nifedipine and amlodipine having the most peripheral arterial dilatory effects but few or no AV or sinus node effects, whereas verapamil and diltiazem having prominent AV and sinus node effects and but only some peripheral arterial dilatory effects. Although different CCBs are structurally and, potentially, therapeutically diverse, superiority of 1 agent over another in [[UA]]/[[NSTEMI]] has not been demonstrated, except for the increased risks posed by rapid-release, short-acting dihydropyridines such as nifedipine. Calcium channel blockers may be used to control ongoing or recurring ischemia-related symptoms in patients who already are receiving adequate doses of nitrates and beta blockers, in patients who are unable to tolerate adequate doses of 1 or both of these agents, and in patients with variant angina. Definitive evidence for a benefit of CCBs in [[UA]]/[[NSTEMI]] is predominantly limited to symptom control. When beta blockers cannot be used, and in the absence of clinically significant LV dysfunction, heart rate–slowing CCBs are preferred.<ref name="pmid17692738"/>.
===Immediate Management===
====Discharge From the ED or Chest Pain Unit====
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 [[ECG]]s and [[cardiac troponin]] at 3- to 6-hour intervals. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' In patients with possible [[ACS]] and a normal [[ECG]], normal cardiac [[troponin]]s, and no history of [[CAD]], it is reasonable to initially perform  rest myocardial perfusion imaging with a technetium-99m radiopharmaceutical to exclude [[myocardial ischemia]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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 blocker]]s), with instructions about activity level and clinician follow-up. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


===ACE inhibitors===
==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)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref><ref name="pmid17692738">{{cite journal |author=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 |title=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=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-11}}</ref><ref name="pmid21545940">{{cite journal| author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM et al.| title=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. | journal=J Am Coll Cardiol | year= 2011 | volume= 57 | issue= 19 | pages= e215-367 | pmid=21545940 | doi=10.1016/j.jacc.2011.02.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21545940  }} </ref>==
Angiotensin converting enzyme inhibitors is another class of medication which has been shown to reduce mortality in patients with [[MI]], recent [[MI]] and left ventricular dysfunction, and high risk chronic [[CAD]] with normal left ventricular function. HOPE trial<ref>Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators.
===Immediate Management (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888  }} </ref>===
Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G.
N Engl J Med. 2000 Jan 20;342(3):145-53. Erratum in: 2000 May 4;342(18):1376. N Engl J Med 2000 Mar 9;342(10):748.
PMID: 10639539</ref> was a landmark study in evaluating the role of ramipril(an ACE inhibitor) in a broad category of high risk patients. In this randomized, placebo controlled trial involving 9297 high risk patients, Ramipril was shown to significantly reduce the rates of death, myocardial infarction, and stroke in a broad range of high-risk patients who are not known to have a low ejection fraction or heart failure.


{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Patients with definite [[ACS]] and ongoing ischemic symptoms, positive [[cardiac biomarker]]s, new [[ST-segment]] deviations, new deep [[T-wave inversion]]s, 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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''6.''' Patients with possible [[ACS]] and negative [[cardiac biomarker]]s who are unable to exercise or who have an abnormal resting [[ECG]] should undergo a [[pharmacological stress test]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}


==ACC / AHA Guidelines (DO NOT EDIT) <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
{|class="wikitable"
{{cquote|
|-
===Class I===
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected [[ACS]] with a low or intermediate probability of [[CAD]], in whom the follow-up [[12-lead ECG]] and [[cardiac biomarker]]s measurements are normal, performance of a noninvasive coronary imaging test (i.e., CCTA) is reasonable as an alternative to stress testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}


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 non cardiac diagnosis''', [[chronic stable angina]], '''possible ACS''', and '''definite ACS'''. ''(Level of Evidence: C)''
===Anti-Ischemic Therapy (DO NOT EDIT)<ref name="pmid17692738">{{cite journal |author=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 |title=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=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-11}}</ref>===
 
{|class="wikitable"
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)''
|-
 
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
3. In patients with suspected [[ACS]] in whom [[ischemic heart disease]] is present or suspected, if the follow-up [[12 lead ECG]] and [[cardiac biomarker]]s 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)''
|-
 
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Bed/chair rest with continuous ECG monitoring is recommended for all UA/NSTEMI patients during the early hospital phase. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
4. In low-risk patients who are referred for outpatient stress testing, precautionary appropriate pharmacotherapy (e.g., [[ASA]], sublingual [[NTG]], and/or [[beta blocker]]s) should be given while awaiting results of the stress test. ''(Level of Evidence: C)''
|}
 
{|class="wikitable"
5. Patients with definite [[ACS]] and ongoing ischemic symptoms, positive [[cardiac biomarker]]s, new [[ST-segment deviation]]s, 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)''
|-
 
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
6. Patients with possible [[ACS]] and negative [[cardiac biomarker]]s who are unable to exercise or who have an abnormal resting ECG should undergo a [[pharmacological stress test]]. ''(Level of Evidence: B)''
|-
 
| bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
7. Patients with definite [[ACS]] and [[ST-segment elevation]] in leads V7 to V9 due to [[left circumflex artery]] 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 non invasive coronary imaging test (i.e., Cardiac / Coronary [[CT Angiography]]) is reasonable as an alternative to stress testing. ''(Level of Evidence: B)''}}
 
==See Also==
* [[The Living Guidelines: UA/NSTEMI | The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines]]
 
==Sources==
*The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction <ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>


==References==
==References==
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[[Category:Ischemic heart diseases]]
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Latest revision as of 21:10, 5 December 2022
Resident
Survival
Guide

Acute Coronary Syndrome Main Page

Unstable angina / NSTEMI Microchapters

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Patient Information

Overview

Classification

Pathophysiology

Unstable Angina
Non-ST Elevation Myocardial Infarction

Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders

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Unstable angina non ST elevation myocardial infarction immediate management On the Web

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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:

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

  1. ↑ 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. ↑ 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. ↑ 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)
  4. ↑ 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.

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