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

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'''{{Infobox_Disease
{{WikiDoc Cardiology Network Infobox}}
| Name          = Unstable angina pectoris
| Image          =
| Caption        =
| DiseasesDB    = 8695
| ICD10          = {{ICD10|I|20||i|20}}
| ICD9          = {{ICD9|413}}
| ICDO          =
| OMIM          =
| MedlinePlus    =
| eMedicineSubj  = med
| eMedicineTopic = 133
| MeshID        = D000787
}}
{{Search infobox}}
 
{{CMG}}
{{CMG}}
__NOTOC__
'''Associate Editor-In-Chief:''' {{CZ}};  Smita Kohli, M.D.;  {{NMG}};  [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.


{{Editor Join}}
{{Editor Join}}


==Overview of Immediate Management in UA / NSTEMI==
==Overview==
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
Initial management of acute coronary syndorme (ACS) begins with differentiating between the spectrum of [[ACS]] which includes [[STEMI]], [[Unstable angina pathophysiology & etiology|Unstable Angina]] and [[Non ST elevation myocardial infarction pathophysiology & etiology|Non-ST Elevation Myocardial Infarction]].  
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==
Because the symptoms for all these can be similar, a medical evaluation is necessary as mentioned in earlier sections (see [[Unstable angina / non ST elevation myocardial infarction initial therapy | Initial Therapy]]). 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]].  
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.


==Anti-ischemic and analgesic therapy==
*Patients with [[STEMI]] must be evaluated for immediate reperfusion therapy (see [[ST Elevation Myocardial Infarction Reperfusion Therapy|Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)]]).  
Goals of treatment in [[ACS]] are to relieve the ischemia, limit the amount of myocardial damage and to prevent adverse outcomes, namely death and myocardial [re]infarction. Unless contraindicated, [[Aspirin]], a [[beta blocker]], an [[anticoagulant]], a [[glycoprotein IIb/IIA inhibitor]] and a [[thienopyridine]] should be included in the treatment.
*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]] 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)]].  
Risk stratification early in the course of admission is important so that patients who are intermediate to high risk, including those with ongoing ischemia and evidence of hemodynamic instability should be admitted to a critical care unit, whenever possible.


===Nitrates===
==Risk stratification==
[[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 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 should be admitted to a critical care unit, whenever possible.


===Morphine===
Once a patient with documented high-risk [[ACS]] is admitted, standard medical therapy is indicated which includes [[Unstable angina / NSTEMI oxygen therapy |Oxygen]], [[ASA]], [[Unstable angina/NSTEMI beta blockers | Beta Blockers]], [[Unstable angina / non ST elevation myocardial infarction anticoagulant therapy | Anticoagulant Therapy]], [[Unstable angina / non ST elevation myocardial infarction antiplatelet therapy| Antiplatelet Therapy]] with a [[GP IIb/IIIa inhibitor]], and a [[thienopyridine]](for example [[clopidogrel]]), unless contraindicated.
[[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===
==Immediate Management==
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.
You can read in greater detail about each of the therapies below in greater detail by clicking on the link for that therapy.
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.
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
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===
[[Unstable angina / NSTEMI oxygen therapy |Oxygen]] | [[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 Blocker]] | [[UA/NSTEMI inhibitors of RAS | Inhibitors of Renin-Angiotensin-Aldosterone axis]]
Calcium channel blockers(CCBs) consist of three subclasses:
*Dihydropyridines (e.g., nifedipine, amlodipine),
*Phenylalkylamines (e.g., verapamil), and
*Benzothiazepines (e.g., diltiazem).


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"/>.
==ACC / AHA Guidelines (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><ref name="pmid21444888">{{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 |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]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref>==


===Inhibitors of Renin-Angiotensin-Aldosterone axis===
This class of medication includes Angiotensin converting enzyme(ACE) inhibitors, angiotensin receptor blockers and aldosterone receptor blockers.
[[ACE inhibitors]] is amongst the class of medications which have 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.
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.
In patients who cannot tolerate [[ACE inhibitors]], angiotensin II receptor blockers can be used.
==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><ref name="pmid21444888">{{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 |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]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref>==
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===Class I===
===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) [1] [2]
1. Bed/chair rest with continuous [[ECG]] monitoring is recommended for all [[Unstable angina]] / [[NSTEMI]] patients during the early hospital phase. (Level of Evidence: C) [1] [2]


2. Supplemental [[oxygen]] should be administered to patients with [[UA]] / [[NSTEMI]] with an arterial saturation <90%, respiratory distress, or other high risk features for [[hypoxemia]]. ([[Pulse oximetry]] is useful for continuous measurement of SaO²) (Level of Evidence: B)
2. Supplemental [[oxygen]] should be administered to patients with [[Unstable angina]] / [[NSTEMI]] with an arterial saturation <90%, [[respiratory distress]], or other high risk features for [[hypoxemia]]. ([[Pulse oximetry]] is useful for continuous measurement of SaO²) (Level of Evidence: B)


3. Patients with [[UA]] / [[NSTEMI]] with ongoing ischemic discomfort should receive sublingual [[NTG]] (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C)
3. Patients with [[Unstable angina]] / [[NSTEMI]] with ongoing [[ischemic]] discomfort should receive sublingual [[nitroglycerine]] (NTG) (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C)


4. Intravenous [[NTG]] is indicated in the first 48 h after [[UA]] / [[NSTEMI]] for treatment of persistent [[ischemia]], [[heart failure]], or [[hypertension]]. The decision to administer intravenous [[NTG]] and the dose used should not preclude therapy with other proven mortality reducing interventions such as [[beta blockers]] or [[ACE inhibitors]]. (Level of Evidence: B)
4. Intravenous [[NTG]] is indicated in the first 48 h after [[Unstable angina]] / [[NSTEMI]] for treatment of persistent [[ischemia]], [[heart failure]], or [[hypertension]]. The decision to administer intravenous [[NTG]] and the dose used should not preclude therapy with other proven mortality reducing interventions such as [[beta blockers]] or [[ACE inhibitors]]. (Level of Evidence: B)


5. Oral [[beta blocker]] therapy should be initiated within the first 24 h for patients who do not have 1 or more of the following: a- Signs of Heart Failure, b- Evidence of a low-output state, c- Increased risk for cardiogenic shock, or d- Other relative contraindications to beta blockade (PR interval >0.24 sec, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)
5. Oral [[beta blocker]] therapy should be initiated within the first 24 h for patients who do not have 1 or more of the following: a- Signs of [[heart failure]], b- Evidence of a [[low output state]], c- Increased risk for [[cardiogenic]] shock, or d- Other relative contraindications to beta blockade (PR interval >0.24 sec, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)


6. In [[UA]] / [[NSTEMI]] patients with continuing or frequently recurring [[ischemia]] and in whom [[beta blockers]] are contraindicated, a non dihydropyridine [[calcium channel blocker]] (e.g., [[verapamil]] or [[diltiazem]]) should be given as initial therapy in the absence of clinically significant Left Ventricular dysfunction or other contraindications. (Level of Evidence: B)
6. In [[Unstable angina]] / [[NSTEMI]] patients with continuing or frequently recurring [[ischemia]] and in whom [[beta blockers]] are contraindicated, a non dihydropyridine [[calcium channel blocker]] (e.g., [[verapamil]] or [[diltiazem]]) should be given as initial therapy in the absence of clinically significant [[left ventricular dysfunction]] or other contraindications. (Level of Evidence: B)


7. An [[Angiotensin Converting Enzyme inhibitor]] ([[ACE]]) should be administered orally within the first 24 h to [[UA]] / [[NSTEMI]] patients with [[pulmonary congestion]] or [[LV ejection fraction]] ([[LVEF]]) ≤40%, in the absence of [[hypotension]] (systolic blood pressure <100 mmHg or <30 mmHg below baseline) or known contraindications to that class of medications. (Level of Evidence: A)
7. An [[Angiotensin Converting Enzyme inhibitor]] ([[ACEI]]) should be administered orally within the first 24 h to [[Unstable angina]] / [[NSTEMI]] patients with [[pulmonary congestion]] or [[LV ejection fraction]] ([[LVEF]]) ≤40%, in the absence of [[hypotension]] (systolic blood pressure <100 mmHg or <30 mmHg below baseline) or known contraindications to that class of medications. (Level of Evidence: A)


8. An [[angiotensin receptor blocker]] should be administered to [[UA]] / [[NSTEMI]] patients who are intolerant of [[ACE inhibitors]] and have either clinical or radiological signs of [[HF]] or [[LVEF]] ≤40%. (Level of Evidence: A)
8. An [[angiotensin receptor blocker]] should be administered to [[Unstable angina]] / [[NSTEMI]] patients who are intolerant of [[ACE inhibitors]] and have either clinical or radiological signs of [[HF]] or [[LVEF]] ≤40%. (Level of Evidence: A)


9. Because of the increased risks of mortality, reinfarction, [[hypertension]], [[HF]], and [[myocardial rupture]] associated with their use, [[non steroidal anti-inflammatory drugs]] ([[NSAIDs]]), except for [[ASA]], whether non selective or cyclo oxygenase (COX)-2–selective agents, should be discontinued at the time a patient presents with [[UA]] / [[NSTEMI]]. (Level of Evidence: C)  
9. Because of the increased risks of mortality, reinfarction, [[hypertension]], [[HF]], and [[myocardial rupture]] associated with their use, [[non steroidal anti-inflammatory drugs]] ([[NSAIDs]]), except for [[ASA]], whether non selective or cyclo oxygenase (COX)-2–selective agents, should be discontinued at the time a patient presents with [[Unstable angina]] / [[NSTEMI]]. (Level of Evidence: C)  


===Class IIa===
===Class IIa===


1. It is reasonable to administer supplemental [[oxygen]] to all patients with [[UA]] / [[NSTEMI]] during the first 6 h after presentation. (Level of Evidence: C)
1. It is reasonable to administer supplemental [[oxygen]] to all patients with [[Unstable angina]] / [[NSTEMI]] during the first 6 h after presentation. (Level of Evidence: C)


2. In the absence of contradictions to its use, it is reasonable to administer [[morphine sulfate]] intravenously to [[UA]] / [[NSTEMI]] patients if there is uncontrolled ischemic chest discomfort despite [[NTG]], provided that additional therapy is used to manage the underlying [[ischemia]]. (Level of Evidence: B)
2. In the absence of contradictions to its use, it is reasonable to administer [[morphine sulfate]] intravenously to [[Unstable angina]] / [[NSTEMI]] patients if there is uncontrolled ischemic chest discomfort despite [[NTG]], provided that additional therapy is used to manage the underlying [[ischemia]]. (Level of Evidence: B)


3. It is reasonable to administer intravenous (IV) [[beta blockers]] at the time of presentation for [[hypertension]] to [[UA]] / [[NSTEMI]] patients who do not have 1 or more of the following: a- Signs of [[HF]], b- Evidence of a low-output state, c- Increased risk for [[cardiogenic shock]], d- Other relative contraindications to beta blockade (PR interval >0.24 s, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)
3. It is reasonable to administer intravenous (IV) [[beta blockers]] at the time of presentation for [[hypertension]] to [[Unstable angina]] / [[NSTEMI]] patients who do not have 1 or more of the following: a- Signs of [[HF]], b- Evidence of a [[low output state]], c- Increased risk for [[cardiogenic shock]], d- Other relative contraindications to beta blockade (PR interval >0.24 s, second or third degree [[heart block]], active [[asthma]], or reactive airway disease). (Level of Evidence: B)


4. Oral long acting non dihydropyridine calcium antagonists are reasonable for use in [[UA]] / [[NSTEMI]] patients for recurrent [[ischemia]] in the absence of contraindications after [[beta blockers]] and [[nitrates]] have been fully used. (Level of Evidence: C)
4. Oral long acting non dihydropyridine [[calcium antagonists]] are reasonable for use in [[Unstable angina]] / [[NSTEMI]] patients for recurrent [[ischemia]] in the absence of contraindications after [[beta blockers]] and [[nitrates]] have been fully used. (Level of Evidence: C)


5. An [[ACE inhibitor]] administered orally within the first 24 h of [[UA]] / [[NSTEMI]] can be useful in patients without [[pulmonary congestion]] or [[LVEF]] ≤40% in the absence of [[hypotension]] (systolic blood pressure <100 mm Hg or less than 30 mm Hg below baseline) or known contraindications to that class of medications. (Level of Evidence: B)
5. An [[ACE inhibitor]] administered orally within the first 24 h of [[Unstable angina]] / [[NSTEMI]] can be useful in patients without [[pulmonary congestion]] or [[LVEF]] ≤40% in the absence of [[hypotension]] (systolic blood pressure <100 mm Hg or less than 30 mm Hg below baseline) or known contraindications to that class of medications. (Level of Evidence: B)


6. [[Intra aortic balloon pump]] ([[IABP]]) counter pulsation 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 [[myocardial infarction]] ([[MI]]). (Level of Evidence: C)
6. [[Intra aortic balloon pump]] ([[IABP]]) counter pulsation is reasonable in [[Unstable angina]] / [[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 [[myocardial infarction]] ([[MI]]). (Level of Evidence: C)


===Class IIb===
===Class IIb===


1. The use of extended-release forms of non dihydropyridine [[calcium antagonists]] instead of a [[beta blocker]] may be considered in patients with [[UA]] / [[NSTEMI]]. (Level of Evidence: B)
1. The use of extended-release forms of non dihydropyridine [[calcium antagonists]] instead of a [[beta blocker]] may be considered in patients with [[Unstable angina]] / [[NSTEMI]]. (Level of Evidence: B)


2. Immediate-release dihydropyridine [[calcium antagonists]] in the presence of adequate beta blockade may be considered in patients with [[UA]] / [[NSTEMI]] with ongoing ischemic symptoms or [[hypertension]]. (Level of Evidence: B)
2. Immediate-release dihydropyridine [[calcium antagonists]] in the presence of adequate [[beta blockade]] may be considered in patients with [[Unstable angina]] / [[NSTEMI]] with ongoing ischemic symptoms or [[hypertension]]. (Level of Evidence: B)


===Class III===
===Class III===


1. [[Nitrates]] should not be administered to [[UA]] / [[NSTEMI]] patients with systolic blood pressure <90mmHg or ≥30 mmHg below baseline, severe [[bradycardia]] (<50 bpm), [[tachycardia]] (>100 bpm) in the absence of symptomatic [[heart failure]], or [[right ventricular infarction]]. (Level of Evidence: C)
1. [[NTG]] should not be administered to [[Unstable angina]] / [[NSTEMI]] patients with systolic blood pressure <90mmHg or ≥30 mmHg below baseline, severe [[bradycardia]] (<50 bpm), [[tachycardia]] (>100 bpm) in the absence of symptomatic [[heart failure]], or [[right ventricular infarction]]. (Level of Evidence: C)


2. [[Nitroglycerin]] or other [[nitrates]] should not be administered to patients with [[UA]] / [[NSTEMI]] who had received a phosphodiesterase inhibitor for erectile dysfunction within 24 h of [[sildenafil]] or 48 h of [[tadalafil]] use. The suitable time for the administration of [[nitrates]] after [[vardenafil]] has not been determined. (Level of Evidence: C)
2. [[Nitroglycerin]] or other [[nitrates]] should not be administered to patients with [[Unstable angina]] / [[NSTEMI]] who had received a phosphodiesterase inhibitor for erectile dysfunction within 24 h of [[sildenafil]] or 48 h of [[tadalafil]] use. The suitable time for the administration of [[nitrates]] after [[vardenafil]] has not been determined. (Level of Evidence: C)


3. Immediate-release dihydropyridine [[calcium antagonists]] should not be administered to patients with [[UA]] / [[NSTEMI]] in the absence of a [[beta blocker]]. (Level of Evidence: A)
3. Immediate-release dihydropyridine [[calcium antagonists]] should not be administered to patients with [[Unstable angina]] / [[NSTEMI]] in the absence of a [[beta blocker]]. (Level of Evidence: A)


4. An intravenous [[ACE inhibitor]] should not be given to patients within the first 24 h of [[UA]] / [[NSTEMI]] because of the increased risk of [[hypotension]]. (A possible exception may be patients with refractory [[hypertension]].) (Level of Evidence: B)
4. An intravenous [[ACE inhibitor]] should not be given to patients within the first 24 h of [[Unstable angina]] / [[NSTEMI]] because of the increased risk of [[hypotension]]. (A possible exception may be patients with refractory [[hypertension]].) (Level of Evidence: B)


5. It may be harmful to administer intravenous [[beta blockers]] to [[UA]] / [[NSTEMI]] patients who have contraindications to beta blockade, signs of [[HF]] or low-output state, or other risk factors for [[cardiogenic shock]]. (Level of Evidence: A)
5. It may be harmful to administer intravenous [[beta blockers]] to [[Unstable angina]] / [[NSTEMI]] patients who have contraindications to beta blockade, signs of [[HF]] or [[low output state]], or other risk factors for [[cardiogenic shock]]. (Level of Evidence: A)


6. [[Non steroidal anti-inflammatory drugs]] (except for [[ASA]]), whether non selective or COX-2–selective agents, should not be administered during hospitalization for [[UA]] / [[NSTEMI]] because of the increased risks of mortality, reinfarction, [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. (Level of Evidence: C)}}
6. [[Non steroidal anti-inflammatory drugs]] (except for [[ASA]]), whether non selective or COX-2–selective agents, should not be administered during hospitalization for [[Unstable angina]] / [[NSTEMI]] because of the increased risks of mortality, reinfarction, [[hypertension]], [[heart failure]], and [[myocardial rupture]] associated with their use. (Level of Evidence: C)}}


==See Also==
==See Also==
Line 108: Line 100:


==Sources==
==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>  
*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<ref name="pmid21444888">{{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 |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]] |volume= |issue= |pages= |year=2011 |month=March |pmid=21444888 |doi=10.1161/CIR.0b013e318212bb8b |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=21444888 |accessdate=2011-04-08}}</ref>
* 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==
{{reflist|2}}
{{reflist}}


{{SIB}}
{{SIB}}

Revision as of 17:26, 11 April 2011

Unstable angina pectoris
ICD-10 I20
ICD-9 413
DiseasesDB 8695
eMedicine med/133 
MeSH D000787

Template:Search infobox

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.; Neil Gheewala, M.D. [3]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [4] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.

Overview

Initial management of acute coronary syndorme (ACS) begins with differentiating between the spectrum of ACS which includes STEMI, Unstable Angina and Non-ST Elevation Myocardial Infarction.

Because the symptoms for all these can be similar, a medical evaluation is necessary as mentioned in earlier sections (see Initial Therapy). 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.

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 should be admitted to a critical care unit, whenever possible.

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.

Immediate Management

You can read in greater detail about each of the therapies below in greater detail by clicking on the link for that therapy.

Oxygen | Nitrates | Analgesics | Beta Blockers | Calcium Channel Blocker | Inhibitors of Renin-Angiotensin-Aldosterone axis

ACC / AHA Guidelines (DO NOT EDIT) [1][2]

“

Class I

1. Bed/chair rest with continuous ECG monitoring is recommended for all Unstable angina / NSTEMI patients during the early hospital phase. (Level of Evidence: C) [1] [2]

2. Supplemental oxygen should be administered to patients with Unstable angina / NSTEMI with an arterial saturation <90%, respiratory distress, or other high risk features for hypoxemia. (Pulse oximetry is useful for continuous measurement of SaO²) (Level of Evidence: B)

3. Patients with Unstable angina / NSTEMI with ongoing ischemic discomfort should receive sublingual nitroglycerine (NTG) (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C)

4. Intravenous NTG is indicated in the first 48 h after Unstable angina / NSTEMI for treatment of persistent ischemia, heart failure, or hypertension. The decision to administer intravenous NTG and the dose used should not preclude therapy with other proven mortality reducing interventions such as beta blockers or ACE inhibitors. (Level of Evidence: B)

5. Oral beta blocker therapy should be initiated within the first 24 h for patients who do not have 1 or more of the following: a- Signs of heart failure, b- Evidence of a low output state, c- Increased risk for cardiogenic shock, or d- Other relative contraindications to beta blockade (PR interval >0.24 sec, second or third degree heart block, active asthma, or reactive airway disease). (Level of Evidence: B)

6. In Unstable angina / NSTEMI patients with continuing or frequently recurring ischemia and in whom beta blockers are contraindicated, a non dihydropyridine calcium channel blocker (e.g., verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant left ventricular dysfunction or other contraindications. (Level of Evidence: B)

7. An Angiotensin Converting Enzyme inhibitor (ACEI) should be administered orally within the first 24 h to Unstable angina / NSTEMI patients with pulmonary congestion or LV ejection fraction (LVEF) ≤40%, in the absence of hypotension (systolic blood pressure <100 mmHg or <30 mmHg below baseline) or known contraindications to that class of medications. (Level of Evidence: A)

8. An angiotensin receptor blocker should be administered to Unstable angina / NSTEMI patients who are intolerant of ACE inhibitors and have either clinical or radiological signs of HF or LVEF ≤40%. (Level of Evidence: A)

9. Because of the increased risks of mortality, reinfarction, hypertension, HF, and myocardial rupture associated with their use, non steroidal anti-inflammatory drugs (NSAIDs), except for ASA, whether non selective or cyclo oxygenase (COX)-2–selective agents, should be discontinued at the time a patient presents with Unstable angina / NSTEMI. (Level of Evidence: C)

Class IIa

1. It is reasonable to administer supplemental oxygen to all patients with Unstable angina / NSTEMI during the first 6 h after presentation. (Level of Evidence: C)

2. In the absence of contradictions to its use, it is reasonable to administer morphine sulfate intravenously to Unstable angina / NSTEMI patients if there is uncontrolled ischemic chest discomfort despite NTG, provided that additional therapy is used to manage the underlying ischemia. (Level of Evidence: B)

3. It is reasonable to administer intravenous (IV) beta blockers at the time of presentation for hypertension to Unstable angina / NSTEMI patients who do not have 1 or more of the following: a- Signs of HF, b- Evidence of a low output state, c- Increased risk for cardiogenic shock, d- Other relative contraindications to beta blockade (PR interval >0.24 s, second or third degree heart block, active asthma, or reactive airway disease). (Level of Evidence: B)

4. Oral long acting non dihydropyridine calcium antagonists are reasonable for use in Unstable angina / NSTEMI patients for recurrent ischemia in the absence of contraindications after beta blockers and nitrates have been fully used. (Level of Evidence: C)

5. An ACE inhibitor administered orally within the first 24 h of Unstable angina / NSTEMI can be useful in patients without pulmonary congestion or LVEF ≤40% in the absence of hypotension (systolic blood pressure <100 mm Hg or less than 30 mm Hg below baseline) or known contraindications to that class of medications. (Level of Evidence: B)

6. Intra aortic balloon pump (IABP) counter pulsation is reasonable in Unstable angina / 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 myocardial infarction (MI). (Level of Evidence: C)

Class IIb

1. The use of extended-release forms of non dihydropyridine calcium antagonists instead of a beta blocker may be considered in patients with Unstable angina / NSTEMI. (Level of Evidence: B)

2. Immediate-release dihydropyridine calcium antagonists in the presence of adequate beta blockade may be considered in patients with Unstable angina / NSTEMI with ongoing ischemic symptoms or hypertension. (Level of Evidence: B)

Class III

1. NTG should not be administered to Unstable angina / NSTEMI patients with systolic blood pressure <90mmHg or ≥30 mmHg below baseline, severe bradycardia (<50 bpm), tachycardia (>100 bpm) in the absence of symptomatic heart failure, or right ventricular infarction. (Level of Evidence: C)

2. Nitroglycerin or other nitrates should not be administered to patients with Unstable angina / NSTEMI who had received a phosphodiesterase inhibitor for erectile dysfunction within 24 h of sildenafil or 48 h of tadalafil use. The suitable time for the administration of nitrates after vardenafil has not been determined. (Level of Evidence: C)

3. Immediate-release dihydropyridine calcium antagonists should not be administered to patients with Unstable angina / NSTEMI in the absence of a beta blocker. (Level of Evidence: A)

4. An intravenous ACE inhibitor should not be given to patients within the first 24 h of Unstable angina / NSTEMI because of the increased risk of hypotension. (A possible exception may be patients with refractory hypertension.) (Level of Evidence: B)

5. It may be harmful to administer intravenous beta blockers to Unstable angina / NSTEMI patients who have contraindications to beta blockade, signs of HF or low output state, or other risk factors for cardiogenic shock. (Level of Evidence: A)

6. Non steroidal anti-inflammatory drugs (except for ASA), whether non selective or COX-2–selective agents, should not be administered during hospitalization for Unstable angina / NSTEMI because of the increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture associated with their use. (Level of Evidence: C)

”

See Also

Sources

  • 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[2]
  • The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction [1]

References

  1. ↑ 1.0 1.1 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)
  2. ↑ 2.0 2.1 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 (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. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888. Retrieved 2011-04-08. Unknown parameter |month= ignored (help)

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