Unstable angina non ST elevation myocardial infarction nitrate therapy: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
(New page: '''{{Infobox_Disease | Name = Unstable angina pectoris | Image = | Caption = | DiseasesDB = 8695 | ICD10 = {{ICD10|I|20||i|20}} | ICD9 ...)
 
No edit summary
Line 23: Line 23:
{{Editor Join}}
{{Editor Join}}


==Anti-ischemic therapy==
==Mechanism of Benefit==
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.
*[[Nitroglycerin]], an endothelium-independent [[vasodilator]], has both peripheral and coronary vascular effects.
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.
*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.  


===Nitrates===
==Dosing==
[[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.
*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]].  
 
==Indications==
*It will also be helpful in patients with [[heart failure]] and [[hypertension]].


==ACC / AHA Guidelines (DO NOT EDIT) <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><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>==
==ACC / AHA Guidelines (DO NOT EDIT) <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><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>==
Line 35: Line 40:
===Class I===
===Class I===


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)
1. 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)


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)
2. 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)


===Class III===
===Class III===
Line 44: Line 49:


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 [[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)}}


==Sources==
==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<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>
*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>   
* 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==

Revision as of 13:10, 9 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.

Associate Editor-In-Chief: Neil Gheewala, M.D. [3]

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.

Mechanism of Benefit

  • 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.

Dosing

  • 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.

Indications

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

“

Class I

1. 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)

2. 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)

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)

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)

”

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

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 (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)
  2. ↑ 2.0 2.1 Anderson JL, Adams CD, Antman EM; et al. (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". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter |month= ignored (help)

Template:SIB

Template:WikiDoc Sources

Retrieved from "https://www.wikidoc.org/index.php?title=Unstable_angina_non_ST_elevation_myocardial_infarction_nitrate_therapy&oldid=573412"