View source for Unstable angina non ST elevation myocardial infarction immediate management

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| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{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}}

==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]]).

==Risk Stratification==
[[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]].

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:
*[[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 blockers]]
*[[UA/NSTEMI inhibitors of RAS | Renin-angiotensin-aldosterone inhibitors]]'''

==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>==

===ED or Outpatient Facility Presentation===
{|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.''' 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>
|-
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
| 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>
|}

===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>
|}

==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>==
===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>===

{|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>
|}

{|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.''' 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>
|}

===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"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| 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>
|}
{|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.''' [[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>
|}

==References==
{{Reflist|2}}
{{WH}}
{{WS}}

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