Unstable angina/ NSTEMI resident survival guide

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

Definition

Unstable angina is an unexpected chest pain while resting or sleeping,that could get worse with time lasting at least 20 minutes up to 30 minutes. It is caused by a temporary reduced blood flow, resulting in a decreased oxygen supply to the myocardial tissue.

Causes

Life Threatening Causes

• Reduced myocardial perfussion
• Mycordial infarction
• Cocaine-associated mycoardial infarction

Common Causes

• Atherosclerosis
• Non-occlusive thrombus

Management

Diagnosis

CHARACTERIZE THE SYMPTOMS ❑ Chest pain or discomfort while resting ❑ The pain is longer than 20 minutes ❑ It started without physical exertion ❑ Rest doesn´t help to relieve it ❑ Gets worse with time
PERSONAL HISTORY ❑ Age ❑ Previous MI ❑ Previous PCI or CABG
PHYSICAL EXAMINATION ❑ Measure blood pressure ❑ Measure heart rate ❑ Auscultation of murmurs ❑ CHF
LABS & TESTS ❑ EKG ❑ Troponin I and T ❑ CK-MB ❑ Creatinine ❑ Glucose ❑ Hemoglobin

Treatment

❑ Administer 300mg Aspirin immediately after hospital admission ❑ Administer oxygen in patients with saturation <90% ❑ Administer nitroglycerine sub-lingual ADD DOSES ❑ Administer morphine IV initial dose 2-4mg with increments of 2-8mg every 5 to 15 minutes ❑ Administer beta-blockers to all patients without contraindications ❑ Administer statins, atorvastatine 80mg ❑ Initiate anti thrombotic therapy

Determine Risk of adverse coronary event (TIMI)

LOW RISK Initial conservative strategy

HIGH RISK Initial invasive strategy

❑ Administer 300mg of copidogrel ❑ Administer fondaparinaux or UFH in case of renal failure

❑ Administer IV GP IIb/IIIa inhibitors (eptifibatide or tirofiban) OR ❑ Administer Bivalirudin

Perform a Stress test

Angiography

LOW RISK

HIGH RISK

NEGATIVE

POSITIVE

Recurrent symptoms?

❑ Continue Aspirin ❑ Continue with clopidrogel or ticagelor for 12 months ❑ Discontinue with GP inhibitors ❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas)

NO

❑ Heart failure ❑ Serious arrhythmias ❑ Subsequent isquemia

Continue Aspirin ❑ Continue with clopidrogel or ticagelor for 12 months ❑ Discontinue with GP inhibitors ❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas

PCI ❑ Administer clopidogrel 24 hrs before ❑ As as possible in no bleeding risk patients who are unstable or with high risk of isquemia ❑ Administer UFH (50-100 units/kg)

CABG ❑ Continue aspirin + UFH ❑ Discontinue clopidogel 5 days before ❑ Discontinue enoxiparin and fondaparinaux 12-24 hrs before ❑ Discontinue IV GP inhibitors 4 hrs bfore ❑ Discontinue bivalirudin 3 hrs before

INTENSIVE STRATEGY - ANGIOGRAPHY

NEGATIVE

POSITIVE

❑ Continue Aspirin ❑ Continue with clopidrogel or ticagelor for 12 months ❑ Discontinue with GP inhibitors ❑ UFH (for 48hrs) or Enoxiparin (for 8 dyas)

PCI ❑ Administer clopidogrel 24 hrs before ❑ As as possible in no bleeding risk patients who are unstable or with high risk of isquemia ❑ Administer UFH (50-100 units/kg)

CABG ❑ Continue aspirin + UFH ❑ Discontinue clopidogel 5 days before ❑ Discontinue enoxiparin and fondaparinaux 12-24 hrs before ❑ Discontinue IV GP inhibitors 4 hrs bfore ❑ Discontinue bivalirudin 3 hrs before

Do´s

• Administer 300 mg of clopidogrel as initial treatment instead of aspirin in case of gastrointestinal intolerance of hypersensitivity reaction.
• Oxygen must be administered in patients with arteria saturation less than 90% or in respiratory distress
• Administer sublingual nitroglycerin in patients with ischemic chest pain. IV should be administer in patients with persistent chest pain after three sublingual nitroglycerins.
• Nitroglycerin should be administer to all patients with hypertension or heart failure.
• Beta-bloquers should be administer to all patients with hypertension, tachycardia or ongoing chest pain.
• Statins should be administer to all patients with unstable angina. The recommendation is atorvastatin 80mg/day
• Non-steroidal anti-inflamatory drugs should be discontinued immediately.
• P2Y12 platelet inhibitor therapy should be continued for 12 months with a maintenance dose of either
  • Clopidogrel - 75mg per day
  • Prasogrel - 10mg per day
  • Ticagrelor - 90mg twice a day

References

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