Unstable angina non ST elevation myocardial infarction overview: Difference between revisions

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===Elderly===
===Elderly===
Elderly patients represent a group of patients who have more comorbidities and who are both at risk for both [[CAD]] as well as for associated complications. However, they do derive equivalent or greater benefit from intervention when compared to younger patients. This group is likely to present with atypical symptoms like [[dyspnea]] and [[confusion]] rather than [[chest pain]].
On the other hand, presence of noncardiac comorbidities such as [[chronic obstructive lung disease]], [[gastroesophageal reflux disease]], upper-body musculoskeletal symptoms, [[pulmonary embolism]], and [[pneumonia]] is also higher, thus making the diagnosis of [[UA]]/[[NSTEMI]] challenging.
Secondly, they are more likely to have altered or abnormal cardiovascular anatomy, increased cardiac [[afterload]] due to decreased arterial compliance and [[arterial hypertension]], [[orthostatic hypotension]], cardiac hypertrophy, and ventricular dysfunction, especially [[diastolic dysfunction]].
Thirdly, elderly patients generally have other cardiac comorbidities and risk factors, such as [[hypertension]], prior [[MI]], [[HF]], cardiac conduction abnormalities, prior [[CABG]], peripheral and cerebrovascular disease, [[diabetes mellitus]], [[renal insufficiency]], and [[stroke]].
As a result, they are on mulitple medications and hence at risk for drug interactions and polypharmacy. When considering revascularization procedures, general medical and cognitive status, bleeding risk and other risk of interventions, anticipated life expectancy, and patient or family preferences must be considered.


===Chronic Kidney Disease===
===Chronic Kidney Disease===

Revision as of 20:07, 14 January 2013

Acute Coronary Syndrome Main Page

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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

Epidemiology and Demographics

Risk Stratification

Natural History, Complications and Prognosis

Special Groups

Women
Heart Failure and Cardiogenic Shock
Perioperative NSTE-ACS Related to Noncardiac Surgery
Stress (Takotsubo) Cardiomyopathy
Diabetes Mellitus
Post CABG Patients
Older Adults
Chronic Kidney Disease
Angiographically Normal Coronary Arteries
Variant (Prinzmetal's) Angina
Substance Abuse
Cardiovascular "Syndrome X"

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Blood Studies
Biomarkers

Electrocardiogram

Chest X Ray

Echocardiography

Coronary Angiography

Treatment

Primary Prevention

Immediate Management

Anti-Ischemic and Analgesic Therapy

Cholesterol Management

Antitplatelet Therapy

Antiplatelet therapy recommendations
Aspirin
Thienopyridines
Glycoprotein IIb/IIIa Inhibitor

Anticoagulant Therapy

Additional Management Considerations for Antiplatelet and Anticoagulant Therapy

Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS

Mechanical Reperfusion

Initial Conservative Versus Initial Invasive Strategies
PCI
CABG

Complications of Bleeding and Transfusion

Discharge Care

Medical Regimen
Post-Discharge Follow-Up
Cardiac Rehabilitation

Long-Term Medical Therapy and Secondary Prevention

ICD implantation within 40 days of myocardial infarction

ICD within 90 days of revascularization

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Unstable angina non ST elevation myocardial infarction overview On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Varun Kumar, M.B.B.S; Lakshmi Gopalakrishnan, M.B.B.S.; Cafer Zorkun, M.D., Ph.D. [2]; Neil Gheewala, M.D. [3]; Smita Kohli, M.D.

Overview

Unstable angina and Non ST elevation myocardial infarction (NSTEMI) belong to two different ends of the spectrum of acute coronary syndrome. Unstable angina is differentiated from NSTEMI by the absence of elevated cardiac biomarkers. The basic pathology in both the conditions involves a non-occlusive thrombus formation from a previously disrupted atherosclerotic plaque causing inadequate blood supply to the heart muscle.

The Spectrum of Acute Coronary Syndromes

  • Unstable angina, NSTEMI and STEMI are distinguished pathophysiologically as to whether or not the thrombus is occlusive (as in the case of STEMI) or non-occlusive (as in the case of UA and NSTEMI).
  • Frequently, Unstable Angina and NSTEMI are indistinguishable on inital evaluation as these two conditions are at different spectrums of ischemia. If the ischemia is significant to cause myocardial damage, there will be an elevation of Cardiac biomarkers (CK-MB or troponin) and would be classified as an NSTEMI (see Biomarkers). Often, these may not be detected for up to 12 hours in the bloodstream, which emphasizes the need for thorough evaluation. [1] [2]

Definition

Unstable Angina (UA): Angina pectoris is classified as stable when its characteristics are unchanged for 60 days. Stable angina pectoris usually responds to sublingual nitroglycerin or rest. Unstable angina occurs at rest and may not improve with rest.

Unstable angina is defined as new onset angina pectoris (or chest pain which is ischemic in origin) with the following features:[3] [4] [5] [6] [7] [8] [9] [10] [11] [1] [2] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] [72] [73] [74] [75] [76] [77] [78] [79] [80] [81] [82] [83] [84] [85] [86] [87] [88] [89] [90] [91] [92] [93] [94]

  • Occurs at rest or with lesser degrees of exertion than stable angina,
  • Lasts less than 30minutes,
  • Follows a crescendo pattern (i.e., occurs more frequently than previous)
  • There no sign of myocardial necrosis unlike in STEMI or NSTEMI, and there is no release of biomarkers of myonecrosis (CK or troponin).

Non-ST Elevation MI (NSTEMI):

Classification

Braunwald in 1989 proposed a classification for unstable angina based on severity and clinical circumstances. This classification was employed in various clinical trials and studies to determine its prognostic importance and clinical usefulness. In recent years with the more detailed understanding of the pathophysiology of unstable angina and the discovery of improved markers of myocardial injury, acute phase proteins and hemostatic markers, especially cardiac troponin I and troponin T, it was suggested to extend Class IIIB (angina at rest within the past 48 hrs) of the original classification, by subclassifying it into troponin negative and troponin positive patients.

Pathophysiology

Unstable Angina

Unstable angina occurs when myocardial oxygen demand exceeds myocardial oxygen supply at rest or with minimal exertion. This supply/demand mismatch can be caused by conditions that increase oxygen demand or reduce oxygen supply. [95] [96] [97] [98] [99] [100] [101] [102] [103] [1] [2] [104] [105] [106] [107] [108] [109] [110] [111] [112] [113] [114] [115] [116] [117] [118] [119] [120] [121] [122] [123] [124] [125] [126] [127] [128] [129] [130] [131] [132] [133] [134] [135] [136] [137] [138] [139] [140] [141] [142] [143] [144] [145] [146] [147] [148] [149] [150] [151] [152] [153] [154] [155] [156] [157] [158] [159] [160] [161] [162] [163] [164] [165] [166] [167] [168] [169] [170] [171] [172] [173] [174] [175] [176] [177] [178] [179] [180] [181] [182] [183] [184] [185] [186]

Non ST Elevation Myocardial Infarction

As alluded to in prior sections, unstable angina and NSTEMI are at different ends of the spectrum of the same disease. While there is no way to determine which patients presenting with unstable angina will ultimately progress to NSTEMI, the distinction between the two entities is clear. Often, for patients presenting prior to the four hour window before cardiac biomarkers are positive (namely CK-MB), the EKG in context of the patient's chest pain will be marker for whether patient has STEMI versus UA/NSTEMI and needs to urgently undergo percutaneous revascularization.

Epidemiology and Demographics

Over 9 million patients in the United States alone have angina. An estimated 80,700,000 American adults (one in three) have one or more types of cardiovascular disease (CVD), of whom 38,200,000 are estimated to be age 60 or older. Except as noted, the estimates were extrapolated to the U.S. population in 2005 from NHANES 1999–2004.

Risk Stratification

  • Patients with UA have lower short term mortality than NSTEMI or STEMI.
  • Early risk stratification is, therefore, recommended and is based on the initial history, physical exam, ECG, assessment of renal function and cardiac biomarkers.
  • Various models to calculate risk score and determine prognosis are available for example TIMI score, PURSUIT risk model, GRACE risk score etc. This evaluation is helpful in selecting the site of care and type of therapy.
  • Physician should document their opinion of the likelihood of ACS in one of the three categories of low, intermediate or high likelihood. Patients with high risk score and/or hemodynamic instability should be managed in coronary care unit while those with intermediate to low risk score and hemodynamic stability can be managed in a step down unit.
  • A continuous ECG monitoring (telemetry) should be used to monitor for arrythmias.

Natural History, Complications and Prognosis

Unstable angina / NSTEMI are signs of more severe heart disease. Natural history is complicated by the development of arrhythmias and heart failure. In a study it was shown that 14% of the cases of unstable angina can progress to MI. Sudden death is an infrequent sequel of both UA and NSTEMI.

Special Groups

Women

Although women are traditionally at lower risk for CAD as compared to men at all ages, UA/NSTEMI is still common amongst this group and importantly, women can manifest CAD somewhat differently than men. It is also important to keep in mind that women with CAD are, on average, older than men and are more likely to have comorbidities such as hypertension, diabetes mellitus, and heart failure with preserved systolic function; to manifest angina rather than MI; and, to have atypical symptoms of angina and MI.

Diabetic Patient

75% of all deaths among diabetic patients are due to coronary artery disease. Diabetic patients with unstable angina or NSTEMI tend to have a more severe disease with worse outcomes. Long term morbidity and mortality in diabetic patients with no previous cardiovascular disease are the same as that of nondiabetic patients with established cardiovascular disease after hospitalization for unstable coronary artery disease.[187]

Post CABG Patients

Post-CABG patients with unstable angina or NSTEMI are associated with a more severe coronary artery disease compared to the patients who have not undergone a bypass surgery. Medical treatment in this patient population should follow the same guidelines as for UA/NSTEMI in non–post CABG patients.

Elderly

Elderly patients represent a group of patients who have more comorbidities and who are both at risk for both CAD as well as for associated complications. However, they do derive equivalent or greater benefit from intervention when compared to younger patients. This group is likely to present with atypical symptoms like dyspnea and confusion rather than chest pain. On the other hand, presence of noncardiac comorbidities such as chronic obstructive lung disease, gastroesophageal reflux disease, upper-body musculoskeletal symptoms, pulmonary embolism, and pneumonia is also higher, thus making the diagnosis of UA/NSTEMI challenging. Secondly, they are more likely to have altered or abnormal cardiovascular anatomy, increased cardiac afterload due to decreased arterial compliance and arterial hypertension, orthostatic hypotension, cardiac hypertrophy, and ventricular dysfunction, especially diastolic dysfunction. Thirdly, elderly patients generally have other cardiac comorbidities and risk factors, such as hypertension, prior MI, HF, cardiac conduction abnormalities, prior CABG, peripheral and cerebrovascular disease, diabetes mellitus, renal insufficiency, and stroke. As a result, they are on mulitple medications and hence at risk for drug interactions and polypharmacy. When considering revascularization procedures, general medical and cognitive status, bleeding risk and other risk of interventions, anticipated life expectancy, and patient or family preferences must be considered.

Chronic Kidney Disease

Drug and Substance Abusers

Prinzmetal's Angina

Cardiovascular Syndrome X

Presentation and Diagnosis

UA can have typical or atypical presentations. The 3 classic forms of presentation are:

  • Rest angina (angina commencing when the patient is at rest)
  • New onset (less than 2 months) severe angina (at least CCS class II), or
  • Increasing angina-previously diagnosed angina that has become distinctly more frequent, longer in duration, or lower in threshold (i.e., increased by 1 or more CCS class to at least CCS class III severity)

NSTEMI generally presents as prolonged, more intense rest angina or angina equivalent.

  • Patients with suspected ACS must be evaluated rapidly.
  • Evaluation should not be done over the phone but in person and in a place where a 12 lead ECG can be obtained.
  • A focused history, examination, ECG and cardiac biomarkers are helpful to determine where the patient will be managed and whether the patient needs to be transferred or referred to a different hospital/setting.
  • Physical examination should focus on identifying the precipitating factors, comorbid conditions, rule out alternative diagnosis and assess hemodynamic status of the patient.

Unstable angina is associated with negative cardiac biomarkers whereas NSTEMI is associated with elevated cardiac biomarkers. Depending on the patient's symptoms and degree of suspicion for ACS, early coronary angiography can be performed to make a definitive diagnosis.

Treatment

Immediate management is directed towards relief of chest pain.

  • Nitrates, ASA and morphine are recommended to control the symptoms from possible ACS.
  • Beta blockers, thienopyridines (like Clopidogrel and prasugrel) should be administered in the absence of contraindication to their use.
  • Based on the suspicion for likelihood of ACS, anticoagulants and GP IIb/IIIa inhibitors can be started early in the course of presentation.
  • Two strategies in the treatment are early invasive or conservative strategies. Most trials have shown benefit of early invasive therapy with cardiac catheterization and revascularisation procedures. Early invasive therapy is now recommended for patients with UA/NSTEMI and ST segment changes at presentation and/or positive troponins during first 24hrs of presentation.

Discharge Care

  • Discharge care after UA/NSTEMI must include a medication reconciliation of inpatient and discharge medications, life style modification counselling and instructions on smoking cessation, cardiac rehabilitation and arrangements for follow-up.
  • Patients with UA/NSTEMI diagnosis should be discharged home on an ASA, clopidogrel, beta blocker, nitrates, ACE inhibitors and statins, unless contraindicated.
  • Cardiac rehab has been shown to improve exercise tolerance, improve patient compliance and assist in lifestyle modification and all patient should be referred for this.
  • Both patient and family should be informed about the treatment plan and a what to do if symptoms recur.

References

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  160. Park JS, Zhang SY, Jo SH, et al: Common adrenergic receptor polymorphisms as novel risk factors for vasospastic angina. Am Heart J 2006; 151:864-869 PMID 16569551
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  166. Kawano H, Motoyama T, Yasue H, et al: Endothelial function fluctuates with diurnal variation in the frequency of ischemic episodes in patients with variant angina. J Am Coll Cardiol 2002; 40:266-270. PMID 12106930
  167. Matsuguchi T, Araki H, Nakamura N, et al: Prevention of vasospastic angina by alcohol ingestion: Report of 2 cases. Angiology 1988; 39:394-400. PMID 3364807
  168. Raxwal V, Gupta K: Images in cardiovascular medicine. Coronary artery spasm. Circulation 2006; 113:e689-e690. PMID 16606795
  169. Chen HS, Pinto DS: Images in clinical medicine. Prinzmetal's angina. N Engl J Med 2003; 349:e1. PMID 12840104
  170. Wang K, Asinger RW, Marriott HJ: ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128-2135. PMID 14645641
  171. Unverdorben M, Haag M, Fuerste T, et al: Vasospasm in smooth coronary arteries as a cause of asystole and syncope. Cathet Cardiovasc Diagn 1997; 41:430-434. PMID 9258492
  172. Lip GY, Gupta J, Khan MM, Singh SP: Recurrent myocardial infarction with angina and normal coronary arteries. Int J Cardiol 1995; 51:65-71. PMID 8522399
  173. Pepine CJ, el-Tamimi H, Lambert CR: Prinzmetal's angina (variant angina). Heart Dis Stroke 1992; 1:281-286. PMID 1344118
  174. Crea F: Variant angina in patients without obstructive coronary atherosclerosis: a benign form of spasm. Eur Heart J 1996; 17:980-982. PMID 8809510
  175. Hirano Y, Ueharfa H, Nakamura H, et al: Diagnosis of vasospastic angina: Comparison of hyperventilation and cold-pressor stress echocardiography, and coronary angiography with intracoronary injection of acetylcholine. Int J Cardiol 2007; 116:331-337. PMID 16890307
  176. Nakao K, Ohgushi M, Yoshimura M, et al: Hyperventilation as a specific test for diagnosis of coronary artery spasm. Am J Cardiol 1997; 80:545-549. PMID 9294979
  177. Antman E, Muller J, Goldberg S, et al: Nifedepine therapy for coronary artery spasm. Experience in 127 patients. N Engl J Med 1980; 302:1269-1273. PMID 6767986
  178. De Cesare N, Cozzi S, Apostolo A, et al: Facilitation of coronary spasm by propranolol in Prinzmetal's angina: Fact or unproven extrapolation?. Coron Artery Dis 1994; 5:323-330. PMID 8044344
  179. Tzivoni D, Keren A, Benhorin J, et al: Prazosin therapy for refractory variant angina.Am Heart J 1983; 105:262-266. PMID 6823808
  180. Kaski JC: Management of vasospastic angina—role of nicorandil. Cardiovasc Drugs Ther 9 Suppl 1995; 2:221-227. PMID 7647026
  181. Kawano H, Motoyama T, Hirai N, et al: Estradiol supplementation suppresses hyperventilation-induced attacks in postmenopausal women with variant angina. J Am Coll Cardiol 2001; 37:735-740. PMID 11693745
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