Unstable angina/ NSTEMI resident survival guide: Difference between revisions

< Unstable angina

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Revision as of 20:41, 27 January 2014

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^[1]

❑ 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^[2] 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^[3] (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 ^[4]
Administer sublingual nitroglycerin in patients with ischemic chest pain. IV should be administer in patients with persistent chest pain after three sublingual nitroglycerins. ^[5]
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. ^[6] ^[7]
Statins should be administer to all patients with unstable angina. The recommendation is atorvastatin 80mg/day ^[8] ^[9]
Non-steroidal anti-inflamatory drugs should be discontinued immediately. ^[10] ^[11]
Patients 75 years and older have an increased risk of bleeding the administration of anti-platelet therapy should be cautions, except in high risk situations such as diabetes and prior myocardial infarction.
P2Y12 platelet inhibitor therapy should be continued for 12 months with a maintenance dose of either ^[1]
- Clopidogrel - 75mg per day
- Prasogrel - 10mg per day
- Ticagrelor - 90mg twice a day

Don´ts

Do not administer IV upstream GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding with aspirin and P2Y12 receptor inhibitors therapy.
Prasugrel is potentially harmful as part of a due anti-platelet therapy in patients who are planned for PCI, with prior history of strokes o TIAs.
IV beta-blockers should not be administer to hemodynamically unstable patients.
Patients under 60kg (132lbs) should not receive a complete dose of prasugrel (10mg), due to high exposure to the active metabolite. They should receive half the dose (5mg) although it has not be proved to be as effective as a complete dose.
Do not administer fibrinolytic therapy to patients with unstable angina, as it is not beneficial.^[12]
Abciximab should not be administer to patients not programmed for PCI. ^[13]

References

↑ ^1.0 ^1.1 Harrington RA, Becker RC, Cannon CP, Gutterman D, Lincoff AM, Popma JJ; et al. (2008). "Antithrombotic therapy for non-ST-segment elevation acute coronary syndromes: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)". Chest. 133 (6 Suppl): 670S–707S. doi:10.1378/chest.08-0691. PMID 18574276.
↑ Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators. Yusuf S, Mehta SR, Chrolavicius S, Afzal R, Pogue J; et al. (2006). "Comparison of fondaparinux and enoxaparin in acute coronary syndromes". N Engl J Med. 354 (14): 1464–76. doi:10.1056/NEJMoa055443. PMID 16537663. Review in: ACP J Club. 2006 Sep-Oct;145(2):30-1
↑ Antman EM, McCabe CH, Gurfinkel EP, Turpie AG, Bernink PJ, Salein D; et al. (1999). "Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial". Circulation. 100 (15): 1593–601. PMID 10517729.
↑ name="pmid23554440">{{cite journal| author=Shuvy M, Atar D, Gabriel Steg P, Halvorsen S, Jolly S, Yusuf S et al.| title=Oxygen therapy in acute coronary syndrome: are the benefits worth the risk? | journal=Eur Heart J | year= 2013 | volume= 34 | issue= 22 | pages= 1630-5 | pmid=23554440 | doi=10.1093/eurheartj/eht110 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?
↑ Kaplan K, Davison R, Parker M, Przybylek J, Teagarden JR, Lesch M (1983). "Intravenous nitroglycerin for the treatment of angina at rest unresponsive to standard nitrate therapy". Am J Cardiol. 51 (5): 694–8. PMID 6402912.
↑ Rosendorff C, Black HR, Cannon CP, Gersh BJ, Gore J, Izzo JL; et al. (2007). "Treatment of hypertension in the prevention and management of ischemic heart disease: a scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention". Circulation. 115 (21): 2761–88. doi:10.1161/CIRCULATIONAHA.107.183885. PMID 17502569.
↑ López-Sendón J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H; et al. (2004). "Expert consensus document on beta-adrenergic receptor blockers". Eur Heart J. 25 (15): 1341–62. doi:10.1016/j.ehj.2004.06.002. PMID 15288162.
↑ Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R; et al. (2004). "Intensive versus moderate lipid lowering with statins after acute coronary syndromes". N Engl J Med. 350 (15): 1495–504. doi:10.1056/NEJMoa040583. PMID 15007110. Review in: ACP J Club. 2004 Sep-Oct;141(2):33
↑ Schwartz GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D; et al. (2001). "Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial". JAMA. 285 (13): 1711–8. PMID 11277825.
↑ Trelle S, Reichenbach S, Wandel S, Hildebrand P, Tschannen B, Villiger PM; et al. (2011). "Cardiovascular safety of non-steroidal anti-inflammatory drugs: network meta-analysis". BMJ. 342: c7086. doi:10.1136/bmj.c7086. PMC 3019238. PMID 21224324. Review in: Evid Based Med. 2011 Oct;16(5):142-3
↑ Coxib and traditional NSAID Trialists' (CNT) Collaboration. Bhala N, Emberson J, Merhi A, Abramson S, Arber N; et al. (2013). "Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials". Lancet. 382 (9894): 769–79. doi:10.1016/S0140-6736(13)60900-9. PMC 3778977. PMID 23726390. Review in: Ann Intern Med. 2013 Oct 15;159(8):JC12
↑ Anderson HV (1995). "Intravenous thrombolysis in refractory unstable angina pectoris". Lancet. 346 (8983): 1113–4. PMID 7475596.
↑ Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE; et al. (2012). "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". J Am Coll Cardiol. 60 (7): 645–81. doi:10.1016/j.jacc.2012.06.004. PMID 22809746.

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