Unstable angina/ NSTEMI resident survival guide: Difference between revisions

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{{familytree  | | | | | | | B01 | | | | | | B01= Determine the risk of [[adverse coronary event]] <br>
{{familytree  | | | | | | | B01 | | | | | | B01= Determine the risk of [[adverse coronary event]] <br>
❑[[Unstable angina resident survival guide#Thrombolysis in Myocardial Infarction (TIMI) Risk Score|TIMI Score]]
❑[[Unstable angina resident survival guide#Thrombolysis in Myocardial Infarction (TIMI) Risk Score|TIMI Score]]
❑[[Unstable angina resident survival guide#HEART Score|HEART Score]]}}
❑[[Unstable angina resident survival guide#HEART Risk Score|HEART Score]]}}
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{{familytree  | | | C01 | | | | | | C02 | | C01= '''Low risk''' <br> '''Initial conservative strategy'''| C02= '''High risk''' <br> '''Initial invasive strategy'''}}
{{familytree  | | | C01 | | | | | | C02 | | C01= '''Low risk''' <br> '''Initial conservative strategy'''| C02= '''High risk''' <br> '''Initial invasive strategy'''}}

Revision as of 16:15, 30 January 2014

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

Definition

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

Causes

Life Threatening Causes

  • Reduced myocardial perfussion
  • Mycordial infarction
  • Cocaine-associated mycoardial infarction[1]

Common Causes

  • Atherosclerosis
  • Non-occlusive thrombus

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to unstable angina from the "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction [2]

Characterize the symptoms:

❑Chest pain

❑ At rest
❑ Duration> 20 minutes
❑ Absence of physical exertion
❑ No relief with rest
❑ Worse with time

❑ Nausea
❑ Vomiting

❑ Sweating
 
 
 
 
 
Obtain a detailed history:

❑ Age
❑ Previous MI
❑ Previous PCI or CABG
❑ Cardiac risk factors:

❑ Hypertension
❑ Diabetes
❑ Hypercholesterolemia
❑ Tobacco use
 
 
 
 
 
Examine the patient:

❑ Measure blood pressure
❑ Measure heart rate
❑ Auscultation of murmurs

❑ CHF
 
 
 
 
 
Order labs and tests:

❑ EKG
❑ Bio-markers

❑ Troponin I
❑ CK-MB

❑ Creatinine
❑ Glucose

❑ Hemoglobin

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to unstable angina from the "2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non-ST-elevation myocardial infarction [2]

 
 
 
 
 
 
Initial Treatment
❑ Administer 300mg Aspirin[3]

❑ Administer Oxygen in patients with saturation <90%
❑ Administer sub-lingual Nitroglycerine, (0.4 - 0.8mg)[4]
❑ Administer Morphine IV (initial dose 2-4 mg with increments of 2-8mg every 5 to 15 minutes)
❑ Administer Beta-blockers (unless contraindicated)
❑ Administer Statins

❑ Atorvastatin, (80mg )
❑ Initiate Antithrombotic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the risk of adverse coronary event

❑TIMI Score

❑HEART Score
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk
Initial conservative strategy
 
 
 
 
 
High risk
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Administer P2Y12 receptor inhibitors
❑ Clopidogrel (300mg)
❑ Ticagrelor (180mg)
❑ Prasugrel (60mg)

❑ Administer Antithrombotic treatment

❑ Fondaparinux
❑ UFH in case of renal failure.[5]
 
 
 
 
 
❑ Administer IV GP IIb/IIIa inhibitors
❑ Eptifibatide
❑ Tirofiban
OR
❑ Administer Bivalirudin
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent symptoms?
 
 
 
 
 
❑ Perform an Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrence of symptoms
❑ Heart failure
❑ Serious arrhythmia
❑ Subsequent ischemia
 
No recurrent symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an Angiography
 
❑ Perform a Stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low Risk
 
High Risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue Aspirin for life
❑ Continue P2Y12 receptor inhibitors (for 12 months)
❑ Clopidogrel (75mg once a day)
❑ Ticagrelor (90mg twice a day)
❑ Prasugrel (10mg once a day)

❑ Discontinue GP IIb/IIIa inhibitors
❑ Continue Antithrombotic therapy (for 8 days and then discontinue)

❑ UFH(for 48hrs)
❑ Enoxaparin
❑ Fondaparinux (up to 8 days)
 
 
 
 
 
 


Management following Angiography

 
 
 
 
 
Findings on Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PCI
 
CABG
 
Medical treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue Aspirin for life
❑ Continue P2Y12 receptor inhibitors (for 12 months)
❑ Clopidogrel (75mg once a day)
❑ Ticagrelor (90mg twice a day)
❑ Prasugrel (10mg once a day)

❑ Discontinue GP IIb/IIIa inhibitors
❑ Continue Antithrombotic therapy

❑ UFH(for 48hrs)
❑ Enoxaparin
❑ Fondaparinux (up to 8 days)
 
❑ Administer Aspirin for life
Administer P2Y12 receptor inhibitor (if not initially started)
❑ Clopidogrel (75mg once a day)
❑ Ticagrelor (90mg twice a day)
❑ Prasugrel (10mg once a day)

❑ Administer Antithrombotic therapy

❑ UFH(50-100 units/kg)
 

❑ Continue Aspirin
❑ Discontinue IV GP IIb/IIIa inhibitors (4 hrs before)
❑ Antithrombotic therapy

❑ Continue UFH
❑ Discontinue Enoxaparin (12-24 hrs before)
❑ Discontinue Fondaparinux (12-24 hrs before)
❑ Discontinue Bivalirudin (3 hrs before)
 
❑ Continue Aspirin

❑ Continue a loading dose of P2Y12 receptor inhibitors (if not given before angiography)

❑ Clopidogrel (600mg)
❑ Prasugrel (60mg)
❑ Ticagrelor (180mg)

❑ Discontinue IV GP IIb/IIIa inhibitors if started before Angiography
❑ Manage Antithrombotic therapy:

❑ Continue IV UFH, if given before angiography (for 48 hrs or until discharge)
❑ Continue Enoxaparin for entire hospital stay, if given before Angiography (up to 8 days)
❑ Continue Fondaparinux for entire hospital stay, if given before Angiography (up to 8 days)
❑ Discontinue Bivalirudin or continue,if given before Angiography (0.25mg/kg per hr for up to 72hrs)
 
 
 

Thrombolysis in Myocardial Infarction (TIMI) Risk Score

 
 
 
 
 
Adults 65 years and older

Previous coronary artery stenosis > 50%

  • Cardiac catherterization
  • Angioplasty or stent
  • Bypass
  • Myocardial infraction

Cardiac risk factors - three or more

  • Hypertension
  • Diabetes
  • High cholesterol
  • MI in family history
  • Tobacco history

Use of aspirin the previous week

Anginal events (two or more) in the previous day

ST segment alteration (>1mm elevation or depression)

Cardio bio-markers elevated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

HEART Risk Score

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 [6]
  • Administer sublingual nitroglycerin in patients with ischemic chest pain. IV should be administer in patients with persistent chest pain after three sublingual nitroglycerins. [7]
  • 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. [8] [9]
  • Statins should be administer to all patients with unstable angina. The recommendation is atorvastatin 80mg/day [10] [11]
  • Non-steroidal anti-inflamatory drugs should be discontinued immediately. [12] [13]
  • 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: [3]
    • Clopidogrel - 75mg per day
    • Prasogrel - 10mg per day
    • Ticagrelor - 90mg twice a day

Don'ts

  • Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding, already 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.[14]
  • Abciximab should not be administer to patients not programmed for PCI. [2]

References

  1. ↑ McCord J, Jneid H, Hollander JE, de Lemos JA, Cercek B, Hsue P; et al. (2008). "Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology". Circulation. 117 (14): 1897–907. doi:10.1161/CIRCULATIONAHA.107.188950. PMID 18347214.
  2. ↑ 2.0 2.1 2.2 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.
  3. ↑ 3.0 3.1 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.
  4. ↑ Doucet S, Malekianpour M, Théroux P, Bilodeau L, Côté G, de Guise P; et al. (2000). "Randomized trial comparing intravenous nitroglycerin and heparin for treatment of unstable angina secondary to restenosis after coronary artery angioplasty". Circulation. 101 (9): 955–61. PMID 10704160.
  5. ↑ 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
  6. ↑ 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?
  7. ↑ 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.
  8. ↑ 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.
  9. ↑ 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.
  10. ↑ 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
  11. ↑ 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.
  12. ↑ 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
  13. ↑ 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
  14. ↑ Anderson HV (1995). "Intravenous thrombolysis in refractory unstable angina pectoris". Lancet. 346 (8983): 1113–4. PMID 7475596.


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