Unstable angina non ST elevation myocardial infarction nitrate therapy

Unstable angina pectoris
ICD-10	I20
ICD-9	413
DiseasesDB	8695
eMedicine	med/133
MeSH	D000787

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

Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Smita Kohli, M.D.

Associate Editor-In-Chief: Neil Gheewala, M.D. [3]

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Anti-ischemic therapy

Goals of treatment in ACS are to relieve the ischemia, limit the amount of myocardial damage and to prevent adverse outcomes, namely death and myocardial [re]infarction. Unless contraindicated, Aspirin, a beta blocker, an anticoagulant, a glycoprotein IIb/IIA inhibitor and a thienopyridine should be included in the treatment. Risk stratification early in the course of admission is important so that patients who are intermediate to high risk, including those with ongoing ischemia and evidence of hemodynamic instability should be admitted to a critical care unit, whenever possible.

Nitrates

Nitroglycerin, an endothelium-independent vasodilator, has both peripheral and coronary vascular effects. By venodilation, it decreases the myocardial preload, ultimately, decreasing the myocardial oxygen demand. It also dilates the coronary arteries, thus, decreasing the amount of stenosis and relieves pain. In addition, it promotes collateral flow and redistribution of coronary blood flow to ischemic regions. If three sublingual 0.4mg tablets of NTG fail to relieve the pain, intravenous NTG may be initiated along with oral or intravenous beta blocker. It will also be helpful in patients with heart failure and hypertension.

ACC / AHA Guidelines (DO NOT EDIT)

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Class I 3. Patients with UA / NSTEMI with ongoing ischemic discomfort should receive sublingual NTG (0.4 mg) every 5 min for a total of 3 doses, after which assessment should be made about the need for intravenous NTG, if not contraindicated. (Level of Evidence: C) 4. Intravenous NTG is indicated in the first 48 h after UA / NSTEMI for treatment of persistent ischemia, heart failure, or hypertension. The decision to administer intravenous NTG and the dose used should not preclude therapy with other proven mortality reducing interventions such as beta blockers or ACE inhibitors. (Level of Evidence: B) Class III 1. Nitrates should not be administered to UA / NSTEMI patients with systolic blood pressure <90mmHg or ≥30 mmHg below baseline, severe bradycardia (<50 bpm), tachycardia (>100 bpm) in the absence of symptomatic heart failure, or right ventricular infarction. (Level of Evidence: C) 2. Nitroglycerin or other nitrates should not be administered to patients with UA / NSTEMI who had received a phosphodiesterase inhibitor for erectile dysfunction within 24 h of sildenafil or 48 h of tadalafil use. The suitable time for the administration of nitrates after vardenafil has not been determined. (Level of Evidence: C)

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Sources

• 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
• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction