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.
• 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
  • 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.
• Abciximab should not be administer to patients not programmed for PCI.

References

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