Unstable angina / non ST elevation myocardial infarction prinzmetal's angina: Difference between revisions
(/* ACC / AHA 2007 Guidelines - Unstable Angina / NSTEMI - Patients with Prinzmetals' Angina (DO NOT EDIT) {{cite journal |author=Anderson JL, Adams CD, Antman EM, et al |title=ACC/AHA 2007 guidelines for the management of patients with unstable an...) |
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| [[File:Siren.gif|30px|link=Unstable angina/ NSTEMI resident survival guide]]|| <br> || <br> | |||
| [[Unstable angina/ NSTEMI resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']] | |||
|} | |||
{{Unstable angina / NSTEMI}} | {{Unstable angina / NSTEMI}} | ||
{{CMG}}; '''Associate Editor-In-Chief:''' Smita Kohli, M.D. | {{CMG}}; '''Associate Editor-In-Chief:''' Smita Kohli, M.D. | ||
{{SK}} Prinzmetal's angina, variant angina, angina inversa | |||
==Overview | ==Overview== | ||
Prinzmetal's angina, also known as variant angina or angina inversa, is chest pain at rest that occurs in periodic cycles. It is unrelated to exertion although can occur with exertion. | [[Prinzmetal's angina]], also known as variant angina or angina inversa, is [[chest pain]] at rest that occurs in periodic cycles. It is unrelated to exertion although can occur with exertion. | ||
Prinzmetal's angina is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to atherosclerosis. | Prinzmetal's angina is caused by [[vasospasm]], a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to [[atherosclerosis]]. | ||
Attacks can be precipitated by an emotional [[stress]], [[hyperventilation]], [[exercise]], or exposure to cold. A circadian variation in the episodes of angina is most often present, with most attacks occurring in the early morning. | Attacks can be precipitated by an emotional [[stress]], [[hyperventilation]], [[exercise]], or exposure to cold. A circadian variation in the episodes of angina is most often present, with most attacks occurring in the early morning. | ||
It is characterized by transient ST-segment elevation that spontaneously resolves or resolves with [[ | It is characterized by transient [[ST-segment elevation]] that spontaneously resolves or resolves with [[nitroglycerin]] use without progression to [[MI]]. The majority of patients have normal exercise tolerance, and stress testing may be negative. | ||
Because the anginal discomfort usually occurs at rest without a precipitating cause, it may simulate [[UA]]/[[NSTEMI]] secondary to [[coronary atherosclerosis]]. | Because the anginal discomfort usually occurs at rest without a precipitating cause, it may simulate [[UA]]/[[NSTEMI]] secondary to [[coronary atherosclerosis]]. | ||
==Mechanism== | ==Mechanism== | ||
*The precise mechanisms have not been established, but a systemic alteration in [[nitric oxide]] production or an imbalance between endothelium-derived relaxing and contracting factors may | *The precise mechanisms have not been established, but a systemic alteration in [[nitric oxide]] production or an imbalance between endothelium-derived relaxing and contracting factors may be causative. | ||
*Enhanced phospholipase C (PLC) activity has also been documented. | *Enhanced phospholipase C (PLC) activity has also been documented. | ||
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*Typically, [[NTG]] is extremely effective in relieving the spasm. | *Typically, [[NTG]] is extremely effective in relieving the spasm. | ||
*In variant angina, the spasm can be superimposed on severe or | *In variant angina, the spasm can be superimposed on severe or non-severe coronary stenosis or supervene in an angiographically normal coronary artery segment. Hence, [[coronary angiography]] is usually part of the workup of these patients and can help guide the treatment. | ||
*Provocative tests can be used to precipitate coronary artery spasm when the diagnosis is suspected but not objectively documented. | *Provocative tests can be used to precipitate coronary artery spasm when the diagnosis is suspected but not objectively documented. | ||
:*[[Nitrates]] and [[calcium channel blockers]] should be withdrawn well before provocative testing. These tests are more often used during [[coronary angiography]]. | :*[[Nitrates]] and [[calcium channel blockers]] should be withdrawn well before provocative testing. These tests are more often used during [[coronary angiography]]. | ||
:*[[Acetylcholine]] and [[methacholine]] are now predominantly used for pharmacological provocative tests. | :*[[Acetylcholine]] and [[methacholine]] are now predominantly used for pharmacological provocative tests. | ||
:*Although the spasm is usually promptly relieved with NTG administered intracoronarily or intravenously, it may at times be refractory to therapy with NTG and can lead to [[MI]] and even death. For these reasons, provocative tests are now rarely used. | :*Although the spasm is usually promptly relieved with [[NTG]] administered intracoronarily or intravenously, it may at times be refractory to therapy with NTG and can lead to [[MI]] and even death. For these reasons, provocative tests are now rarely used. | ||
==Treatment== | ==Treatment== | ||
*Coronary spasm is usually very responsive to [[NTG]], longacting [[nitrates]], and [[calcium channel blockers]], which are considered first-line therapies. | *Coronary spasm is usually very responsive to [[NTG]], longacting [[nitrates]], and [[calcium channel blockers]], which are considered first-line therapies. | ||
*[[Calcium antagonists]] have proved extremely effective in preventing the coronary artery spasm of variant angina and they should ordinarily be prescribed in maximally tolerated doses on a long-term basis. Because nitrates and calcium channel blockers act through different mechanisms, they may have additive vasodilatory effect. | *[[Calcium antagonists]] have proved extremely effective in preventing the coronary artery spasm of variant angina and they should ordinarily be prescribed in maximally tolerated doses on a long-term basis. Because [[nitrates]] and [[calcium channel blockers]] act through different mechanisms, they may have additive vasodilatory effect. | ||
*[[Beta-blockers]] have theoretical adverse potential, and their clinical effect is controversial. | *[[Beta-blockers]] have theoretical adverse potential, and their clinical effect is controversial. | ||
*Alpha-receptor blockers have been reported to be of benefit. | *[[Alpha-receptor blockers]] have been reported to be of benefit. | ||
*[[Nicorandil]], a vasodilator that influences coronary arterial tone by acting through potassium channel activation, appears to be effective for the treatment of vasospastic angina. | *[[Nicorandil]], a vasodilator that influences coronary arterial tone by acting through potassium channel activation, appears to be effective for the treatment of vasospastic angina. | ||
*[[Aspirin]], helpful in [[unstable angina]], may theoretically increase the severity of ischemic episodes in patients with variant angina because it inhibits biosynthesis of the naturally occurring coronary vasodilator prostacyclin. | *[[Aspirin]], helpful in [[unstable angina]], may theoretically increase the severity of ischemic episodes in patients with variant angina because it inhibits biosynthesis of the naturally occurring coronary vasodilator [[prostacyclin]]. | ||
*[[Revascularization]] may be helpful in patients with variant angina and discrete, proximal fixed obstructive lesions. | *[[Revascularization]] may be helpful in patients with variant angina and discrete, proximal fixed obstructive lesions. | ||
*Patients who have experienced ischemia-associated [[ventricular fibrillation]] who continue to manifest ischemia despite maximal medical treatment should receive an implantable cardioverter-defibrillator. | *Patients who have experienced ischemia-associated [[ventricular fibrillation]] who continue to manifest ischemia despite maximal medical treatment should receive an implantable cardioverter-defibrillator. | ||
== | ==2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) <ref name=Guidelines> Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print) </ref>== | ||
===Medical Regimen and Use of Medications at Discharge=== | |||
{|class="wikitable" | {|class="wikitable" | ||
|- | |- | ||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"| | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.'''CCBs alone or in combination with long-acting nitrates are useful to treat and reduce the frequency of vasospastic angina.''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
<nowiki>"</nowiki>'''1.''' | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.'''Treatment with HMG-CoA reductase inhibitor, cessation of tobacco use, and additional atherosclerosis risk factor modification and are useful in patients with vasospastic angina. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.'''Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | |||
|- | |- | ||
| bgcolor=" | | bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Provocative testing during invasive coronary angiography†† may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
<nowiki>"</nowiki>''' | |||
|- | |- | ||
| bgcolor="LightGreen"| | |} | ||
<nowiki>"</nowiki>'''3.''' Treatment with [[nitrate]]s and [[calcium channel blocker]]s is recommended in patients with [[variant angina]] whose [[coronary angiogram]] shows no or [[non obstructive coronary artery lesions]]. Risk factor modification is recommended, with patients with atherosclerotic lesions considered to be at higher risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
==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 (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888 }} </ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>== | |||
===Variant (Prinzmetals) Angina (DO NOT EDIT)<ref name="pmid21444888">{{cite journal| author=Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE et al.| title=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. | journal=Circulation | year= 2011 | volume= 123 | issue= 18 | pages= e426-579 | pmid=21444888 | doi=10.1161/CIR.0b013e318212bb8b | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21444888 }} </ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine |journal=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Diagnostic investigation is indicated in patients with a clinical picture suggestive of coronary spasm, with investigation for the presence of [[transient myocardial ischemia]] and [[ST-segment elevation]] during [[chest pain]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' [[Coronary angiography]] is recommended in patients with episodic [[chest pain]] accompanied by transient [[ST segment elevation]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Treatment with [[nitrate]]s and [[calcium channel blocker]]s is recommended in patients with [[variant angina]] whose [[coronary angiogram]] shows no or [[non obstructive coronary artery lesions]]. Risk factor modification is recommended, with patients with atherosclerotic lesions considered to be at higher risk. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] | | colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] | ||
|- | |- | ||
|bgcolor="LightCoral"| | |bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Provocative testing is not recommended in patients with variant angina and high-grade obstructive stenosis on [[coronary angiography]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
<nowiki>"</nowiki>'''1.''' Provocative testing is not recommended in patients with variant angina and high-grade obstructive stenosis on [[coronary angiography]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|} | |} | ||
Line 71: | Line 94: | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"| | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Percutaneous coronary intervention]] may be considered in patients with [[chest pain]] and [[transient ST segment elevation]] and a significant [[coronary artery stenosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
<nowiki>"</nowiki>'''1.'''[[Percutaneous coronary intervention]] may be considered in patients with [[chest pain]] and [[transient ST segment elevation]] and a significant [[coronary artery stenosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |- | ||
|bgcolor="LemonChiffon"| | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Provocative testing may be considered in patients with no significant angiographic [[CAD]] and no documentation of [[transient ST segment elevation]] when clinically relevant symptoms possibly explained by coronary artery spasm are present. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | ||
<nowiki>"</nowiki>'''2.''' Provocative testing may be considered in patients with no significant angiographic [[CAD]] and no documentation of [[transient ST segment elevation]] when clinically relevant symptoms possibly explained by coronary artery spasm are present. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|} | |} | ||
==References== | ==References== | ||
{{ | {{Reflist|2}} | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Ischemic heart diseases]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Mature chapter]] | |||
[[Category:Up-To-Date]] | |||
[[Category:Up-To-Date cardiology]] | |||
[[Category:Best pages]] |
Latest revision as of 00:34, 30 July 2020
Resident Survival Guide |
Unstable angina / NSTEMI Microchapters |
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Unstable angina / non ST elevation myocardial infarction prinzmetal's angina On the Web |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Smita Kohli, M.D.
Synonyms and keywords: Prinzmetal's angina, variant angina, angina inversa
Overview
Prinzmetal's angina, also known as variant angina or angina inversa, is chest pain at rest that occurs in periodic cycles. It is unrelated to exertion although can occur with exertion. Prinzmetal's angina is caused by vasospasm, a narrowing of the coronary arteries caused by contraction of the smooth muscle tissue in the vessel walls rather than fixed narrowings of the coronary arteries due to atherosclerosis. Attacks can be precipitated by an emotional stress, hyperventilation, exercise, or exposure to cold. A circadian variation in the episodes of angina is most often present, with most attacks occurring in the early morning. It is characterized by transient ST-segment elevation that spontaneously resolves or resolves with nitroglycerin use without progression to MI. The majority of patients have normal exercise tolerance, and stress testing may be negative. Because the anginal discomfort usually occurs at rest without a precipitating cause, it may simulate UA/NSTEMI secondary to coronary atherosclerosis.
Mechanism
- The precise mechanisms have not been established, but a systemic alteration in nitric oxide production or an imbalance between endothelium-derived relaxing and contracting factors may be causative.
- Enhanced phospholipase C (PLC) activity has also been documented.
- An inflammatory etiology is supported by the finding of elevated levels of serum hs-CRP in these patients.
- Histological findings in patients undergoing coronary atherectomy suggest that repetitive coronary vasospasm may provoke vascular injury and lead to the formation of neointimal hyperplasia at the initial site of spasm, leading to rapid progression of coronary stenosis in some patients.
Diagnosis
- The key to the diagnosis of variant angina is the documentation of ST-segment elevation in a patient during transient chest discomfort and that resolves with the relief of chest discomfort.
- Continuous 12-lead ECG monitoring can be performed for this purpose in-hospital or as an outpatient.
- Typically, NTG is extremely effective in relieving the spasm.
- In variant angina, the spasm can be superimposed on severe or non-severe coronary stenosis or supervene in an angiographically normal coronary artery segment. Hence, coronary angiography is usually part of the workup of these patients and can help guide the treatment.
- Provocative tests can be used to precipitate coronary artery spasm when the diagnosis is suspected but not objectively documented.
- Nitrates and calcium channel blockers should be withdrawn well before provocative testing. These tests are more often used during coronary angiography.
- Acetylcholine and methacholine are now predominantly used for pharmacological provocative tests.
- Although the spasm is usually promptly relieved with NTG administered intracoronarily or intravenously, it may at times be refractory to therapy with NTG and can lead to MI and even death. For these reasons, provocative tests are now rarely used.
Treatment
- Coronary spasm is usually very responsive to NTG, longacting nitrates, and calcium channel blockers, which are considered first-line therapies.
- Calcium antagonists have proved extremely effective in preventing the coronary artery spasm of variant angina and they should ordinarily be prescribed in maximally tolerated doses on a long-term basis. Because nitrates and calcium channel blockers act through different mechanisms, they may have additive vasodilatory effect.
- Beta-blockers have theoretical adverse potential, and their clinical effect is controversial.
- Alpha-receptor blockers have been reported to be of benefit.
- Nicorandil, a vasodilator that influences coronary arterial tone by acting through potassium channel activation, appears to be effective for the treatment of vasospastic angina.
- Aspirin, helpful in unstable angina, may theoretically increase the severity of ischemic episodes in patients with variant angina because it inhibits biosynthesis of the naturally occurring coronary vasodilator prostacyclin.
- Revascularization may be helpful in patients with variant angina and discrete, proximal fixed obstructive lesions.
- Patients who have experienced ischemia-associated ventricular fibrillation who continue to manifest ischemia despite maximal medical treatment should receive an implantable cardioverter-defibrillator.
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [1]
Medical Regimen and Use of Medications at Discharge
Class I |
"1.CCBs alone or in combination with long-acting nitrates are useful to treat and reduce the frequency of vasospastic angina.(Level of Evidence: B)" |
"2.Treatment with HMG-CoA reductase inhibitor, cessation of tobacco use, and additional atherosclerosis risk factor modification and are useful in patients with vasospastic angina. (Level of Evidence: B)" |
"3.Coronary angiography (invasive or noninvasive) is recommended in patients with episodic chest pain accompanied by transient ST-elevation to rule out severe obstructive CAD. (Level of Evidence: C)" |
Class IIb |
"1. Provocative testing during invasive coronary angiography†† may be considered in patients with suspected vasospastic angina when clinical criteria and noninvasive testing fail to establish the diagnosis (Level of Evidence: B)" |
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 (DO NOT EDIT)[2][3]
Variant (Prinzmetals) Angina (DO NOT EDIT)[2][3]
Class I |
"1. Diagnostic investigation is indicated in patients with a clinical picture suggestive of coronary spasm, with investigation for the presence of transient myocardial ischemia and ST-segment elevation during chest pain. (Level of Evidence: A)" |
"2. Coronary angiography is recommended in patients with episodic chest pain accompanied by transient ST segment elevation. (Level of Evidence: B)" |
"3. Treatment with nitrates and calcium channel blockers is recommended in patients with variant angina whose coronary angiogram shows no or non obstructive coronary artery lesions. Risk factor modification is recommended, with patients with atherosclerotic lesions considered to be at higher risk. (Level of Evidence: B)" |
Class III |
"1. Provocative testing is not recommended in patients with variant angina and high-grade obstructive stenosis on coronary angiography. (Level of Evidence: B)" |
Class IIb |
"1. Percutaneous coronary intervention may be considered in patients with chest pain and transient ST segment elevation and a significant coronary artery stenosis. (Level of Evidence: B)" |
"2. Provocative testing may be considered in patients with no significant angiographic CAD and no documentation of transient ST segment elevation when clinically relevant symptoms possibly explained by coronary artery spasm are present. (Level of Evidence: C)" |
References
- ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 2.0 2.1 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE; et al. (2011). "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". Circulation. 123 (18): e426–579. doi:10.1161/CIR.0b013e318212bb8b. PMID 21444888.
- ↑ 3.0 3.1 Anderson JL, Adams CD, Antman EM; et al. (2007). "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/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". JACC. 50 (7): e1–e157. PMID 17692738. Text "doi:10.1016/j.jacc.2007.02.013 " ignored (help); Unknown parameter
|month=
ignored (help)
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- Pages with citations using unnamed parameters
- Pages with citations using unsupported parameters
- Ischemic heart diseases
- Intensive care medicine
- Disease
- Cardiology
- Emergency medicine
- Mature chapter
- Up-To-Date
- Up-To-Date cardiology
- Best pages