Unstable angina/ NSTEMI resident survival guide: Difference between revisions

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::❑ Maintenance dose 0.15 mcg/kg/min </div>}}
::❑ Maintenance dose 0.15 mcg/kg/min </div>}}
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{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | A01 | | | | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Coronary artery bypass grafting ([[CABG|<span style="color:white;">CABG</span>]])'''<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed?term=15466654 | publisher =  | date =  | accessdate = }}</ref> <br>  It is usually preferred for: <br> ❑ Patients with left main or left main equivalent disease <br> ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction <br> ❑ Diabetic patients </div>}}
{{familytree |boxstyle=background: #FA8072; color: #F8F8FF; | A01 | | | | | |A01=<div style="float: left; text-align: left; width: 25em; padding:1em;"> '''Coronary artery bypass grafting ([[CABG|<span style="color:white;">CABG</span>]])'''<ref name="www.ncbi.nlm.nih.gov">{{Cite web  | last =  | first =  | title = ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed?term=15466654 | publisher =  | date =  | accessdate = }}</ref> <br>  It is considered in: <br> ❑ Patients with left main or left main equivalent disease <br> ❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction <br> ❑ Diabetic patients </div>}}
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Revision as of 17:47, 12 May 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]; Rim Halaby, M.D. [3]

Unstable angina/ NSTEMI Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Unstable angina is an unexpected chest pain that starts on minimal exertion, rest or sleep, lasts at least 20 minutes up to half an hour and is not relieved by medications or rest. Unstable angina and non ST elevation myocardial infarction (NSTEMI) belong to two different ends of the spectrum of acute coronary syndrome. Unstable angina is differentiated from NSTEMI by the absence of elevated cardiac biomarkers.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Unstable angina and NSTEMI are life-threatening conditions and must be treated as such irrespective of the causes.

Common Causes

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

Boxes in the red color signify that an urgent management is needed.

 
 
 
Identify cardinal findings of Unstable angina/ NSTEMI :

Chest pain or chest discomfort

❑ Sudden onset
❑ Sensation of heaviness, tightness, pressure, or squeezing
❑ Duration> 20 minutes
❑ Radiation to the left arm, jaw, neck, right arm, back or epigastrium
❑ No relief with medications
❑ No relief with rest
❑ Worse with time
❑ Worse with exertion
❑ Associated symptoms of palpitations, nausea, vomiting and sweating

Characteristic ECG changes consistent with unstable angina/ NSTEMI

❑ No changes
❑ Non specific ST / T wave changes
❑ Flipped or inverted T waves
❑ ST depression (carries the poorest prognosis)
Increase in troponin and / or CK MB
 
 
 
 
 
 
 
 
 
 
 
 
 
Rule out life threatening alternative diagnoses:

Aortic dissection
(suggestive findings: back pain, |interscapular pain, aortic regurgitation, pulsus paradoxus, blood pressure discrepancy between the arms)
Pulmonary embolism
(suggestive findings: acute onset of dyspnea, tachypnea, hemoptysis, previous DVT)
Cardiac tamponade
(suggestive findings: hypotension, jugular venous distention, muffled heart sounds, pulsus paradoxus)
Tension pneumothorax
(suggestive findings: sudden dyspnea, tachycardia, chest trauma, unilateral absence of breath sound)

Esophageal rupture
(suggestive findings: vomiting, subcutaneous emphysema)
 
 
 
 
 
 
 
 
 
 
 
 
Begin initial treatment:
❑ Administer 162 - 325 mg of non enteric aspirin
❑ Orally, crushed or chewed, OR
❑ Intravenously

❑ Administer 2-4 L/min oxygen via nasal cannula when saturation <90%

❑ Caution in COPD patients: maintain an oxygen saturation between 88% and 92%

❑ Administer beta-blockers (unless contraindicated) and titrate to the heart rate and blood pressure
Contraindicated in heart failure , prolonged or high degree AV block , reactive airway disease , high risk of cardiogenic shock and low cardiac output state

Metoprolol IV, 5 mg every 5 min, up to 3 doses
Carvedilol IV, 25 mg, two times a day

❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
Contraindicated in suspected right ventricular MI , recent use of phosphodiesterase inhibitors , decreased blood pressure 30 mmHg below baseline
❑ Administer IV morphine if needed

❑ Initial dose 4-8 mg
❑ 2-8 mg every 5 to 15 minutes, as needed

❑ Administer 80 mg atorvastatin
❑ Monitor with a 12-lead ECG all the time

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine if the patient has any of the following indications that require immediate angiography and revascularization:

❑ Hemodynamic instability or cardiogenic shock
❑ Severe left ventricular dysfunction or heart failure
❑ Recurrent or persistent rest angina despite intensive medical therapy
❑ New or worsening mitral regurgitation or new VSD
❑ Sustained VT or VF

❑ Prior PCI within past 6 months or CABG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to angiography
 
Low risk
Initial conservative strategy
 
High risk
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Administer ONE of the following antiplatelet agents (before or at the time of PCI):
P2Y12 receptor inhibitors

Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg

Prasugrel is contraindicated in case of prior history of strokes or TIAs, active pathological bleeding, age ≥75 years, when urgent coronary artery bypass graft surgery (CABG) is likely, body weight <60 kg, propensity to bleed, concomitant use of medications that increase the risk of bleeding
❑ IV GP IIb/IIIa inhibitors

Abciximab
❑ Loading dose 0.25 mg/kg IV bolus
❑ Maintenance dose 0.125 mg/kg/min
Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus
❑ Another 180 mcg/kg IV bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <50 mL/min
❑ Avoid in hemodialysis patients
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
❑ Decrease infusion by 50% if creatinine clearance <30 mL/min

Administer ONE of the following anticoagulant therapy:
Unfractionated heparin

If GP IIb/IIIa receptor antagonist is planned
❑ 50- to 70-U/kg IV bolus
If no GP IIb/IIIa receptor antagonist is planned
❑ 70- to 100-U/kg bolus

Bivalirudin

❑ 0.75-mg/kg IV bolus, then 1.75–mg/kg/h infusion
❑ Additional bolus of 0.3 mg/kg if needed
❑ Decrease infusion to 1 mg/kg/h when creatinine clearance <30 mL/min
 
Administer one of the following antiplatelet agents:

Clopidogrel

❑ Loading dose (300 mg)
❑ Maintenance dose for up to 12 months (75 mg)

Ticagrelor

❑ Loading dose (180 mg)
❑ Maintenance dose for up to 12 months (90 mg twice daily)
 
Administer one of the following antiplatelet agents:

Before PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min

At the time of PCI
P2Y12 receptor inhibitors

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

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
 
 
 
 
 
 
 
 
 
Coronary artery bypass grafting (CABG)[1]
It is considered in:
❑ Patients with left main or left main equivalent disease
❑ Patients with three or two vessel disease involving the left anterior descending artery with left ventricular dysfunction
❑ Diabetic patients
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2]

Characterize the symptoms:

Chest pain

❑ Sudden onset
❑ Sensation of tightness, pressure, or squeezing
❑ Absence of physical exertion
❑ Duration> 20 minutes
❑ Radiation to the jaw or left arm
❑ No relief with medications
❑ No relief with rest
❑ Worse with time

Dyspnea
Nausea
Vomiting

Sweating
 
 
 
 
 
Obtain a detailed history:

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

Hypertension
Diabetes
Hypercholesterolemia
Smoking
Obesity
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Auscultate the heart searching for murmurs
❑ Search for signs of CHF

❑ Decreased air entry in the lungs
❑ Edema in the extremities
 
 
 
 
 
Rule out life threatening alternative diagnoses:

Aortic dissection
Pulmonary embolism
Tension pneumothorax
Cardiac tamponade

Esophageal rupture
 
 
 
 
 
Order labs and tests:

EKG
❑ Biomarkers

❑ Troponin I
❑ CK-MB

Creatinine
Glucose

Hemoglobin

Treatment

Shown below is an algorithm summarizing the management of unstable angina and NSTEMI based on 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 162 - 325 mg of aspirin

❑ Administer oxygen when saturation <90%

❑ 2-4 L/min via nasal cannula

❑ Administer beta-blockers (unless contraindicated)

Metoprolol IV, 5 mg every 5 min, up to 3 doses
Carvedilol IV, 6,25 mg, two times a day (titrate to heart rate)

❑ Administer sublingual nitroglycerin 0.4 mg every 5 minutes for a total of 3 doses
❑ Administer IV morphine if needed

❑ Initial dose 2-4 mg
❑ 2-8 mg every 5 to 15 minutes, as needed

❑ Administer 80 mg atorvastatin
❑ Administer antithrombotic treatment

Fondaparinux, or
UFH in case of renal failure
❑ Monitor with a 12-lead EKG all the time
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the risk of adverse coronary event:

TIMI Score, or
HEART Risk Score, or

GRACE Risk Score
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low risk
Initial conservative strategy
 
 
 
 
 
High risk
Initial invasive strategy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer one of the following antiplatelet agents:

Clopidogrel

❑ Loading dose (300 mg)
❑ Maintenance dose for up to 12 months (75 mg)

Ticagrelor

❑ Loading dose (180 mg)
❑ Maintenance dose for up to 12 months (90 mg twice daily)
 
 
 
 
 

Administer one of the following antiplatelet agents:
Before PCI
P2Y12 receptor inhibitors

Clopidogrel (600 mg), or
Ticagrelor (180 mg), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min

At the time of PCI
P2Y12 receptor inhibitors

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

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent or worsening symptoms?
 
 
 
 
 
❑ Perform an angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Recurrence of symptoms
Heart failure
❑ Serious arrhythmia
❑ Subsequent ischemia
 
No recurrent symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an angiography

Administer upstream antiplatelet agent:
P2Y12 receptor inhibitors

Clopidogrel
❑ Loading dose (600 mg)
❑ Maintenance dose (75 mg), or
Ticagrelor
❑ Loading dose (180 mg)
❑ Maintenance dose (90 mg twice daily), or

❑ IV GP IIb/IIIa inhibitors

Eptifibatide
❑ Loading dose 180 mcg/kg IV bolus followed by another bolus after 10 minutes
❑ Maintenance dose 2 mcg/kg/min, or
Tirofiban
❑ Loading dose 25 mcg/kg
❑ Maintenance dose 0.15 mcg/kg/min
 
❑ Perform a stress test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low Risk
 
High Risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform an angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Continue aspirin for life
❑ Continue P2Y12 receptor inhibitors up to 12 months
Clopidogrel (75 mg once a day), or
Ticagrelor (90 mg twice a day)

❑ Discontinue GP IIb/IIIa inhibitors
❑ Continue antithrombotic therapy:

UFH for 48 hours, or
Enoxaparin for up to 8 days, or
Fondaparinux for up to 8 days
 
 
 
 
 
 


Management Following Angiography

 
 
 
 
 
Findings on Angiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
PCI
 
CABG
 
Medical treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess whether antiplatelet therapy is necessary
❑ Assess whether anticoagulation therapy is necessary
 
❑ Administer aspirin for life

❑ Administer a loading dose of P2Y12 receptor inhibitor (if not initially started)

Clopidogrel 600 mg
Ticagrelor 180 mg
Prasugrel 60 mg
❑ Discontinue anticoagulant in uncomplicated cases
 

❑ Continue aspirin
❑ Discontinue IV GP IIb/IIIa inhibitors (4 hours before CABG)
❑ Manage the P2Y12 receptor inhibitor therapy (if CABG can be delayed)

❑ Discontinue clopidogrel (5 days prior to CABG)
❑ Discontinue ticagrelor (5 days prior to CABG)
❑ Discontinue prasugrel (7 days prior to CABG)

❑ Manage the antithrombotic therapy

❑ Continue UFH
❑ Discontinue enoxaparin (12-24 hours prior to CABG)
❑ Discontinue fondaparinux (24 hours prior to CABG)
❑ Discontinue bivalirudin (3 hours prior to CABG)
 
❑ Continue aspirin

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

Clopidogrel (600 mg), or
Prasugrel (60 mg)

❑ Discontinue IV GP IIb/IIIa inhibitors if started
❑ Manage antithrombotic therapy if given before angiography:

❑ Continue IV UFH for 48 hours or until discharge
❑ Continue enoxaparin for entire hospital stay, up to 8 days
❑ Continue fondaparinux for entire hospital stay, up to 8 days
❑ Discontinue bivalirudin or continue, 0.25 mg/kg/hour for up to 72 hours
 
 
 

Thrombolysis in Myocardial Infarction (TIMI) Risk Score

Shown below is a table summarizing the TIMI scoring system. The risk of subsequent death, myocardial Infarction or need for revascularization within two weeks from the initial presentation is 4.7%, 8.3%, 13.2%, 19.9%, 26.2%, 40.9% for risk scores of 0-1, 2, 3, 4, 5, 6 and 7 respectively.[3]

Criteria Score
Adults 65 years and older 1
Previous coronary artery stenosis > 50%
  • Cardiac catherterization
  • Angioplasty or stent
  • Bypass
  • Myocardial infraction
1
Cardiac risk factors (three or more)
  • Hypertension
  • Diabetes
  • High cholesterol
  • MI in family history
  • Tobacco history
1
Use of aspirin the previous week 1
Anginal events (two or more) in the previous day 1
ST segment alteration (>1mm elevation or depression) 1
Cardio bio-markers elevated 1

HEART Risk Score[4]

Factors Degree Score
History Highly suspicious

Moderately suspicious


Slightly suspicious

2

1


0

EGC Significant ST depression

Non-specific repolarisation disturbance


Normal

2

1


0

Age >65 years

45-65 years


<45 years

2

1


0

Risk Factors > 3 risk factors or history of atherosclerotic disease

1 or 2 risk factors


No risk factors

2

1


0

Troponin >3x the normal limit

1-3x the normal limit


< the normal limit

2

1


0

TOTAL
























GRACE Risk Score[5]

Factor Categories Score
Age (years) <40

40-49


50-59


60-69


70-79


>80

0

18


36


55


73


91

Heart Rate (bpm) <70

70-89


90-109


110-149


150-199


>200

0

7


13


23


36


46

Systolic Blood Pressure (mmHg) <80

80-99


100-119


120-139


140-159


160-199


>200

63

58


47


37


26


11


0

Creatinine (mg/dL) 0-0.39

0.4-0.79


0.8-1.19


1.2-1.59


1.6-1.99


2-3.99


>4

2

5


8


11


14


23


31

Killip Class Class I

Class II


Class III


Class IV

0

21


43


64


Cardiac arrest at admission 43
Elevated Cardiac Bio-markers 15
ST-segment deviation 30















































Do's

  • Administer a loading dose followed by a maintenance dose of clopidogrel, ticagrelor or prasugrel (if PCI is planned) as initial treatment instead of aspirin among patients with gastrointestinal intolerance or hypersensitivity reaction to aspirin.

Don'ts

  • Do not administer IV GP IIb/IIIa inhibitors to patients with low risk of ischemic events or at high risk of bleeding and who are already on aspirin and P2Y12 receptor inhibitors therapy.
  • Do not administer IV beta-blockers among hemodynamically unstable patients.
  • Do not administer a complete dose of prasugrel among patients under 60kg (132lbs) due to high exposure to the active metabolite. They should receive half the dose of prasugrel although there is no evidence that half the dose is as effective as a complete dose.

References

  1. "ACC/AHA 2004 guideline update for coronary arter... [Circulation. 2004] - PubMed - NCBI".
  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. Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G; et al. (2000). "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making". JAMA. 284 (7): 835–42. PMID 10938172.
  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. de Araújo Gonçalves P, Ferreira J, Aguiar C, Seabra-Gomes R (2005). "TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS". Eur Heart J. 26 (9): 865–72. doi:10.1093/eurheartj/ehi187. PMID 15764619.
  6. 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.
  7. 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
  8. 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
  9. Anderson HV (1995). "Intravenous thrombolysis in refractory unstable angina pectoris". Lancet. 346 (8983): 1113–4. PMID 7475596.


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