Unstable angina non ST elevation myocardial infarction natural history, complications and prognosis: Difference between revisions
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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:''' {{CZ}} | {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}; {{RT}} | ||
==Overview== | ==Overview== | ||
[[Unstable angina]] / [[NSTEMI]] are signs of | [[Unstable angina]]/[[NSTEMI]] are signs of severe [[heart disease]]. Natural history is [[Complication (medicine)|complicated]] by the development of [[arrhythmia]]s and [[heart failure]]. In a study it was shown that 14% of the cases of unstable angina can progress to an [[MI]]. [[Sudden death]] is an infrequent sequel of both unstable angina and NSTEMI. | ||
==Complications== | ==Natural History, Complications, and Prognosis== | ||
=== | ===Natural History=== | ||
=== | * [[Unstable angina]]/[[NSTEMI]] are signs of severe [[heart disease]]. | ||
(In | *[[Patient|Patients]] can present with a history of [[cardiopulmonary]] [[Symptom|symptoms]]. | ||
*14% of the cases of unstable angina progress to an [[ST elevation myocardial infarction|MI]]. | |||
* If left untreated, the natural course of the [[disease]] can be [[Complication (medicine)|complicated]] by [[arrhythmias]] and [[heart failure]]. | |||
*[[Sudden cardiac death|Sudden death]] is an infrequent sequel. | |||
===Complications=== | |||
====Unstable Angina==== | |||
* The [[incidence]] of [[Ischemia|ischemic]] [[Complication (medicine)|complications]] and the risk of death in unstable angina pectoris is lower than that in [[Patient|patients]] with either [[non ST elevation myocardial infarction]] ([[NSTEMI]]) or that in [[Patient|patients]] with [[ST segment elevation myocardial infarction]] ([[STEMI]]) but higher than that in patients with [[chronic stable angina]] pectoris. | |||
* Unstable angina can lead to: | |||
:*[[Cardiac arrhythmia]]s | |||
::*[[Ventricular tachycardia]] | |||
:*[[Congestive heart failure]] | |||
:*[[Hypotension]] | |||
:* New [[mitral regurgitation]] | |||
:*[[MI]] is one of the most common [[Complication (medicine)|complication]] ([[incidence]] is greatest within the first 6 - 8 weeks after admission). | |||
:*[[Sudden death]] is an infrequent complication and results from [[Cardiac arrhythmia|arrhythmias]] and [[ST elevation myocardial infarction|MI]]. | |||
====List of Factors Affecting the Development and Complications of NSTEMI (In Alphabetical Order)==== | |||
* Blood lipid levels | * Blood lipid levels | ||
* [[Catecholamine]] levels ([[smoking]], [[cocaine]], [[stress]]) | * [[Catecholamine]] levels ([[smoking]], [[cocaine]], [[stress]]) | ||
* Degree of coronary vasoconstriction | * Degree of [[coronary]] [[vasoconstriction]] | ||
* Endothelial function | *[[Endothelium|Endothelial]] function | ||
* Extent of collaterals | * Extent of collaterals | ||
* Extent of [[plaque rupture]] or erosion | * Extent of [[plaque rupture]] or erosion | ||
* Inflammatory substrate | *[[Inflammation|Inflammatory]] substrate | ||
* Location of the culprit coronary lesion | * Location of the culprit [[coronary]] [[lesion]] | ||
* [[Microembolization]] and microvascular obstruction | * [[Microembolization]] and microvascular obstruction | ||
* Stenosis morphology and severity | *[[Stenosis]] [[morphology]] and severity | ||
* Systemic factors | * Systemic factors | ||
:* Heart rate and [[blood pressure]] | :* [[Heart rate]] and [[blood pressure]] | ||
* Thrombotic factors | *[[Thrombosis|Thrombotic]] factors | ||
:* Blood viscosity | |||
:*[[Blood]] viscosity | |||
:* Intrinsic clotting activity | :* Intrinsic clotting activity | ||
:* [[Leukocyte]] activation | :* [[Leukocyte]] activation | ||
:* Level of [[fibrinolytic]] activity | :* Level of [[fibrinolytic]] activity | ||
:* Plaque tissue factor levels | :*[[Plaque]] [[tissue factor]] levels | ||
:* Platelet aggregability and reactivity | :*[[Platelet]] aggregability and reactivity | ||
===Prognosis=== | |||
== | ==== Unstable Angina ==== | ||
* In unstable angina [[Adverse event|adverse events]] tend to occur early after admission and can be predicted by clinical and [[The electrocardiogram|EKG]] characteristics. | |||
* The greater the magnitude and duration of [[The electrocardiogram|EKG]] changes, the poorer the [[prognosis]]. | |||
*[[ST depression]] on [[The electrocardiogram|EKG]] at admission and the presence of transient [[ischemia]] predicting an increased risk of [[ST elevation myocardial infarction|MI]] and subsequent death whereas normal [[The electrocardiogram|EKG]] patterns are associated with a good outcome. | |||
*1 year [[ST elevation myocardial infarction|MI]] or death rate in [[Patient|patients]] with new [[ST interval|ST]] deviation (more than 1 mm from baseline) has been shown to be 11% compared to 6.8% in [[Patient|patients]] with isolated [[T-wave inversion]]. | |||
*The most powerful predictors of [[MI]] and [[death]] include history of [[hypertension]] and presence of transient [[ischemia]]. | |||
*Persistence of [[pain]] is also associated with an unfavorable outcome. | |||
*Significant determinants of poor outcome include: | |||
**[[Congestive heart failure]] | |||
**[[Hypotension]] | |||
** New or worsening [[mitral regurgitation]] | |||
** Sustained [[Ventricular tachycardia]] | |||
** Poor [[ejection fraction]] - underlying [[LV dysfunction]] | |||
** Refractory [[angina]] | |||
** Extensive [[coronary artery disease]] | |||
== | ====Prognosis in NSTEMI ==== | ||
* Cardiac [[troponin I]] is a very sensitive marker of degree of [[Myocardium|myocardial]] damage and provides a [[Prognosis|prognostic]] value in [[Patient|patients]] with NSTEMI. | |||
* | |||
* Elevated [[BNP]] concentration is associated with an increased risk of mortality and [[congestive heart failure]] among [[Patient|patients]] with NSTEMI.<ref name="pmid12706919">{{cite journal| author=Morrow DA, de Lemos JA, Sabatine MS, Murphy SA, Demopoulos LA, DiBattiste PM et al.| title=Evaluation of B-type natriuretic peptide for risk assessment in unstable angina/non-ST-elevation myocardial infarction: B-type natriuretic peptide and prognosis in TACTICS-TIMI 18. | journal=J Am Coll Cardiol | year= 2003 | volume= 41 | issue= 8 | pages= 1264-72 | pmid=12706919 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12706919 }} </ref> | |||
* In case of NSTEMI treated non-invasively, elevated levels of high sensitivity troponin T, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) are independently associated with an increased risk of [[myocardial infarction]], [[stroke]], and [[cardiovascular]] death. | |||
*In contrast, among [[Patient|patients]] with NSTEMI treated invasively, elevated levels of only NT-proBNP and GDF-15 have been associated with an increased risk of subsequent [[myocardial infarction]], [[stroke]], and cardiovascular death.<ref name="pmid24170388">{{cite journal| author=Wallentin L, Lindholm D, Siegbahn A, Wernroth L, Becker RC, Cannon CP et al.| title=Biomarkers in Relation to the Effects of Ticagrelor in Comparison With Clopidogrel in Non-ST-Elevation Acute Coronary Syndrome Patients Managed With or Without In-Hospital Revascularization: A Substudy From the Prospective Randomized Platelet Inhibition and Patient Outcomes (PLATO) Trial. | journal=Circulation | year= 2014 | volume= 129 | issue= 3 | pages= 293-303 | pmid=24170388 | doi=10.1161/CIRCULATIONAHA.113.004420 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24170388 }} </ref> | |||
====Prediction Rules==== | |||
* https://www.mdcalc.com/grace-acs-risk-mortality-calculator | |||
* https://www.mdcalc.com/timi-risk-score-ua-nstemi | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Ischemic heart diseases]] | |||
[[Category:Intensive care medicine]] | |||
[[Category:Disease]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category: | [[Category:Mature chapter]] | ||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
[[Category:Up-To-Date cardiology]] | [[Category:Up-To-Date cardiology]] | ||
[[Category: | [[Category:Best pages]] | ||
Latest revision as of 21:07, 5 December 2022
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Resident Survival Guide |
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Unstable angina / NSTEMI Microchapters |
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Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
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Special Groups |
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Diagnosis |
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Laboratory Findings |
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Treatment |
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Antitplatelet Therapy |
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Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
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Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
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Mechanical Reperfusion |
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Discharge Care |
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Case Studies |
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Unstable angina non ST elevation myocardial infarction natural history, complications and prognosis On the Web |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Raviteja Guddeti, M.B.B.S. [3]
Overview
Unstable angina/NSTEMI are signs of severe heart disease. Natural history is complicated by the development of arrhythmias and heart failure. In a study it was shown that 14% of the cases of unstable angina can progress to an MI. Sudden death is an infrequent sequel of both unstable angina and NSTEMI.
Natural History, Complications, and Prognosis
Natural History
- Unstable angina/NSTEMI are signs of severe heart disease.
- Patients can present with a history of cardiopulmonary symptoms.
- 14% of the cases of unstable angina progress to an MI.
- If left untreated, the natural course of the disease can be complicated by arrhythmias and heart failure.
- Sudden death is an infrequent sequel.
Complications
Unstable Angina
- The incidence of ischemic complications and the risk of death in unstable angina pectoris is lower than that in patients with either non ST elevation myocardial infarction (NSTEMI) or that in patients with ST segment elevation myocardial infarction (STEMI) but higher than that in patients with chronic stable angina pectoris.
- Unstable angina can lead to:
-
- Congestive heart failure
- Hypotension
- New mitral regurgitation
- MI is one of the most common complication (incidence is greatest within the first 6 - 8 weeks after admission).
- Sudden death is an infrequent complication and results from arrhythmias and MI.
List of Factors Affecting the Development and Complications of NSTEMI (In Alphabetical Order)
- Blood lipid levels
- Catecholamine levels (smoking, cocaine, stress)
- Degree of coronary vasoconstriction
- Endothelial function
- Extent of collaterals
- Extent of plaque rupture or erosion
- Inflammatory substrate
- Location of the culprit coronary lesion
- Microembolization and microvascular obstruction
- Stenosis morphology and severity
- Systemic factors
- Thrombotic factors
- Blood viscosity
- Intrinsic clotting activity
- Leukocyte activation
- Level of fibrinolytic activity
- Plaque tissue factor levels
- Platelet aggregability and reactivity
Prognosis
Unstable Angina
- In unstable angina adverse events tend to occur early after admission and can be predicted by clinical and EKG characteristics.
- The greater the magnitude and duration of EKG changes, the poorer the prognosis.
- ST depression on EKG at admission and the presence of transient ischemia predicting an increased risk of MI and subsequent death whereas normal EKG patterns are associated with a good outcome.
- 1 year MI or death rate in patients with new ST deviation (more than 1 mm from baseline) has been shown to be 11% compared to 6.8% in patients with isolated T-wave inversion.
- The most powerful predictors of MI and death include history of hypertension and presence of transient ischemia.
- Persistence of pain is also associated with an unfavorable outcome.
- Significant determinants of poor outcome include:
- Congestive heart failure
- Hypotension
- New or worsening mitral regurgitation
- Sustained Ventricular tachycardia
- Poor ejection fraction - underlying LV dysfunction
- Refractory angina
- Extensive coronary artery disease
Prognosis in NSTEMI
- Cardiac troponin I is a very sensitive marker of degree of myocardial damage and provides a prognostic value in patients with NSTEMI.
- Elevated BNP concentration is associated with an increased risk of mortality and congestive heart failure among patients with NSTEMI.[1]
- In case of NSTEMI treated non-invasively, elevated levels of high sensitivity troponin T, N-terminal pro-brain natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) are independently associated with an increased risk of myocardial infarction, stroke, and cardiovascular death.
- In contrast, among patients with NSTEMI treated invasively, elevated levels of only NT-proBNP and GDF-15 have been associated with an increased risk of subsequent myocardial infarction, stroke, and cardiovascular death.[2]
Prediction Rules
- https://www.mdcalc.com/grace-acs-risk-mortality-calculator
- https://www.mdcalc.com/timi-risk-score-ua-nstemi
References
- ↑ Morrow DA, de Lemos JA, Sabatine MS, Murphy SA, Demopoulos LA, DiBattiste PM; et al. (2003). "Evaluation of B-type natriuretic peptide for risk assessment in unstable angina/non-ST-elevation myocardial infarction: B-type natriuretic peptide and prognosis in TACTICS-TIMI 18". J Am Coll Cardiol. 41 (8): 1264–72. PMID 12706919.
- ↑ Wallentin L, Lindholm D, Siegbahn A, Wernroth L, Becker RC, Cannon CP; et al. (2014). "Biomarkers in Relation to the Effects of Ticagrelor in Comparison With Clopidogrel in Non-ST-Elevation Acute Coronary Syndrome Patients Managed With or Without In-Hospital Revascularization: A Substudy From the Prospective Randomized Platelet Inhibition and Patient Outcomes (PLATO) Trial". Circulation. 129 (3): 293–303. doi:10.1161/CIRCULATIONAHA.113.004420. PMID 24170388.