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Chest Pain &
Unstable Angina
Eugene Yevstratov MD
Based on UCLA protocol of the management of Chest Pain & Unstable Angina
Diagnostic criteria for acute
myocardial infarction
1 ST elevation > 1 mm in 2 or more
contiguous limb or precordial leads
2 Left bundle branch block, not known
to be old
3 ECG findings useful for establishing
the likelihood of coronary artery
disease:
ST segment depression > 1 mm
Inverted T-waves > 1 mm in two or more
contiguous leads
The major factors in the initial history
and physical exam that relate to the
likelihood of coronary artery disease
1 Chest pain assessment by physician
(definite angina, probable angina,
probably not angina)
2 Prior myocardial infarction or
documented coronary artery disease
• Number of risk factors (diabetes,
smoking, hypercholesterolemia,
hypertension, post menopausal)
4 Age
Likelihood of significant coronary
artery disease in patients with
symptoms suggesting unstable angina
Low Likelihood: (e.g., 0.01-0.14) Chest pain,
"probably not angina" in patients with one or no risk
factors, but not diabetes. T wave flat or inverted < 1
mm. Normal ECG.
Intermediate Likelihood: (e.g., 0.15-0.84) "Definite
angina" in patients with no risk factors for CAD.
High Likelihood: (e.g., 0.85-0.99) Known history of
prior MI or CAD. "Definite angina" in male > 60 or
females > 70. Transient hemodynamic or ECG
changes during pain. ST elevation or
depression of > 1 mm.
Marked symmetrical T wave inversion in multiple leads.
Risk Assessment
• Low risk: Nonresting angina with increased
frequency, severity, or duration. Angina
provoked at a lower threshold. New onset
angina 2 weeks to 2 months. Normal or
unchanged ECG.
• Intermediate risk: Rest angina now resolved.
Rest angina < 20 minutes in duration, angina
with dynamic T wave changes. New onset
angina < 2 weeks at minimal exertion. Age > 65
years. Q waves or ST depression on ECG.
• High risk: Ongoing rest pain > 20 minutes.
Angina with pulmonary edema, S3, or rales.
Angina with new or worsening mitral
regurgitation. Rest angina with dynamic ST
changes > 1 mm. Angina with hypotension.
The most important factors related
to short term and long term
survival in patients with acute
myocardial
infarction or unstable angina
1. Left ventricular function (LVEF)
2. Extent of coronary artery disease
3. Age
4. Co-morbid conditions
5. Unmodified coronary risk factors
The treatment of acute myocardial
infarction is detailed in the UCLA
Acute Myocardial Infarction Practice
1. Activate the CLOT team (CCU fellow)
2. All patients should receive regular ASA 325 mg as
soon as possible unless a definite
contraindication is present (evidence of ongoing
life-threatening hemorrhage or a clear history of
severe hypersensitivity to ASA).
Have patient chew the aspirin. All patients should
receive clopidogrel 300 mg dose in combination
with aspirin, unless contraindicated. If aspirin
allergic, use clopidigrel 300 mg loading dose
alone.
The treatment of acute myocardial
infarction is detailed in the UCLA
Acute Myocardial Infarction Practice
3. Patients in which acute pericarditis or aortic
dissection is not suspected, have no evidence
of major or lifethreatening hemorrhage, and no
significant predisposition to hemorrhage
should be given an intravenous bolus of
heparin
4. Patients without contraindications should be
treated with intravenous followed by oral beta
blockers (exclude cardiogenic shock,
hypotension, decompensated heart failure
prior to treatment)
The treatment of acute myocardial
infarction is detailed in the UCLA
Acute Myocardial Infarction
Practice
5. Patients with ongoing chest pain despite
SL NTG and beta blockers, with SBP > 90
mmHg should be started on an intravenous
nitroglycerine drip
6. The rapid initiation of therapy aimed
at reperfusion (direct catheterization or
thrombolytic therapy) should not be
delayed. Direct catheterization is the
preferred treatment strategy
Unstable Angina General Care
Monitoring: Patients should remain on
continuous ECG monitoring for ischemia
and arrhythmia detection.
Oxygen: Patients with obvious cyanosis,
respiratory distress, or high risk features
should receive supplemental oxygen. A
finger pulse oximeter check should be used
to confirm adequate oxygenation. If pulse
oximeter sat < 92% full assessment including
arterial blood gas determination should be
considered prior to initiating oxygen. Routine
use of oxygen in all patients is not indicated.
.
Unstable Angina General Care
Activity: Patients should be placed at
bed rest during the initial phase of
medical management.
Diet: Patients should remain NPO
except for meds until clinical stability
demonstrated and necessity/timing of
cardiac catheterization determined.
Initial Pharmacologic Treatment
• Antiplatelet Therapy:
• Intravenous Heparin or Low Molecular Weight
Heparin
• Beta blockers
• Glycoprotein IIb/IIIa Receptor Antagonists
• Nitroglycerin
• Morphine sulfate
• Calcium channel blockers
• Thrombolytic therapy
• Intra-aortic balloon counterpulsation
Laboratory Testing
• ECG initially, with ongoing or recurrent
symptoms, with relief of chest pain, and 6
hours after admission.
• CBC with platelets.
• PT (INR), PTT.
• Serum creatinine, glucose.
• Lipid panel on admission (nonfasting)
unless patient has had a recent
determination.
• Troponin I q6 x 2 and CK-MB should be
measured q8 hours x 3 (omit 2nd/3rd CKMB if 6 hour troponin is negative).
Diagnostic Algorithms
Diagnostic Algorithms
Chest Pain
Initial Therapy:
• ASA: all patients without
contraindications should be started on
ASA (consider clopidogrel)
• NTG SL: prescription and instructions
on the prn use should be given
• Appointment for stress testing within
72 hours
Treatment Stratification
Patients with coronary artery disease will live longer
when treated with a HMG CoA Reductase Inhibitor.
In the 4S trial there was a 34% risk reduction in
major cardiac events, a 42% risk reduction in
cardiovascular mortality and a 30% reduction in all
cause mortality associated with statin treatment.
The LIPID trial demonstrated that even patients with
"low or normal" levels of total cholesterol and LDL
cholesterol (LDL 70-170 mg/dl) have mortality
reduction with statin treatment. Patients should be
educated that these medications are for the
treatment of atherosclerosis, not because the
patient has “failed” dietary treatment and that use
of these medications lowers the risk of recurrent
events, need for hospitalizations, revascularization,
strokes, and mortality.
The HOPE trial demonstrated that
in patients with CAD, CVD, PVD or
diabetes the use of an ACE inhibitor
was associated with a reduction in
cardiovascular events, cardiovascular
mortality, and all cause mortality.
This benefit was seen in patients
without hypertension and with normal
left ventricular ejection fractions.
Eugene Yevstratov MD
Phone: 0054111540682712 (ARG)
Private: 0030372236344 /
0030372231698 (UKr)
Fax: 001 775 796 2780 (USA)
Email: [email protected]
[email protected]
Link: http://myprofile.cos.com/eugenefox