Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Unstable Angina Clinical Presentation

  • Author: Walter Tan, MD, MS; Chief Editor: Eric H Yang, MD  more...
 
Updated: Nov 22, 2015
 

History

Patients with unstable angina represent a heterogeneous population. Therefore, the clinician must obtain a focused history of the patient’s symptoms and coronary risk factors and immediately review the electrocardiogram (ECG) to develop an early risk stratification. (See Prognosis.)

Initially, obtain a history to determine whether any evidence of angina is present, then aim to identify whether it is stable or unstable.

Unstable angina differs from stable angina in that the discomfort is usually more intense and easily provoked, and ST-segment depression or elevation on ECG may occur. Otherwise, the manifestations of unstable angina are similar to those of other conditions of myocardial ischemia, such as chronic stable angina and myocardial infarction (MI).

Angina can take many forms, and inquiry should be directed at eliciting not only chest pain but also any associated discomfort and its frequency, location, radiation pattern, and precipitating and alleviating factors.

Ischemic pain can manifest as heaviness, tightness, aching, fullness, or burning of the chest, epigastrium, or arm or forearm (usually the left). These sensations less typically involve the lower jaw, neck, or shoulder. Important associated symptoms may be dyspnea, generalized fatigue, diaphoresis, nausea and vomiting, flulike symptoms, and, less commonly, lightheadedness or abdominal pain. The intensity of pain on a 1-10 scale does not correlate with diagnosis or prognosis.

Elderly and female patients are more likely to present with atypical signs and symptoms.

Next

Physical Examination

The physical examination is usually not as sensitive or specific for unstable angina as the history or diagnostic tests. An unremarkable physical examination is not uncommon. Perform a quick assessment of patients’ vital signs, and perform a cardiac examination. Specific diagnoses that must be explicitly considered are the following:

  • Aortic dissection
  • Leaking or ruptured thoracic aneurysm
  • Pericarditis with tamponade
  • Pulmonary embolism
  • Pneumothorax
  • Peptic ulcer disease

Increased autonomic activity may manifest as diaphoresis or tachycardia, and bradycardia may result from vagal stimulation from inferior wall myocardial ischemia.

A large area of myocardial jeopardy may manifest as signs of transient myocardial dysfunction and typically signifies a higher-risk situation. Such signs include the following:

  • Systolic blood pressure less than 100 mm Hg or overt hypotension
  • Elevated jugular venous pressure
  • Dyskinetic apex
  • Reverse splitting of the second heart sound
  • Presence of a third or fourth heart sound
  • New or worsening apical systolic murmur due to papillary muscle dysfunction
  • Rales or crackles

Findings indicative of peripheral arterial occlusive disease or prior stroke increase the likelihood of associated coronary artery disease (CAD) and are as follows:

  • Carotid bruit
  • Supraclavicular or femoral bruits
  • Diminished peripheral pulses or blood pressure

Any sign of congestive heart failure (CHF), including isolated sinus tachycardia, particularly in physiologically vulnerable populations (eg, very elderly patients), should trigger expeditious workup, treatment, or consultation with a cardiologist. Such patients can deteriorate rapidly.

The number and diversity of clinical conditions that cause the transient myocardial ischemia of unstable angina, along with its varying intensity and frequency of pain, have made classification within this disorder difficult.

Previous
Next

Braunwald Classification

The Braunwald classification (see Table 4 below) is conceptually useful, in that it factors in the clinical presentation (new or progressive vs rest angina), context (primary, secondary, or post-MI), and intensity of antianginal therapy.

Table 4. Braunwald Classification of Unstable Angina (Open Table in a new window)

Characteristic Class/Category Details
Severity I Symptoms with exertion
II Subacute symptoms at rest (2-30 days prior)
III Acute symptoms at rest (within prior 48 hr)
Clinical precipitating factor A Secondary
B Primary
C Postinfarction
Therapy during symptoms 1 No treatment
2 Usual angina therapy
3 Maximal therapy

Patients in Braunwald class I have new or accelerated exertional angina, whereas those in class II have subacute (>48 hours since last pain) or class III acute (< 48 hours since last pain) rest angina. The clinical circumstances associated with unstable angina are categorized as follows:

  • Secondary (anemia, fever, hypoxia)
  • Primary
  • Postinfarction (< 2 weeks after MI)

Intensity of antianginal therapy is subclassified as follows:

  • No treatment
  • Usual oral therapy
  • Intense therapy (eg, intravenous [IV] nitroglycerin)
Previous
Next

Canadian Cardiovascular Society Grading System

Because of its simplicity and practicality, the Canadian Cardiovascular Society Grading System for effort-related angina is widely used to describe symptom severity. The grading system is as follows:

  • Grade I – Angina with strenuous, rapid, or prolonged exertion; ordinary physical activity, such as climbing stairs, does not provoke angina
  • Grade II – Slight limitation of ordinary activity; angina occurs with postprandial, uphill, or rapid walking; when walking more than 2 blocks of level ground or climbing more than 1 flight of stairs; during emotional stress; or in the early hours after awakening
  • Grade III – Marked limitation of ordinary activity; angina occurs with walking 1-2 blocks or climbing a flight of stairs at a normal pace
  • Grade IV – Inability to carry on any physical activity without discomfort; rest pain occurs
Previous
Next

Acute Coronary Syndrome Risk Assessment

Estimation of the likelihood of acute coronary syndrome (ACS) is a complex, multivariable problem that cannot be fully specified in the list below, which is meant more to illustrate major relations than to offer rigid algorithms. A high likelihood of ACS includes any of the following features:

  • History of previous MI, sudden death, or other known history of CAD
  • Chest, neck, jaw, or left arm pain consistent with prior documented angina
  • Transient hemodynamic or ECG changes during pain
  • ST-segment elevation or depression of 1 mm or more
  • Marked symmetrical T-wave inversion in multiple precordial leads

An intermediate likelihood of ACS includes the absence of high-likelihood features but the presence of 1 of the following risk characteristics:

  • Age greater than 70 years
  • Male sex
  • Diabetes mellitus
  • Extracardiac vascular disease (peripheral, brachiocephalic, or renal artery atherosclerosis)
  • ST depression of 0.05-1 mm
  • T-wave inversion of 1 mm or greater in leads with dominant R waves

A low likelihood of ACS includes the absence of high- or intermediate-likelihood features and the presence of any of the following:

  • Chest pain classified as probably not angina
  • Chest discomfort reproduced by palpation
  • T-wave flattening or inversion of less than 1 mm in leads with dominant R waves
  • Normal ECG findings
Previous
Next

Thrombolysis in Myocardial Infarction Risk Score

The Thrombolysis in Myocardial Infarction (TIMI) Risk Score for unstable angina/non-ST elevation MI (UA/NSTEMI) is currently the best-validated prognostic instrument that is simple enough to use in settings such as an emergency department. The gradient of MI, severe recurrent ischemia, or death is somewhat proportionate to the TIMI Risk Score (see the image below), though an adverse prognosis appears to be mitigated by the use of newer antithrombotic strategies.

Thrombolysis in Myocardial Infarction (TIMI) Risk Thrombolysis in Myocardial Infarction (TIMI) Risk Score correlates with major adverse outcome and effect of therapy with low-molecular-weight heparin. ARD = absolute risk difference; ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; No. = number; NNT = number needed to treat.

The presence of any of the following variables constitutes 1 point, with the sum constituting the patient risk score on a scale of 0-7:

  • Age 65 years or older
  • Use of aspirin in the preceding 7 days
  • Known coronary stenosis of 50% or greater
  • Elevated serum cardiac markers
  • At least 3 risk factors for CAD (including diabetes mellitus, active smoking, family history of CAD, hypertension, or hypercholesterolemia)
  • Severe anginal symptoms (≥2 anginal events in the preceding 24 hours)
  • ST deviation on ECG
Previous
 
 
Contributor Information and Disclosures
Author

Walter Tan, MD, MS Associate Professor of Medicine, Wake Forest University School of Medicine; Director of Cardiac Cath Labs, Wake Forest Baptist Medical Center

Walter Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American Heart Association, American Stroke Association, National Stroke Association, Society for Vascular Medicine, Society of Interventional Radiology

Disclosure: Nothing to disclose.

Coauthor(s)

David J Moliterno, MD Professor of Medicine, Jefferson Morris Gill Professor of Cardiology, Chief, Division of Cardiovascular Medicine, University of Kentucky; Vice Chairman of Internal Medicine, Chandler Medical Center; Medical Director, Gill Heart Institute

David J Moliterno, MD is a member of the following medical societies: American College of Cardiology, European Society of Cardiology, Association of Professors of Cardiology, American College of Physicians, American Heart Association, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic Arizona

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Acknowledgements

Steven James Filby, MD Fellow in Interventional Cardiology, The Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Director of Cardiology Quality Program KMC, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School

Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Basra SS, Virani SS, Paniagua D, Kar B, Jneid H. Acute coronary syndromes: unstable angina and non-ST elevation myocardial infarction. Heart Fail Clin. 2016 Jan. 12 (1):31-48. [Medline].

  2. What are the symptoms of heart attack and unstable angina?. eMedicineHealth. May 8, 2013. Available at http://www.emedicinehealth.com/heart_attack_and_unstable_angina-health/page5_em.htm#Symptoms.. Accessed: May 9, 2013.

  3. Stone GW, Maehara A, Lansky AJ, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011 Jan 20. 364(3):226-35. [Medline].

  4. Harrap SB, Zammit KS, Wong ZY, et al. Genome-wide linkage analysis of the acute coronary syndrome suggests a locus on chromosome 2. Arterioscler Thromb Vasc Biol. 2002 May 1. 22(5):874-8. [Medline].

  5. Zhao YH, Xu Y, Gu YY, Li Y, Zhang JY, Su X. Functional effect of platelet membrane glycoprotein ia gene polymorphism in the pathogenesis of unstable angina pectoris. J Int Med Res. 2011. 39(2):541-8. [Medline].

  6. Fiotti N, Moretti ME, Bussani R, et al. Features of vulnerable plaques and clinical outcome of UA/NSTEMI: Relationship with matrix metalloproteinase functional polymorphisms. Atherosclerosis. 2011 Mar. 215(1):153-9. [Medline].

  7. White AJ, Duffy SJ, Walton AS, et al. Matrix metalloproteinase-3 and coronary remodelling: implications for unstable coronary disease. Cardiovasc Res. 2007 Sep 1. 75(4):813-20. [Medline].

  8. Manzoli A, Andreotti F, Varlotta C, et al. Allelic polymorphism of the interleukin-1 receptor antagonist gene in patients with acute or stable presentation of ischemic heart disease. Cardiologia. 1999 Sep. 44(9):825-30. [Medline].

  9. Tziakas DN, Chalikias GK, Antonoglou CO, et al. Apolipoprotein E genotype and circulating interleukin-10 levels in patients with stable and unstable coronary artery disease. J Am Coll Cardiol. 2006 Dec 19. 48(12):2471-81. [Medline].

  10. Willerson JT. Systemic and local inflammation in patients with unstable atherosclerotic plaques. Prog Cardiovasc Dis. 2002 May-Jun. 44(6):469-78. [Medline].

  11. Scirica BM, Moliterno DJ, Every NR, et al. Differences between men and women in the management of unstable angina pectoris (The GUARANTEE Registry). The GUARANTEE Investigators. Am J Cardiol. 1999 Nov 15. 84(10):1145-50. [Medline].

  12. Skolnick AH, Alexander KP, Chen AY, et al. Characteristics, management, and outcomes of 5,557 patients age > or =90 years with acute coronary syndromes: results from the CRUSADE Initiative. J Am Coll Cardiol. 2007 May 1. 49(17):1790-7. [Medline].

  13. Hoekstra JW, Pollack CV Jr, Roe MT, et al. Improving the care of patients with non-ST-elevation acute coronary syndromes in the emergency department: the CRUSADE initiative. Acad Emerg Med. 2002 Nov. 9(11):1146-55. [Medline].

  14. Effects of recombinant hirudin (lepirudin) compared with heparin on death, myocardial infarction, refractory angina, and revascularisation procedures in patients with acute myocardial ischaemia without ST elevation: a randomised trial. Organisation to Assess Strategies for Ischemic Syndromes (OASIS-2) Investigators. Lancet. 1999 Feb 6. 353(9151):429-38. [Medline].

  15. Luepker RV. WHO MONICA project: what have we learned and where to go from here?. Public Health Rev. 2012. Accessed: May 8, 2013. 33(2):373-96. [Full Text].

  16. GRACE, Global Registry of Acute Coronary Events. Available at http://www.outcomes-umassmed.org/grace/. Accessed: September 16, 2010.

  17. Cannon CP, McCabe CH, Stone PH, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol. 1997 Jul. 30(1):133-40. [Medline].

  18. Lupon J, Valle V, Marrugat J, et al. Six-month outcome in unstable angina patients without previous myocardial infarction according to the use of tertiary cardiologic resources. RESCATE Investigators. Recursos Empleados en el Síndrome Coronario Agudo y Tiempos de Espera. J Am Coll Cardiol. 1999 Dec. 34(7):1947-53. [Medline].

  19. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10. 361(11):1045-57. [Medline].

  20. Tanindi A, Erkan AF, Ekici B. Epicardial adipose tissue thickness can be used to predict major adverse cardiac events. Coron Artery Dis. 2015 Dec. 26 (8):686-91. [Medline].

  21. Karcz A, Holbrook J, Burke MC, et al. Massachusetts emergency medicine closed malpractice claims: 1988-1990. Ann Emerg Med. 1993 Mar. 22(3):553-9. [Medline].

  22. Li Z, Liu X, Wang J, et al. Analysis of urinary metabolomic profiling for unstable angina pectoris disease based on nuclear magnetic resonance spectroscopy. Mol Biosyst. 2015 Dec 10. 11 (12):3387-96. [Medline].

  23. Gurses KM, Kocyigit D, Yalcin MU, et al. Enhanced platelet toll-like receptor 2 and 4 expression in acute coronary syndrome and stable angina pectoris. Am J Cardiol. 2015 Dec 1. 116 (11):1666-71. [Medline].

  24. Meune C, Balmelli C, Twerenbold R, et al. Patients with acute coronary syndrome and normal high-sensitivity troponin. Am J Med. 2011 Dec. 124(12):1151-7. [Medline].

  25. Misra D, Leibowitz K, Gowda RM, Shapiro M, Khan IA. Role of N-acetylcysteine in prevention of contrast-induced nephropathy after cardiovascular procedures: a meta-analysis. Clin Cardiol. 2004 Nov. 27(11):607-10. [Medline].

  26. Than M, Cullen L, Reid CM, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. 2011 Mar 26. 377(9771):1077-84. [Medline].

  27. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012 Oct. 33(20):2551-67. [Medline]. [Full Text].

  28. Januzzi JL, Cannon CP, DiBattiste PM, Murphy S, Weintraub W, Braunwald E. Effects of renal insufficiency on early invasive management in patients with acute coronary syndromes (The TACTICS-TIMI 18 Trial). Am J Cardiol. 2002 Dec 1. 90(11):1246-9. [Medline].

  29. [Guideline] Acute coronary syndrome and myocardial infarction. EBM Guidelines. Evidence-Based Medicine [internet]. Helsinki, Finland: Wiley Interscience. John Wiley & Sons; 2011. [Full Text].

  30. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. Apr 1982. ;103(4 Pt 2):730-6. [Medline].

  31. Nisbet BC, Zlupko G. Repeat Wellens' syndrome: case report of critical proximal left anterior descending artery restenosis. J Emerg Med. 2010 Sep. 39(3):305-8. [Medline].

  32. Kwong RY, Chan AK, Brown KA, et al. Impact of unrecognized myocardial scar detected by cardiac magnetic resonance imaging on event-free survival in patients presenting with signs or symptoms of coronary artery disease. Circulation. 2006 Jun 13. 113(23):2733-43. [Medline].

  33. Kwong RY, Sattar H, Wu H, et al. Incidence and prognostic implication of unrecognized myocardial scar characterized by cardiac magnetic resonance in diabetic patients without clinical evidence of myocardial infarction. Circulation. 2008 Sep 2. 118(10):1011-20. [Medline]. [Full Text].

  34. Stratmann HG, Younis LT, Wittry MD, Amato M, Miller DD. Exercise technetium-99m myocardial tomography for the risk stratification of men with medically treated unstable angina pectoris. Am J Cardiol. 1995 Aug 1. 76(4):236-40. [Medline].

  35. Udelson JE, Spiegler EJ. Emergency department perfusion imaging for suspected coronary artery disease: the ERASE Chest Pain Trial. Md Med. 2001 Spring. Suppl:90-4. [Medline].

  36. [Guideline] Anderson JL, Adams CD, Antman EM, et al. 2012 ACCF/AHA focused update incorporated into the ACCF/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. J Am Coll Cardiol. 2013 Jun 11. 61(23):e179-347. [Medline].

  37. Busko M. New non-ST-elevation ACS guidelines: new title, new approach. Medscape Medical News from WebMD. September 29, 2014. Available at http://www.medscape.com/viewarticle/832513. Accessed: October 4, 2014.

  38. [Guideline] Amsterdam EA, Wenger NK, Brindis RG, 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. J Am Coll Cardiol. 2014 Dec 23. 64(24):e139-228. [Medline].

  39. [Guideline] Anderson JL, Adams CD, Antman EM, et al. 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 Interv... Circulation. 2007 Aug 14. 116(7):e148-304. [Medline].

  40. [Guideline] Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 May 10. 123(18):2022-60. [Medline].

  41. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001 Aug 16. 345(7):494-502. [Medline].

  42. Peters RJ, Mehta SR, Fox KA, et al. Effects of aspirin dose when used alone or in combination with clopidogrel in patients with acute coronary syndromes: observations from the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study. Circulation. 2003 Oct 7. 108(14):1682-7. [Medline].

  43. Steinhubl SR, Berger PB, Mann JT 3rd, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002 Nov 20. 288(19):2411-20. [Medline].

  44. Mega JL, Close SL, Wiviott SD, et al. Cytochrome p-450 polymorphisms and response to clopidogrel. N Engl J Med. 2009 Jan 22. 360(4):354-62. [Medline].

  45. Pare G, Mehta SR, Yusuf S, et al. Effects of CYP2C19 genotype on outcomes of clopidogrel treatment. N Engl J Med. 2010 Oct 28. 363(18):1704-14. [Medline].

  46. Park KW, Kim HS. Options to overcome clopidogrel response variability. Circ J. 2012. 76(2):287-92. [Medline].

  47. O'Connor FF, Shields DC, Fitzgerald A, Cannon CP, Braunwald E, Fitzgerald DJ. Genetic variation in glycoprotein IIb/IIIa (GPIIb/IIIa) as a determinant of the responses to an oral GPIIb/IIIa antagonist in patients with unstable coronary syndromes. Blood. 2001 Dec 1. 98(12):3256-60. [Medline].

  48. De Servi S, Goedicke J, Schirmer A, Widimsky P. Clinical outcomes for prasugrel versus clopidogrel in patients with unstable angina or non-ST-elevation myocardial infarction: an analysis from the TRITON-TIMI 38 trial. Eur Heart J Acute Cardiovasc Care. 2014 Dec. 3(4):363-72. [Medline].

  49. National Clinical Guideline Centre for Acute and Chronic Conditions. Unstable angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. London, UK: National Institute for Health and Clinical Excellence; 2010. [Full Text].

  50. Jneid H, Anderson JL, Wright RS, et al. 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. 2012 Aug 14. 60(7):645-81. [Medline].

  51. US FDA approves expanded indication for BRILINTA to include long-term use in patients with a history of heart attack [press release]. AstraZeneca. September 3, 2015. Available at http://www.astrazeneca.com/Media/Press-releases/Article/20150903. Accessed: September 9, 2015.

  52. Bonaca MP, Bhatt DL, Cohen M, et al, for the PEGASUS-TIMI 54 Steering Committee and Investigators. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015 May 7. 372 (19):1791-800. [Medline].

  53. Simoons ML. Effect of glycoprotein IIb/IIIa receptor blocker abciximab on outcome in patients with acute coronary syndromes without early coronary revascularisation: the GUSTO IV-ACS randomised trial. Lancet. 2001 Jun 16. 357(9272):1915-24. [Medline].

  54. Ibbotson T, McGavin JK, Goa KL. Abciximab: an updated review of its therapeutic use in patients with ischaemic heart disease undergoing percutaneous coronary revascularisation. Drugs. 2003. 63(11):1121-63. [Medline].

  55. Roffi M, Chew DP, Mukherjee D, et al. Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. Circulation. 2001 Dec 4. 104(23):2767-71. [Medline].

  56. Andrade-Castellanos CA, Colunga-Lozano LE, Delgado-Figueroa N, Magee K. Heparin versus placebo for non-ST elevation acute coronary syndromes. Cochrane Database Syst Rev. 2014 Jun 27. 6:CD003462. [Medline].

  57. Cohen M, Demers C, Gurfinkel EP, et al. Low-molecular-weight heparins in non-ST-segment elevation ischemia: the ESSENCE trial. Efficacy and safety of subcutaneous enoxaparin versus intravenous unfractionated heparin, in non-Q-wave coronary events. Am J Cardiol. 1998 Sep 10. 82(5B):19L-24L. [Medline].

  58. Ferguson JJ, Califf RM, Antman EM, et al. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA. 2004 Jul 7. 292(1):45-54. [Medline].

  59. Mehta SR, Granger CB, Eikelboom JW, et al. Efficacy and safety of fondaparinux versus enoxaparin in patients with acute coronary syndromes undergoing percutaneous coronary intervention: results from the OASIS-5 trial. J Am Coll Cardiol. 2007 Oct 30. 50(18):1742-51. [Medline].

  60. Theroux P, Waters D, Lam J, Juneau M, McCans J. Reactivation of unstable angina after the discontinuation of heparin. N Engl J Med. 1992 Jul 16. 327(3):141-5. [Medline].

  61. Direct thrombin inhibitors in acute coronary syndromes: principal results of a meta-analysis based on individual patients' data. Lancet. 2002 Jan 26. 359(9303):294-302. [Medline].

  62. Metz BK, White HD, Granger CB, et al. Randomized comparison of direct thrombin inhibition versus heparin in conjunction with fibrinolytic therapy for acute myocardial infarction: results from the GUSTO-IIb Trial. Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO-IIb) Investigators. J Am Coll Cardiol. 1998 Jun. 31(7):1493-8. [Medline].

  63. Maroo A, Lincoff AM. Bivalirudin in PCI: an overview of the REPLACE-2 trial. Semin Thromb Hemost. 2004 Jun. 30(3):329-36. [Medline].

  64. Stone GW, McLaurin BT, Cox DA, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006 Nov 23. 355(21):2203-16. [Medline].

  65. Schwartz GG, Olsson AG, Ezekowitz MD, et al. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA. 2001 Apr 4. 285(13):1711-8. [Medline].

  66. Murphy SA, Cannon CP, Wiviott SD, McCabe CH, Braunwald E. Reduction in recurrent cardiovascular events with intensive lipid-lowering statin therapy compared with moderate lipid-lowering statin therapy after acute coronary syndromes from the PROVE IT-TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis In Myocardial Infarction 22) trial. J Am Coll Cardiol. 2009 Dec 15. 54(25):2358-62. [Medline].

  67. US FDA. Safety: statin drugs - drug safety communication: class labeling change. US Food and Drug Administration. February 28, 2012. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm293670.htm. Accessed: June 5, 2013.

  68. US FDA. Safety: Zocor (simvastatin): label change - new restrictions, contraindications, and dose limitations. US Food and Drug Administration. June 8, 2011. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm258384.htm. Accessed: June 5, 2013.

  69. US FDA. Safety: Meridia (sibutramine): market withdrawal due to risk of serious cardiovascular events. US Food and Drug Administration. October 8, 2010. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm228830.htm. Accessed: June 5, 2013.

  70. Soukoulis V, Boden WE, Smith SC Jr, O'Gara PT. Nonantithrombotic medical options in acute coronary syndromes: old agents and new lines on the horizon. Circ Res. 2014 Jun 6. 114(12):1944-58. [Medline]. [Full Text].

  71. Anderson HV, Cannon CP, Stone PH, et al. One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction. J Am Coll Cardiol. 1995 Dec. 26(7):1643-50. [Medline].

  72. Boden WE, O'Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med. 1998 Jun 18. 338(25):1785-92. [Medline].

  73. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet. 1999 Aug 28. 354(9180):708-15. [Medline].

  74. Fox KA, Poole-Wilson PA, Henderson RA, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet. 2002 Sep 7. 360(9335):743-51. [Medline].

  75. Damman P, Hirsch A, Windhausen F, Tijssen JG, de Winter RJ. 5-year clinical outcomes in the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) trial a randomized comparison of an early invasive versus selective invasive management in patients with non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol. 2010 Mar 2. 55(9):858-64. [Medline].

  76. Neumann FJ, Kastrati A, Pogatsa-Murray G, et al. Evaluation of prolonged antithrombotic pretreatment ("cooling-off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA. 2003 Sep 24. 290(12):1593-9. [Medline].

  77. Wallentin L, Lagerqvist B, Husted S, Kontny F, Stale E, Swahn E. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during Instability in Coronary artery disease. Lancet. 2000 Jul 1. 356(9223):9-16. [Medline].

  78. [Guideline] American Diabetes Association. Standards of medical care in diabetes--2010. Diabetes Care. 2010 Jan. 33 Suppl 1:S11-61. [Medline]. [Full Text].

 
Previous
Next
 
Pathogenesis of acute coronary syndromes.
Thrombolysis in Myocardial Infarction (TIMI) Risk Score correlates with major adverse outcome and effect of therapy with low-molecular-weight heparin. ARD = absolute risk difference; ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; No. = number; NNT = number needed to treat.
Algorithm for initial invasive strategy. ASA = acetylsalicylic acid (aspirin); GP IIb/IIIa= glycoprotein IIb/IIIa; IV = intravenous; LOE = level of evidence; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction; UFH = unfractionated heparin. (Adapted from 2007 ACC/AHA UA/NSTEMI Guidelines.)
Algorithm for initial conservative strategy. ASA = acetylsalicylic acid (aspirin); EF = ejection fraction; GP IIb/IIIa= glycoprotein IIb/IIIa; IV = intravenous; LOE = level of evidence; LVEF = left ventricular ejection fraction; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction. (Adapted from 2007 ACC/AHA UA/NSTEMI Guidelines.)
Rate and timing of revascularization for patients with unstable angina using invasive versus conservative approach (FRagmin during InStability in Coronary artery disease [FRISC] II).
Time course of elevations of serum markers after acute myocardial infarction. CK = creatine kinase; CK-MB = creatine kinase MB fraction; LDH = lactate dehydrogenase.
Table 1. Patient Characteristics, GUARANTEE Versus CRUSADE Trials
Characteristics GUARANTEE, 1995-96 [11] CRUSADE, 2001-06 [12]
Mean age (y) 62 69
Patients >65 y (%) 44
Female (%) 39 40
Hypertension (%) 60 73
Diabetes mellitus (%) 26 33
Current smoker (%) 25
Hypercholesterolemia (%) 43 50
Previous stroke (%) 9
Previous MI (%) 36 30
Previous angina (%) 66
CHF (%) 14 18
Previous coronary intervention (%) 23 21
Previous coronary bypass surgery (%) 25 19
CHF = congestive heart failure; CRUSADE = Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines; GUARANTEE = Global Unstable Angina Registry and Treatment Evaluation; MI = myocardial infarction.
Table 2. Demographic Characteristics of Patients in International OASIS-2 Registry
Characteristics [14] Australia Brazil Canada Hungary Poland United States
General Number of patients 1899 1478 1626 931 1135 918
Mean age (y) 65 62 66 65 63 66
Women (%) 37 42 37 45 40 37
Clinical NQMI presentation (%) 7 7 14 22 17 16
Abnormal ECG (%) 74 91 82 95 97 87
Select treatments Beta blocker (%) 67 53 73 67 59 57
Calcium blocker (%) 59 51 53 52 43 59
Invasive procedures (index hospitalization) Cardiac catheterization (%) 24 69 43 20 7 58
PCI (%) 7 19 16 5 0.4 24
CABG (%) 4 20 10 7 0.4 17
CABG = coronary artery bypass grafting; ECG = electrocardiographic; NQMI = non-Q wave myocardial infarction; OASIS = Organization to Assess Strategies for Ischemic Syndromes; PCI = percutaneous coronary intervention.
Table 3. Thirty-Day Clinical Outcome in Patients With Acute Coronary Syndromes in Clinical Trials
Study Year Number of Patients Death (%) Myocardial Infarction (%) Major Bleed (%)
TIMI-3 1994 1,473 2.5 9.0 0.3
GUSTO-IIb 1997 8,011 3.8 6.0 1.0
ESSENCE 1998 3,171 3.3 4.5 1.1
PARAGON-A 1998 2,282 3.2 10.3 4.0
PRISM 1998 3,232 3.0 4.2 0.4
PRISM-PLUS 1998 1,915 4.4 8.1 1.1
PURSUIT 1998 10,948 3.6 12.9 2.1
TIMI-11B 1999 3,910 3.9 6.0 1.3
PARAGON-B 2000 5,225 3.1 9.3 1.1
Pooled 40,167 3.5 8.5 1.5
ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; GUSTO-IIb = Global Utilization of Streptokinase and TPA (tissue plasminogen activator) for Occluded Coronary Arteries; PARAGON-A = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PARAGON-B = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PRISM = Platelet Receptor Inhibition in Ischemic Syndrome Management; PRISM-PLUS = Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Angina Signs and Symptoms; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI-11B = Thrombolysis in Myocardial Infarction Clinical Trial 11B; TIMI-3 = Thrombolysis in Myocardial Infarction Clinical Trial 3.
Table 4. Braunwald Classification of Unstable Angina
Characteristic Class/Category Details
Severity I Symptoms with exertion
II Subacute symptoms at rest (2-30 days prior)
III Acute symptoms at rest (within prior 48 hr)
Clinical precipitating factor A Secondary
B Primary
C Postinfarction
Therapy during symptoms 1 No treatment
2 Usual angina therapy
3 Maximal therapy
Table 5. ACC/AHA Recommendations for Preferred Invasive Strategy
Preferred Strategy [39] Patient Characteristics
Invasive Recurrent angina/ischemia at rest or with low-level activities despite intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms of heart failure or new or worsening mitral regurgitation
High-risk findings on noninvasive stress testing
High-risk score (eg, TIMI, GRACE)
Reduced LV systolic function (LVEF < 40%)
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Previous CABG
Conservative Low-risk score (eg, TIMI, GRACE)
Patient or physician preference in the absence of high-risk features
ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass grafting; GRACE = Global Registry of Acute Coronary Events; LV = left ventricle; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis in Myocardial Infarction Clinical Trial; TnI = troponin I; TnT = troponin T.
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.