Angina, Unstable
- Neagum Patel
- Roman Zeltser
- Mitchell FarrellBrian Froelke
- Frank SmeeksScott DulebohnErin HughesPritesh ShethMark PellegriniJames HughesRichard CiresiPhillip Hynes
- 10/27/2018 12:31:22 PM
Introduction
Unstable angina falls along a spectrum under the umbrella term acute coronary syndrome. This public health issue that daily affects a large portion of the population remains the leading cause of death worldwide. Distinguishing between this and other causes of chest pain that include stable angina is important regarding treatment and disposition of the patient. Providers should be aware of the signs and symptoms of acute coronary syndrome as patients rely on health care professionals to make the distinction from other causes of chest pain. Often patients will present to the emergency room. However, acute coronary syndrome can be seen in the outpatient setting as well. Over the years, a significant amount of research has gone into determining the appropriate and most effective treatment modalities, as well as the diagnostic tools available, in evaluating unstable angina and the other variants of acute coronary syndrome. [1],[2],[3]
Etiology
Coronary atherosclerotic disease is the underlying cause of unstable angina in nearly all patients with acute myocardial ischemia. The most common cause of unstable angina is due to coronary artery narrowing due to a thrombus that develops on a disrupted atherosclerotic plaque and is nonocclusive.
A less common cause is vasospasm of a coronary artery (variant Prinzmetal angina). Endothelial or vascular smooth dysfunction causes this vasospasm.[4]
Epidemiology
Coronary artery disease affects a large portion of the population. It is estimated that coronary artery disease causes more than a third of deaths in people over the age of 35. It is the leading cause of death in this particular age group. Roughly 18 million within the United States alone are estimated to be affected by this disease. The incidence is higher in men, but as individuals surpass the age of 75, the incidence of males and females becomes much closer. Other risk factors include obesity, diabetes, hypertension, high cholesterol, smoking history, cocaine or amphetamine abuse, family history, chronic kidney disease, HIV, autoimmune disorders, and anemia.[5]
Pathophysiology
Unstable angina deals with blood flow obstacles causing a lack of perfusion to the myocardium. Initial perfusion starts directly from the heart into the aorta and subsequently into the coronary arteries which supply their respective portions of the heart. The left coronary artery will divide into the circumflex and the left anterior descending artery. Subsequently, this will divide into much smaller branches. The right coronary will divide into smaller branches as well. Unstable angina results when the blood flow is impeded to the myocardium. Most commonly, this block can be from intraluminal plaque formation, intraluminal thrombosis, vasospasm, and elevated blood pressure. Often a combination of these is the provoking factor.
History and Physical
Patients will often present with chest pain, shortness of breath. The chest pain will often be described as pressure-like, although it is not necessarily limited to this description. Tightness, burning, sharp type of pain can be described. Often patients will report discomfort as opposed to actual pain. The pain will often radiate to the jaw or arms, both left and right sides can be affected. Constitutional symptoms such as nausea, vomiting, diaphoresis, dizziness, and palpitations may also be present. Exertion may worsen pain and rest can ease the pain. Nitroglycerin and aspirin administration may also improve the pain. One distinguishing factor of unstable angina is that the pain may not completely resolve with these reported relieving factors. Also, many patients will have already have coronary artery disease. This may be either established coronary artery disease or symptoms they have been experiencing for some time. These patients may have familiarity with the symptoms and may report an increase in episodes of chest pain that takes longer to resolve and an increase in the severity of symptoms. These symptoms indicate unstable angina as the more likely diagnosis, as opposed to stable angina or other causes of chest pain. This is important to note as these difference may indicate impending myocardial infarction, and ST-elevation myocardial infarction (STEMI) and should be evaluated expeditiously as the risk of morbidity and mortality are higher in this scenario versus stable angina. The exam will likely be normal, although the patient may be clutching at their chest, sweating, have labored breathing, their heart sounds may be tachycardic, and rales may be heard due to pulmonary edema.
Evaluation
When a patient presents, he or she should be evaluated quickly. The patient should have an ECG to evaluate for ischemic signs or possible STEMI. The ECG in unstable angina may show hyperacute T-wave, flattening of the T-waves, inverted T-waves, an ST depression. ST elevations indicate STEMI and these patients should be treated with percutaneous coronary intervention or thrombolytics while they wait on the availability of a catheterization lab. Any number of arrhythmias may be present in acute coronary syndrome including junctional rhythms, sinus tachycardia, ventricular tachycardia, ventricular fibrillation, left bundle branch block, and others. However, most commonly, the patient will be in sinus rhythm, especially in the scenario of unstable angina as opposed to infarcted tissue. The patient should also have lab work that includes a complete blood count evaluating for anemia, platelet count, and basic metabolic profile evaluating for electrolyte abnormalities. A troponin test should be performed to determine if any of the myocardium has infarcted. A pro-brain natriuretic peptide (Pro-BNP) can also be checked, as an elevated level is associated with higher mortality. Coagulation studies may be appropriate if the patient will be anticoagulated or anticoagulation is anticipated. Often, a chest x-ray will show the heart size and the size of the mediastinum so the physician may screen for dissection and other explanations of chest pain. It should be stated here that the history should be screened for other emergent causes of chest pain, shortness of breath, pulmonary embolism, aortic dissection, esophageal rupture, pneumonia, and pneumothorax. The patient should be kept on a cardiac monitor to evaluate for any rhythm changes. Further testing may include any number of cardiac stress tests (walking treadmill stress test, stress echocardiogram, myocardial perfusion imaging, cardiac CT/MRI, or the gold standard, cardiac catheterization). These are typically ordered and performed by inpatient providers and primary care providers, but with observation medicine growing, emergency medicine providers may order these. [6],[7]
Treatment / Management
The mainstay of treatment focuses on improving perfusion of the coronary arteries. This is done in several ways. Patients are often treated with aspirin for its antiplatelet therapies, 162 to 325 mg orally, or 300 mg rectally if the patient is unable to swallow. Nitroglycerin comes in several forms (intravenous, sublingual, transdermal, orally) and improves perfusion by vasodilation of the coronaries allowing improved flow and improved blood pressure. This will decrease the amount of work the heart has to perform, which decreases the energy demand of the heart. Supplemental oxygen should be given as well via nasal cannula to maintain appropriate oxygen saturation. These 3 actions are the quickest and most important functions to be performed in evaluating and treating for unstable angina. In patients with continued pain or longer recovery time, the patient's response should be evaluated because they are at much higher risk for myocardial infarction. Other potential therapies include anticoagulation with either low or high molecular weight heparin. Beta-blockers also can decrease the energy demand by decreasing blood pressure and heart rate. [1],[8],[9]
Prognosis
The key complications of unstable angina include:
- myocardial infarction (MI)
- Stroke
- Death
Evidence shows that patients with new-onset ST-segment elevation (more than 1 mm) have a 12-month rate of an MI or death of about 11%, compared to only 7% for patients who only have isolated inversion of the T wave.
Negative prognostic factors include:
- Low ejection fraction
- Ongoing congestive heart failure (CHF)
- New or worsening MR
- Hemodynamic instability
- Sustained VT
- Recurrent episodes of angina despite maximal therapy
Consultations
Once a patient has been diagnosed with unstable angina, a cardiologist and a cardiac surgeon should be consulted. The cardiologist will need to stratify the risk and help make a decision in management.
Deterrence and Patient Education
Prevention
The goals of prevention are to enable the patient to resume all daily living activities, preserve myocardial function and prevent future cardiac events. Today, most cardiac centers have specialized teams like cardiac rehab that offer intensive and more effective counseling.
Lifestyle
Smoking cessation is mandatory to prevent recurrent cardiac events. This applies to everyone in the household Lipid-lowering should try and obtain a target LDL-C level of 70 mg/dl or lower, an HDL level of at least 35 mg/dl, and a triglyceride level of less than 200 mg/dl.
The patient should exercise and eat a low-fat diet.
Control of Hypertension
The target blood pressure should be below 140/90 mm Hg, at the same time the patient should decrease the intake of sodium and alcohol
Diabetes Mellitus Management
Blood sugar levels may be decreased with diet, exercise or pharmacotherapy.
Weight Management and Nutritional Counseling
The patient should be encouraged to lose weight and achieve a body mass index (BMI) of 25 kg/m
Activity Management
Patients at risk for unstable angina should avoid intense physical activity, especially in cold weather.
Pearls and Other Issues
Legally, unstable angina and other variants of acute coronary syndrome constitute a large portion of cases brought against providers. Aggressive evaluations of chest pain, in general, have led to over-testing, high admission rates, and often false positives resulting in inappropriate testing. Over the years, several rules have been developed to limit inappropriate admissions and testing. Several of these have variable sensitivity and specificity. With the number of legal cases that are brought on, physicians are often still somewhat aggressive in the management and treatment of chest pain involving potential acute coronary syndrome.
Enhancing Healthcare Team Outcomes
Unstable angina is a very common disorder that is seen in the emergency room. There are many recommendations on the management of this serious cardiac disorder. Current recommendations are that this disorder should be managed by an interprofessional team that includes primary health care providers, nurse practitioners, physician assistants, pharmacists, cardiologists and emergency room physicians. In addition, a consult from a cardiac surgeon is highly recommended. Both the American College of Cardiology and American Heart Foundation have issued guidelines on the management of unstable angina[10] (Level V). Today most hospitals have healthcare teams that specialize in the management of unstable angina. The members of this team need to be familiar with the latest guidelines and support patients with education on the reduction of risk factors and the benefits of compliance with medications.
Outcomes
Ample evidence exists that quality improvement programs have the lowest morbidity and best outcomes.[11] (Level ll)
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Angina, Unstable - Questions
Take a quiz of the questions on this article.
Take Quiz
A 55-year-old male presents to the emergency department and points to his left fist, which is clenched over his chest. What is he most likely experiencing?
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A patient arrives in the emergency department complaining of "crushing" chest pain. Which of the following most likely will be prescribed?
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What should be the management plan for a elderly white male with history of hypertension and stable angina on aspirin, enalapril, nitrates, and atenolol who presents complaining of daily long episodes of severe chest pain for the past two days who is found to have normal vital signs, normal EKG, and normal cardiac enzymes?
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What drug can alleviate myocardial ischemic angina?
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A patient presents with multiple episodes of resting angina and ST-T wave depressions. He is hemodynamically stable and is started on the usual medical cocktail. What is the next step in the management of this patient?
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Why does a patient with unstable angina undergo cardiac catheterization?
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What type of angina is associated with resting chest pain?
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Which of the following is NOT a theorized cause of unstable angina?
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A 56-year-old male with a history chronic obstructive pulmonary disease on home oxygen, hypertension, and hyperlipidemia is brought to the emergency room with several episodes of chest pain each lasting about 30 minutes. His current medications include hydrochlorothiazide, home oxygen, lovastatin, albuterol, and aspirin. The pain is resolved after nitroglycerin sublingually twice and intravenous heparin. ECG shows 1 mm of ST depression in inferior leads. Troponin is negative. Nuclear medicine stress test shows reversible ischemia. Select the fact that is most indicative that the patient may have an MI, urgent revascularization, or sudden death in the next two weeks.
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A patient presents with unstable angina and negative cardiac enzymes. Select the best initial treatment.
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A 55 year old female with known coronary artery disease and stable angina presents with unstable angina not relieved by sublingual nitroglycerin. The patient is transported to the emergency department. Medications include a statin, a beta blocker, and aspirin. Exam shows heart rate of 115 bpm, blood pressure of 145/90 mmHg, and respiratory rate of 22. She has a new III/VI systolic murmur with radiation to the axilla and bilateral rales to midlung. ECG shows 3 mm of ST depression in II, III, and aVF. Select the treatment that is not indicated.
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A 75-year-old female presents with accelerating chest pain. She has a history of hypertension, diabetes mellitus, hyperlipidemia, renal insufficiency, and atrial fibrillation. Vital signs show temperature 37.8°C, heart rate 98 bpm, blood pressure 190/110, respirations 20, and oxygen saturation 91%. Laboratories show WBC 12.0, hematocrit 30%, BUN 90 mg/dL, and creatine 3.0 mg/dL. Select the contraindication for cardiac catheterization.
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A 65-year-old male presents with chest pain, shortness of breath, and new ST-segment ECG changes. What is the first step in management?
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In patients with unstable angina, which of the following is NOT a contraindication to beta-blocker therapy?
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In patients with unstable angina, which of the following is recommended in those with contraindications to beta-blockade?
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Which of the following would contraindicate using anti-ischemic medications to treat patients with unstable angina after hospital discharge?
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Which statement regarding women and unstable angina is true?
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A 78-year-old female patient is complaining of severe chest pain that does not resolve after two doses of nitroglycerin. She reveals her chest pain has always been relieved after two doses. What is the working diagnosis?
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A provider is in a patient's home when the patient develops acute severe chest pain with radiation to the left arm, shortness of breath, and diaphoresis. 911 is called, but while waiting, what drug(s), if available, should be given to the patient?
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Which does not describe coronary ischemia?
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What is the best enzyme assay to measure for unstable angina?
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What is increasing chest pain without exertion called?
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Angina, Unstable - References
References
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| Castini D,Centola M,Ferrante G,Cazzaniga S,Persampieri S,Lucreziotti S,Salerno-Uriarte D,Sponzilli C,Carugo S, Comparison of CRUSADE and ACUITY-HORIZONS Bleeding Risk Scores in Patients with Acute Coronary Syndromes. Heart, lung [PubMed] |
| Clark MG,Beavers C,Osborne J, Managing the acute coronary syndrome patient: Evidence based recommendations for anti-platelet therapy. Heart [PubMed] |
| Stamou SC,Camp SL,Stiegel RM,Reames MK,Skipper E,Watts LT,Nussbaum M,Robicsek F,Lobdell KW, Quality improvement program decreases mortality after cardiac surgery. The Journal of thoracic and cardiovascular surgery. 2008 Aug [PubMed] |
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