Unstable angina

Vignette says a 50 year old male presents to the emergency department with chief complaints of acute onset chest pain, that started 30 minutes ago; The pain is  sudden in onset, substernal, tight, and crushing in nature, severe in intensity with radiation to the left arm, jaw and neck; He also reports of shortness of breath, diaphoresis and vomiting;  He has a history of hypertension, diabetes mellitus and hyperlipidemia, but is not compliant with his medication; He is active smoker and drinks alcohol occasionally; The patient appears anxious; Vital signs show blood pressure of 130/90 mm of Hg, pulse rate of 98 bpm, respiratory rate of 18 breaths/min, oxygen saturation of 92% in RA and temperature of 97.9 F; ECG shows ST-segment depression in the anterior leads (V1-V4) and T-wave inversion; Cardiac troponins are negative; Echocardiography is normal; Diagnosis?

Diagnosis is Unstable angina.

Pathogenesis of unstable angina involves formation of nonocclusive thrombus over disrupted atherosclerotic plaques (MCC); Other mechanisms are coronary artery vasospasm, oxygen supply demand imbalance, and gradual narrowing of an epicardial coronary artery caused by progressive atherosclerosis or restenosis after stenting.

 

Presents with chest pain or heaviness or tightness with radiation to the left arm, jaw and neck, SOB, diaphoresis, nausea, vomiting.

 

Diagnosis:-

1. ECG shows ST depression and/or T-wave inversion.

2. Cardiac biomarkers (e.g. CK-MB, troponins) are negative.

3. Echocardiography is often normal in unstable angina.

4. Coronary angiography 

 

TIMI scores:-

1. Age > 65 years 

2. ≥ 3 risk factors for CAD 

3. Known stenosis > 50% % by prior angiography

4. ASA < 7 days 

5 ≥ 2 episodes of retrosternal chest pain within 24 hours

6. ST depression ≥ 0.5 mm 7) 

7. Elevated serum troponin or CK-MB

Early invasive strategy is deployed if the TIMI score ≥ 3; the patient is managed with urgent coronary revascularization. 

Conservative approach is deployed if the TIMI score is 0-1; the patient is managed with medical therapy.

 

Management:-

1. Oxygen supply to maintain saturation >90%. 

2. Anti ischemic therapy (e.g. nitrates, beta blockers, CCBs).

3. Anti platelet therapy (e.g. aspirin, P2Y12 inhibitors, GPIIb/IIIa inhibitors).

4. Anticoagulants therapy (e.g. UFH, LMWH).

5. Adjunctive therapy (e.g. statins, ACE inhibitors).

6. Percutaneous coronary intervention (PCI).

REMEMBER THROMBOLYTICS ARE CONTRAINDICATED IN UNSTABLE ANGINA.