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acute coronary syndrome; unstable angina (ACS)

- Chest pain of myocardial ischemia that occurs at rest, new onset of pain with exertion, or pain that has accelerated (more frequent, longer in duration, or lower in threshold). - Recurrent (especially early morning) angina within the 1st few weeks following myocardial infarction is also considered acute coronary syndrome (unstable angina). Etiology: 1) rupture or fissuring of atherosclerotic plaques (most common) 2) severe anemia 3) hypertension 4) heart failure 5) coronary vasospasm 6) Kawasaki disease in young persons - history of childhood mucocutaneous febrile illness [56] 7) non-cardiac surgery [41] - demand cardiac ischemia - stress-induced cardiomyopathy [41] 8) may occur after eating the elderly [57,58] Epidemiology: - 80% of patients hospitalized with acute coronary syndrome are >= 65 years of age [26] Pathology: 1) rupture or fissuring of atherosclerotic plaques results in a) thrombus formation b) increased platelet reactivity c) increased coronary vasomotor tone. 2) left ventricular dysfunction, pulmonary edema, transient mitral regurgitation, or hypotension during episodes of ischemia indicates extensive areas of myocardium at risk Clinical manifestations: 1) chest pain in about 2/3 of patients [11] - women present without chest pain more frequently than men 38& vs 27% [11] 2) dyspnea is most common presentations in women, diabetics & elderly 2) other features may be present a) congestive heart failure b) pulmonary edema, pulmonary crackles c) hypotension d) mitral regurgitation - papillary muscle dysfunction - S3, S4 gallop e) nausea/vomiting diaphoresis Laboratory: - markers of myocardial infarction - recheck in 2-3 hours - serum BNP may be elevated (see Differential diagnosis:) Special laboratory: - electrocardiogram: a) pre-hospital 12-lead EKG may improve outcomes [27] b) ST segment elevation or ST segment depression *H* > 1 mm in 2 contiguous leads c) new left bundle branch block *H* d) Q waves, old ST segment or T wave abnormalities *I* e) T-wave inversion > 2 mm *H* f) T wave inversion in leads with dominant R waves *L* g) deep, symmetric T-wave inversions in leads V2 & V3, accompanied by a flat ST segment, is suggestive of a critical stenosis of the proximal left anterior descending coronary artery (Wellens syndrome) [47] - echocardiogram may show regional wall abnormalities - routine cardiac stress testing is not recommended for asymptomatic patients after acute coronary syndrome who are not entering a cardiac rehabilitation program [3] - early noninvasive cardiac testing associated with slight decreases in myocardial infarction & death [50] *H*=high, *I*=intermediate, *L* low risk No advantage to routine early coronary angiography [9] Radiology: - CT angiography - can rule out acute coronary syndrome [13] - shortens hospital stay but increases subsequent testing & radiation exposure with no reduction in overall cost of care [17] - early CT angiography does not change 1 year outcome [53] Differential diagnosis: - see chest pain, chest pain syndrome - heart failure is usually associated with dyspnea, but not chest pain (see Laboratory:) - hypoglycemia unlikely to occur after eating in a patient with type 2 diabetes [57,58] Complications: 1) 10-20% risk of progression to acute myocardial infarction - higher risk for progression to acute MI is associated with - new onset of pain at rest - a sudden change in anginal pattern - labile ST-T changes on EKG - recurrent or persistent pain after initiation of therapy 2) women with low risk features may be at increase risk when treated with invasive strategy [3] 3) depression is a risk factor for poor outcomes [25] - SSRI escitalopram may lower cardiovascular risk in patients with depression after acute coronary syndrome [42] Management: 1) see initial management of acute coronary syndrome - ischemia-guided strategy based on TIMI score or GRACE score [3] - patients with stable angina with good exercise tolerance are low risk unless imaging demonstrates left main coronary artery disease or multivessel coronary artery disease [56] 2) see ST segment elevation acute coronary syndrome & non ST segment elevation acute coronary syndrome 3) general a) hospitalization b) bed rest, sedation c) correction of precipitating factors - hypertension - anemia - blood transfusion when Hct > 25% helpful [6] - hypoxia d) the TIMI risk score is used to predict risk of death or nonfatal MI in patients presenting with unstable angina or NSTEMI 4) goals of treatment a) aggressively relieve ischemic symptoms with anti-anginal drugs b) morphine for pain relief c) inhibit thrombosis in susceptible patients 5) oxygen: a) 2-4 liters/min by nasal cannula b) do not continue for more than 3 hours unless hypoxia is present 6) pharmacologic agents a) antiplatelet agents - aspirin 162-325 mg PO initially, then - P2Y12 receptor inhibitor (dual antiplatelet therapy or DAPT) - clopidogrel (Plavix) 75 mg PO QD, prasugrel, or ticagrelor [3] - clopidogrel noninferior to ticagrelor & with less bleeding [46,51] - use in combination with aspirin 81 mg QD [3] (DAPT) - low-dose rivaroxaban no better than aspirin [39] - addition of low-dose rivaroxaban to DAPT results in increased bleeding [39] - esomeprazole more effective than famotidine in preventing GI bleed [14] - unless CABG is likely - continue for 1 year [3] - all patients with unstable angina should receive aspirin plus P2Y12 receptor inhibitor (DAPT) for 1 year [3] - it is reasonable to continue DAPT for up to 36 months if reduced LVEF, saphenous vein grafting or diabetes mellitus & low risk of bleeding [3] - abciximab (ReoPro) - may be useful for unstable angina without persistent ST segment elevation [5] - unless CABG is likely (long 1/2 life) - ticagrelor (Brilinta) is more effective clopidogrel with similar bleeding risk [15,16] but more expensive - low-dose prasugrel as effective as standard dose ticagrelor [48] - prasugrel only in patients with PCI [3] b) unfractionated heparin or low-molecular-weight heparin at presentation [3] - except in obesity [3] - use unfractionated heparin if state G4 renal failure (NEJM) [56] - no benefit of heparin (NNT) [31]; NEJM knowledge+ says heparin of benefit [56] - rivaroxaban 5 mg PO BID may be alternative to LMW heparin [55] c) nitrates, except with suspected right ventricular MI [32] - not indicated unless ongoing chest pain (NEJM) [56] d) beta blockers (intravenous esmolol) [32] - contraindicated with cardiogenic shock or high-grade AV block - if contraindicated, use diltiazem or verapamil [3,32] - both beta-blockers & calcium channel blockers contraindication with acute heart failure, pulmonary edema e) calcium channel blocker if beta-blocker contraindication or failure of beta-blocker to control angina pectoris &/or hypertension [56] f) add ACE inhibitor for patients with an anterior wall MI, LV dysfunction, heart failure, or diabetes mellitus [32] - all patients [3] g) high-intensity statin [3] h) in patients with heart failure, use loop diuretic rather than thiazide diuretic i) spironolactone of uncertain value [3] j) anticoagulants increase risk of major bleeding that offset their antithrombotic benefit [18] 7) thrombolytic therapy (ST segment elevation) a) streptokinase b) tissue plasminogen activator (TPA) 8) revascularization may be superior to thrombolytic therapy a) immediate percutaneous coronary intervention (within 2 hours) - if transfer can be facilitated within 2 hours of hospital arrival [3] - benefits high-risk patients only - recurrent angina or myocardial ischemia - elevated troponin I (NSTEMI) - heart failure - new or worsening mitral regurgitation - sustained ventricular tachycardia - hemodynamic instability - STEMI, LBBB, posterior wall MI [3] - bivalirudin vs unfractionated heparin at the time of PCI roughly equivalent [34] b) early percutaneous coronary intervention (within 12-24 hours) - no high-risk features (above) - TIMI score >=3 - Grace score >= 141 (Grace 2.0 score) - rising troponin levels - new ST segment depression c) delayed percutaneous coronary intervention (within 72 hours) - TIMI score = 2 - Grace score = 109-140 (Grace 2.0 score) d) ischemia guided - TIMI score = 0-1 - Grace score < 108 (Grace 2.0 score) e) harm of routine PCI exceeds benefit [30] - no mortality benefit for PCI [30] - risk of MI higher with PCI than with medical management [30] - lower risk for death or MI with PCI at 5 years, but not at 15 years [38] f) diagnostic coronary angiography within 72 hours of hospitalization associated with lower short-term risk for adverse cardiac events [36] - editorialists not convinced [36] g) composite of myocardial infarction, stroke, death, & urgent revascularization less frequent with invasive strategy in octagenarians than with conservative approach (41% vs. 61%) [8] g) coronary angiography associated with reduced 1 year mortality in patients admitted with unstable angina (3.2% vs 8.0%) [40] - addition of revascularization did not affect mortality [40] 8) secondary prophylaxis a) HMG CoA reductase inhibitor (statin) - start within 24-96 hours [3] - more intensive LDL cholesterol lowering appears to be associated with better outcomes - see PROVE-IT, REVERSAL, GRACE studies - atorvastatin 80 mg [28] - no benefit to startin statin within 14 days [10] b) start chronic cardioselective beta-blocker within 3-21 days (atenolol, metoprolol) [3] - continue for 3 years [28] c) ACE inhibitor (ARB as an alternative) or if - systolic heart failure - diabetes mellitus - renal insufficiency [28] d) eplerenone (Inspra) for LV dysfunction after MI [3] e) P2Y12 receptor inhibitor - clopidogrel 75 mg plus aspirin 81 mg for 1 year with or without coronary stent [28] (least expensive) - continue aspirin 81 mg QD indefinitely [28] - low-dose prasugrel appears to be as safe & effective as standard-dose ticagrelor for elderly or low-weight patients with ACS [48] f) SSRI escitalopram may lower cardiovascular risk in patients with depression after acute coronary syndrome [42] g) no benefit of routine screening for depression [44] 10) follow-up - all patients should be referred for cardiac rehabilitation - postpone elective surgery for 12 months [3] Notes: - routine use of the Global Registries of Acute Coronary Events (GRACE) risk score may increase use of early invasive strategy but not other aspects of care [52]

Interactions

disease interactions

Related

Acute Coronary Syndrome (ACS) pretest probability assessment initial management of acute coronary syndrome TIMI risk score

Specific

non ST segment elevation acute coronary syndrome (NSTEACS) post myocardial infarction (MI) angina

General

angina pectoris myocardial ischemia

References

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