Cardiovascular Medicine Book

Circulatory Disorders

Electrocardiogram

Myocardial Infarction

Symptoms

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Unstable Angina PrognosisAka: Unstable Angina Risk

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  1. See Also
    1. Unstable Angina
  2. Indications: Assess risk Unstable Angina adverse event
    1. Risk of Myocardial Infarction or sudden death
    2. Occurs in near future in patient with Unstable Angina
    3. Directs Non-diagnostic Electrocadiogram Protocol
  3. High risk
    1. Ongoing rest Chest Pain >20 minutes
    2. Age over 75 years
    3. Clearly elevated Cardiac Markers (e.g. Troponin I)
    4. New signs of Congestive Heart Failure
      1. Pulmonary edema related to suspected ischemia
      2. New or worsening Mitral Regurgitation murmur
      3. S3 Gallop
      4. New or worsening pulmonary rales
      5. Hypotension
    5. EKG changes
      1. New ST segment deviation >0.5 mV with symptoms
      2. New Left Bundle Branch Block
      3. Sustained Ventricular Tachycardia
  4. Intermediate risk (absence of above high risk features)
    1. Age over 65 years
    2. No high probability ACS physical findings
    3. Equivocal elevation of Serum Cardiac Markers
    4. Known vascular disease
      1. Prior Myocardial Infarction
      2. Known Coronary Artery Disease
      3. Prior Cerebrovascular Accident
    5. Rest Angina
      1. Lasted >20 minutes but now resolved
      2. Lasted <20 minutes and relieved with Nitroglycerin
      3. Nocturnal Angina
    6. Electrocardiogram
      1. Angina with T-wave inversion >0.2 mV
      2. Pathologic Q waves
      3. Rest ST depression <1 mm in multiple leads
  5. Low risk (absence of above high/moderate risk features)
    1. New onset class 1-3 Angina in last 2 weeks <20 minutes
    2. Normal cardiovascular exam
    3. Normal Electrocardiogram
    4. No increase in Serum Cardiac Markers
  6. Interpretation (see Non-diagnostic EKG Protocol)
    1. High Risk by above probability of adverse event
      1. See Immediate MI Management
      2. See Myocardial Ischemia Protocol
    2. Intermediate risk by above probability of adverse event
      1. See Non-diagnostic Electrocardiogram Protocol
      2. Requires risk stratification before discharge
        1. Serial Troponin I for six hours
        2. Exercise Stress Test
    3. Low risk by above probability of adverse event
      1. See Non-diagnostic Electrocardiogram Protocol
      2. May discharge to home from emergency department
      3. Outpatient stress test within 72 hours
      4. Discuss coronary warning signs
      5. Close interval follow-up
  7. References
    1. Braunwald (1994) AHCPR Publication 94-0602

Unstable angina (C0002965)

Definition (MSH)Precordial pain at rest, which may precede a MYOCARDIAL INFARCTION.
Definition (NCI)Angina pectoris (or equivalent type of ischemic discomfort) which has recently changed in frequency, duration, intensity, or occurs at rest.
Definition (NCI)Angina pectoris (or equivalent type of ischemic discomfort) with any 1 of the 3 following features: a) Angina occurring at rest and prolonged, usually greater than 20 minutes; b) New onset angina of at least Canadian Cardiovascular Society Grading Scale (or CCS classification system) classification severity III or greater; c) Recent acceleration in angina accentuated by an increase in severity of at least 1 CCS class to at least CCS class III. The biomarkers of necrosis are below the threshold of myocardial infarction.
ConceptsDisease or Syndrome (T047)
ICD9411.1, 411.1
MSHD000789
EnglishAngina at Rest, Anginal chest pain at rest, Crescendo angina, Impending infarction, INTERMED CORONARY SYND, Intermediate coronary syndrome, Preinfarction Angina, Preinfarction Anginas, Unstable angina, Unstable Angina Pectoris, Unstable Anginas, Worsening angina
Spanishangina de pecho de reposo, angina inestable, angina preinfarto, infarto inminente, sindrome coronario intermedio
Parent ConceptsOther acute and subacute ischemic heart disease NOS (C0340283), Angina Pectoris (C0002962), Acute ischemic heart disease (C1510446), Ambiguous concept (C1274012), Duplicate concept (C1274013)
SourcesDXP, ICD9CM, MSH, MTH, MTHICD9, NCI, NDFRT, QMR, SCTSPA, SNOMEDCT
Derived from the NIH UMLS (Unified Medical Language System)



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