Unstable Angina

Aka: Unstable Angina

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II. Symptoms

  1. Ongoing Angina-type pain
    1. Despite decreasing level of exertion
    2. With increasing severity or frequency
    3. Rest pain in the last week
    4. Class 3 or 4 Chest Pain
    5. Pain following Myocardial Infarction (over 24 hours)
  2. Varying patterns of radiating pain
  3. History non-q wave Myocardial Infarction
  4. Atypical presentations are common over age 65 (50%)
    1. Atypical Chest Pain or arm, epigastric or Neck Pain
    2. Shortness of Breath
    3. Diaphoresis
    4. Nausea
    5. Canto (2002) Am J Cardiol 90:248-53 [PubMed]

III. Signs

  1. Dyskinetic apical impulse
  2. New S3 Gallop rhythm
  3. New S4 Gallop rhythm
  4. New or worsening Mitral Regurgitation murmur
  5. Secondary Congestive Heart Failure
    1. Rales
    2. Hypotension

IV. Differential Diagnosis

  1. Acute Myocardial Infarction
  2. Aortic Dissection
  3. Pericarditis
  4. Cardiac Tamponade
  5. Pneumothorax
  6. Pulmonary Embolus
  7. Peptic Ulcer Disease
  8. Cholecystitis or Cholelithiasis
  9. Esophageal Spasm
  10. Cervical Disc Disease

V. Evaluation: Risk Score

  1. See TIMI Risk Score
  2. See Goldman Risk Score

VI. Diagnostics

  1. Electrocardiogram
    1. Evaluate carefully for any significant ischemic EKG changes (T Wave Inversion, ST depression)
    2. See EKG in Myocardial Ischemia

VII. Labs

  1. Troponin

VIII. Evaluation

  1. Normal serial High Sensitivity Troponins AND normal EKGs
    1. Risk of adverse cardiac event in next 30 days is less than 1%
    2. Consider stress testing (but not mandatory)
  2. Normal serial High Sensitivity Troponins AND ischemic changes on EKG
    1. Ischemic EKG changes are associated with a worse prognosis
    2. Evaluate with same rigorousness as with NSTEMI
    3. See Moderate Risk Acute Coronary Syndrome Management
  3. Increased High Sensitivity Troponin with or without ischemic changes on EKG
    1. Increased short term risk of STEMI and death
    2. Evaluate with same rigorousness as with NSTEMI
    3. See Moderate Risk Acute Coronary Syndrome Management
  4. References
    1. Mattu in Herbert (2014) EM:Rap 14(2): 3-5
    2. Braunwald (2013) Circulation 127(24): 2452-7 [PubMed]

IX. Management

  1. See Ischemic Chest Pain Management

X. Indications: Angiography in Unstable Angina

  1. Failure to stabilize with adequate medical therapy
  2. Recurrent or persistent pain or ischemia
  3. Previous revascularization procedure
  4. Multiple admissions for undiagnosed Chest Pain
  5. High-risk findings on clinical assessment
    1. Congestive Heart Failure
    2. Left Ventricular Dysfunction
    3. Mitral Regurgitation (new or worsening)
    4. Malignant ventricular Arrhythmia
    5. Positive Exercise Stress Test or Stress Imaging

XI. Prognosis

  1. See Unstable Angina Prognosis

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