II. 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

III. Criteria: 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

IV. Criteria: 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

V. Criteria: 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

VI. 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

VII. References

  1. Braunwald (1994) AHCPR Publication 94-0602

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Related Studies

Ontology: Angina, Unstable (C0002965)

Definition (NCI) Angina pectoris (or equivalent type of ischemic discomfort) which has recently changed in frequency, duration, intensity, or occurs at rest.
Definition (NCI_CDISC) 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.(NIH Roadmap Cardiovascular Data Standards Working Group)
Definition (MSH) Precordial pain at rest, which may precede a MYOCARDIAL INFARCTION.
Concepts Disease or Syndrome (T047)
MSH D000789
ICD9 411.1
ICD10 I20.0
SnomedCT 194814006, 155308009, 233818002, 233820004, 64333001, 194817004, 194819001, 155313008, 194816008, 155314002, 4557003, 59021001, 25106000
English Angina, Preinfarction, Anginas, Preinfarction, Anginas, Unstable, Preinfarction Anginas, Unstable Angina, Unstable Anginas, ANGINA UNSTABLE, CRESCENDO ANGINA, Preinfarction Angina, Angina at Rest, Unstable Angina Pectoris, unstable angina pectoris, crescendo angina pectoris, unstable angina pectoris (diagnosis), crescendo angina pectoris (diagnosis), unstable angina, crescendo angina, Angina pectoris unstable, Angina unstable, Angina worsened, Intermed coronary synd, Angina, Unstable, Angina, Unstable [Disease/Finding], Angina;unstable, Infarction;impending, angina at rest, intermediate coronary syndrome, rest angina, angina unstable, pre-infarction syndrome, preinfarction angina, Unstable Angina Pectori, Angina Pectori, Unstable, Angina Pectoris, Unstable, (Angina: [crescendo] or [unstable] or [at rest]) or (preinfarction syndrome) or (impending infarction), Angina at rest (disorder), Preinfarction angina (disorder), Worsening angina (disorder), Unstable angina (disorder), (Angina: [crescendo] or [unstable] or [at rest]) or (preinfarction syndrome) or (impending infarction) (disorder), UNSTABLE ANGINA, Impending infarction (diagnosis), myocardial ischemia impending infarction, Intermediate coronary syndrome, Anginal chest pain at rest, Crescendo angina, Impending infarction, Unstable angina, Angina at rest, Worsening angina, Impending infarction (disorder), coronary; syndrome, crescendo; angina, intermediate coronary; syndrome, preinfarctional; angina, rest; angina, syndrome; coronary, syndrome; intermediate coronary, angina pectoris; at rest, angina pectoris; crescendo, angina pectoris; unstable, unstable; angina, Preinfarction angina, impending infarction
French ANGOR INSTABLE, Angor aggravé, Angor crescendo, Syndrome coronarien intermédiaire, Angor au repos, État de mal angineux, Angor instable, Angor de repos, Angor préinfarctus
Portuguese ANGINA INSTAVEL, Angina instável, Pseudo-angina instável, Angina agravada, Angina de repouso, Síndrome coronária intermédia, Angina em crescendo, Angina de peito instável, Angina em Repouso, Angina Instável, Angina Pré-Infarto
Spanish ANGINA INESTABLE, Angina de pecho inestable, Empeoramiento de la angina, Angina in crescendo, Síndrome coronario intermedio, Angina de reposo, angina preinfarto, angina preinfarto (trastorno), angina de pecho de reposo (trastorno), angina de pecho de reposo, angina inestable, infarto inminente (trastorno), infarto inminente, síndrome coronario intermedio, Angina inestable, Angina de Reposo, Angina Inestable, Angina Preinfarto
Dutch angina verergerd, angina bij rust, angina pectoris instabiel, onstabiele angina, tussentijds coronair syndroom, crescendo-angina, angina pectoris; crescendo, angina pectoris; in rust, angina pectoris; instabiel, coronair; syndroom, crescendo; angina, instabiel; angina, intermediair coronair; syndroom, pre-infarct; angina, rust; angina, syndroom; coronair, syndroom; intermediair coronair, Instabiele angina pectoris, angina instabiel, Angina pectoris in rust, Angina pectoris, onstabiele, Onstabiele angina pectoris, Angina, preïnfarct-
German Angina pectoris in Ruhelage, Angina verschlechtert, Crescendo-Angina, intermediaeres Koronarsyndrom, instabile Angina, ANGINA PECTORIS INSTABIL, Angina pectoris instabil, Angina pectoris, instabile, Instabile Angina pectoris, Angina, Ruhe-, Ruheangina, Angina, Präinfarkt-, Präinfarktangina
Italian Angina pectoris instabile, Sindrome coronarica intermedia, Angina ingravescente, Angina in crescendo, Angina a riposo, Angina pre-infartuale, Angina instabile
Japanese 安静狭心症, 中間冠動脈症候群, 漸増型狭心症, アンギナ増悪, アンギナゾウアク, フアンテイキョウシンショウ, チュウカンカンドウミャクショウコウグン, アンセイキョウシンショウ, 狭心症-安静時, 心筋梗塞前症候群, 心筋梗塞先行狭心痛, 不安定狭心症, 狭心痛-心筋梗塞先行, ゼンゾウガタキョウシンショウ, 安静時狭心症, 狭心症-不安定
Swedish Angina, instabil
Finnish Epävakaa rasitusrintakipu
Czech Nestabilní angina pectoris, Zhoršená angina pectoris, Crescendo angina, Intermediární koronární syndrom, Klidová angina pectoris, NAP, angina pectoris nestabilní, nestabilní angina pectoris
Korean 불안정성 협심증
Polish Dławica niestabilna, Dusznica bolesna niestabilna, Dławica piersiowa niestabilna
Hungarian Intermediaer coronaria syndroma, Instabil angina, Nyugalmi angina, Crescendo angina, Angina rosszabbodott, Angina pectoris, instabil
Norwegian Ustabil angina, Ustabil angina pectoris