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

V. Evaluation: 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

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

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

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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