overview of the acute management of unstable angina and non

8/9/2019 Overview of the Acute Management of Unstable Angina and Non

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Overview of the acute management of unstable angina and non-ST elevation myocardial infarctionAuthorsJeffrey A Breall, MD, PhDJulian M Aroesty, MDMichael Simons, MDSection EditorsChristopher P Cannon, MDJames Hoekstra, MDDonald Cutlip, MDDeputy EditorGordon M Saperia, MD, FACCDisclosures

All topics are updated as ne e!idence "ecomes a!aila"le and ourpeer re!ie processis complete#Literature review current through:Jan $%&'# ( This topic last updated:Apr &&, $%&$#

!T"OD#$TO!) *nsta"le an+ina *A-, acute non.S/ ele!ation myocardial infarction 0S/1M2-, and

acute S/ ele!ation myocardial infarction S/1M2- are the three presentations of acute coronary

syndromes ACS-# /he first step in the mana+ement of patients ACS is prompt reco+nition, since the

"eneficial effects of therapy are +reatest hen performed soon after hospital presentation# For patients

presentin+ to the emer+ency department ith chest pain suspicious for an ACS, the dia+nosis of

myocardial infarction can "e confirmed "y the 1CG and serum cardiac "iomarker ele!ation3 the history is

relied upon hea!ily to make the dia+nosis of unsta"le an+ina# See4Criteria for the dia+nosis of acute

myocardial infarction4and42nitial e!aluation and mana+ement of suspected acute coronary syndrome in

the emer+ency department4#-

5nce the dia+nosis of either *A or an acute 0S/1M2 is made, the acute mana+ement of the patient

in!ol!es the simultaneous achie!ement of se!eral +oals 6&,$78

9elief of ischemic pain# See:2nitial medical therapy:"elo#-

Assessment of the patient:s hemodynamic status and correction of a"normalities# Hypertensionand tachycardia, "oth of hich ill markedly increase myocardial o;y+en consumption

reon+.term antiplatelet therapy to reduce the risk of recurrent coronary artery throm"osis or, ith

PC2, coronary artery stent throm"osis
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Statins

>on+.term oral anticoa+ulation in the presence of left !entricular throm"us or chronic atrial

fi"rillation to pre!ent em"oli=ation

Possi"le use of an an+iotensin con!ertin+ en=yme AC1- inhi"itor in patients at increased risk

/his topic ill summari=e emer+ent?early mana+ement issues for patients ith *A or acute 0S/1M2 and

then direct the reader to a more detailed discussion in other topics# /he mana+ement of the patient after a

re!asculari=ation strate+y has "een chosen and carried out is discussed separately# See45!er!ie of

the non.acute mana+ement of unsta"le an+ina and non.S/ ele!ation myocardial infarction4#-

/he mana+ement of the patient ith S/ ele!ation M2 or ith a complication of an acute M2 e+,

cardio+enic shock, mitral re+ur+itation, !entricular septal defect- is discussed separately# See 45!er!ie

of the acute mana+ement of S/ ele!ation myocardial infarction4and 4Pro+nosis and treatment of

cardio+enic shock complicatin+ acute myocardial infarction4and 4Mechanical complications of acute

myocardial infarction4and42nitial e!aluation and mana+ement of suspected acute coronary syndrome in

the emer+ency department4#-

%E!E"AL &"!$&LES) An increasin+ num"er of centers use structured al+orithms, checklists, or

critical pathays to screen patients ith a suspected ACS al+orithm &- 6'.@7# Many of these strate+ies

com"ine dia+nostic e!aluation, such as electrocardio+raphy and serum "iomarkers, ith therapeutic

inter!entions, such asaspirin, "eta "lockers, antithrom"otic a+ents, and, in most patients, early coronary

an+io+raphy and re!asculari=ation# See 42nitial e!aluation and mana+ement of suspected acute coronary

syndrome in the emer+ency department4#-

Definitions) Amon+ patients considered to ha!e an+ina, there are three presentations of an+ina that

su++est an acute coronary syndrome ACS- 6&78

9est an+ina, hich is usually more than $% minutes in duration

0e onset an+ina that markedly limits physical acti!ity

2ncreasin+ an+ina that is more fre


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these to syndromes# For this reason, and "ecause the patho+enetic mechanisms of the to conditions

are similar, they are often considered to+ether# See 4Classification of unsta"le an+ina and non.S/

ele!ation myocardial infarction4#-

Elderly patients) 2t is estimated that % to percent of M2s occur in patients years of a+e and ''

percent occur in patients E years of a+e 6,&%7# 2n addition, as many as @% percent of all deaths related

to M2 occur in persons years of a+e#

Althou+h patients a+e E and older ha!e "een underrepresented in clinical trials of ACS, the folloin+

o"ser!ations concernin+ acute M2 in older adults compared to youn+er patients are +enerally accepted

6&&78

1lderly patients are more likely to ha!e an 0S/1M2 rather than an S/1M2#

1lderly patients more fre


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2ntensi!e medical and inter!entional mana+ement can "e undertaken ith close monitorin+ for

ad!erse effects#

2nformation of particular rele!ance to older adults ill "e mentioned throu+hout the remainder of this topic#

$ocaine associated myocardial infarction) M2 is a ell.descri"ed complication amon+ patients

presentin+ ith cocaine.induced ischemic symptoms# See 41!aluation and mana+ement of the

cardio!ascular complications of cocaine a"use4, section on :9eperfusion and re!asculari=ation:#-

e a+ree ith the $%%@ American Heart Association scientific statement on the Mana+ement of cocaine.

associated chest pain and myocardial infarction, hich states that these patients should "e mana+ed in a

manner similar to other ACS patients 6&E7#

/he folloin+ to points ere also made8

Ben=odia=epines should "e administered early

Beta "lockers should not "e used in the settin+ of acute cocaine into;ication ith chest pain due

to the possi"ility of e;acer"ation of coronary artery !asoconstriction

!TAL 'ED$AL T(E"A&)) Patients ith *A or 0S/1M2 should "e treated ith an early medical

re+imen similar to that used in a S/1M2 ith one e;ception8 there is no e!idence of "enefit and possi"le

harm- from fi"rinolysis# 2nitial therapy, hich should "e instituted ithin $% minutes of presentation, is

discussed in detail separately# See 42nitial e!aluation and mana+ement of suspected acute coronary

syndrome in the emer+ency department4, section on :2mmediate 1D inter!entions:#-

Dru+ meta"olism is more likely to "e reduced in elderly patients, particularly ith re+ard to dru+s that are

e;creted "y the kidney# Dose adustment is necessary ith GP 22"?222a inhi"itors and unfractionated or lo

molecular ei+ht heparin, "ut not ithaspirinandclopido+rel6&&7# See :1lderly patients:a"o!e#-

Anti-ischemic and analgesic therapy

O*ygen) e recommend supplemental o;y+en for patients ith an arterial saturation less than %

percent, patients in respiratory distress, or those ith other hi+h risk features for hypo;emia 6&7#

/he role of supplemental o;y+en in patients ithout hypo;ia has not "een ell.studied# A $%&% Cochrane

re!ie e!aluated three trials of '@E patients ith presumed myocardial infarction M2- ho ere randomly

assi+ned to supplemental o;y+en or room air# 1nrolled patients ere either hypo;ic and normo;ic# /he

study found no si+nificant difference in mortality pooled relati!e risk $#@@, 6I C2 %#@@.#'7 in an

intention.to.treat analysis and '#%', 6I C2 %#'.#@'7 amon+ those ith confirmed M2-# 0o su"+roup

analysis as performed on those ith normo;ia 6&@7#

/he su++estion of harm ith supplemental o;y+en found in this Cochrane re!ie is of concern,

particularly in patients ith normo;ia, as a pathophysiolo+ic "asis for such harm has "een articulated 6&7#

Hypero;ia, hich mi+ht occur ith the administration of o;y+en to normo;ic indi!iduals, has "een shon

to ha!e a direct !asoconstrictor effect on the coronary arteries 6&7#

*ntil "etter e!idence to support the use of supplemental o;y+en in normo;ic patients ith acute M2 is

a!aila"le, e su++est a eak recommendation- its use#

!itroglycerin) Su"lin+ual nitro+lycerinis administered to patients presentin+ ith ischemic type chest

pain, folloed "y intra!enous nitro+lycerin in patients ith persistent pain after three su"lin+ual
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nitro+lycerin ta"lets, hypertension, or heart failure# See40itrates in the mana+ement of acute coronary

syndrome4#-

0itrates must "e used ith caution or a!oided in settin+s in hich hypotension is likely or could result in

serious hemodynamic decompensation, such as ri+ht !entricular infarction or se!ere aortic stenosis# 2n

addition, nitrates are contraindicated in patients ho ha!e taken a phosphodiesterase inhi"itor for erectile

dysfunction ithin the pre!ious $ hours# See 4Se;ual acti!ity in patients ith heart disease4and 49i+ht!entricular myocardial infarction4, section on :5ptimi=ation of ri+ht !entricular preload:#-

'orphine) 2ntra!enous morphine sulfateat an initial dose of $ to m+, ith increments of $ to @ m+

repeated at to & minute inter!als, should "e +i!en for the relief of chest pain or an;iety#

+eta bloc,ers) Controlled trials ha!e repeatedly documented the "eneficial effects of "eta "lockers in

patients ith acute myocardial infarction3 hoe!er, there ha!e "een no randomi=ed trials specifically

addressin+ the efficacy of these dru+s in non.S/ ele!ation ACS# See 4Beta "lockers in the mana+ement

of acute coronary syndrome4, section on :Summary and recommendations:#-

0e!ertheless, +i!en the pro!en efficacy in unselected patients ith an acute M2 and the a"sence of harm

in 0S/1M2 or *A, the $%%E ACC?AHA +uidelines recommended that "eta "locker therapy should "e

administered uni!ersally to all patients ithout contraindications 6&7# Similar recommendations ere made

"y a $%% task force of the 1uropean Society of Cardiolo+y 6$%7#

2n our !ie, treatment should include early use of intra!enous "eta "lockade in patients ithout

contraindications ho ha!e on+oin+ chest pain, hypertension, or tachycardia not caused "y heart failure#

/his approach is supported "y the $%%E AHA scientific statement on hypertension 6$&7# A cardioselecti!e

a+ent metoprololor atenolol- is preferred#

Hoe!er, "ased upon the results of the C5MM2/?CCS$ trial, the lar+est place"o.controlled trial e!er

performed ith "eta "lockers in acute M2, it seems reasona"le to defer intra!enous "eta "lockers in

patients ho are hemodynamically compromised in hom mortality may actually "e increased "y such

therapy# 5nce the patient is sta"le, an oral "eta "locker can "e started ith +radual uptitration to the

maintenance doses cited "elo# See4Beta "lockers in the mana+ement of acute coronary syndrome4,

section on :1arly administration:#-

Statin therapy) Statin therapy should "e instituted prior to hospital dischar+e, ith some data

supportin+ initiation at the time of dia+nosis 6&7# e recommend therapy ith ator!astatin@% m+?day,

hich as used in the P951 2/./2M2 $$ and M29AC> trials 6$$,$'7# Amon+ patients ho ere

pre!iously treated ith a different statin re+imen, e su++est sitchin+ to ator!astatin @% m+?day#

See 4Cholesterol loerin+ after an acute coronary syndrome4, section on :Continuation of prior statin

therapy:#-

2nitial intensi!e statin therapy, rather than +radual dose titration upard, is recommended "ecause of the

su++estion of "enefit in the P951 2/./2M2 $$ trial ithin '% days 6$7, an inter!al "efore the first serum

cholesterol measurement on therapy ould usually "e o"tained# See4Cholesterol loerin+ after an acutecoronary syndrome4#-

Based on these recommendations, most patients should ha!e a lipid profile performed early in their

hospitali=ation, althou+h some patients may ha!e had recent outpatient testin+# 2n the e!ent that testin+ is

not performed early after an ACS, !alues o"tained up to four days after the e!ent may represent "aseline

!alues# See4Measurement of serum lipids and lipoproteins4, section on :After an ACS:#-
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rction/abstract/21http://www.uptodate.com/contents/metoprolol-drug-information?source=see_linkhttp://www.uptodate.com/contents/atenolol-drug-information?source=see_linkhttp://www.uptodate.com/contents/beta-blockers-in-the-management-of-acute-coronary-syndrome?source=see_link&anchor=H12#H12http://www.uptodate.com/contents/beta-blockers-in-the-management-of-acute-coronary-syndrome?source=see_link&anchor=H12#H12http://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/1http://www.uptodate.com/contents/atorvastatin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/22,23http://www.uptodate.com/contents/cholesterol-lowering-after-an-acute-coronary-syndrome?source=see_link&anchor=H9#H9http://www.uptodate.com/contents/cholesterol-lowering-after-an-acute-coronary-syndrome?source=see_link&anchor=H9#H9http://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/24http://www.uptodate.com/contents/cholesterol-lowering-after-an-acute-coronary-syndrome?source=see_linkhttp://www.uptodate.com/contents/cholesterol-lowering-after-an-acute-coronary-syndrome?source=see_linkhttp://www.uptodate.com/contents/measurement-of-serum-lipids-and-lipoproteins?source=see_link&anchor=H24362763#H24362763


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1!aluation of the response to statin therapy after an acute coronary syndrome should "e deferred for to

months, since acute phase responses and perhaps other factors can transiently loer >D>.cholesterol "y

% to % percent and thus, in some patients, cause spuriously normal.appearin+ le!els folloin+ an acute

coronary syndrome# Hoe!er, the ma+nitude of this effect, at least soon after hospitali=ation, appears to

"e less ith current therapies that limit the de+ree of myocardial inury, such as percutaneous coronary

inter!ention or fi"rinolytic therapy 6$7# See4Measurement of serum lipids and lipoproteins4, section on:After an ACS:and 4Cholesterol loerin+ after an acute coronary syndrome4#-

/he lon+.term >D>.cholesterol +oal is discussed separately# See42ntensity of lipid loerin+ therapy in

secondary pre!ention of coronary heart disease4#-

Antithrombotic therapy

Antiplatelet therapy) 2n the a"sence of an a"solute contraindication, antiplatelet therapy

ithaspirinand a platelet P$K&$ receptor "locker is indicated in allpatients ith a non.S/ ele!ation

ACS 6&,$7# See 4Antiplatelet a+ents in acute non.S/ ele!ation acute coronary syndromes4#-

Anticoagulation) For all patients ith non.S/ ele!ation ACS, e recommend anticoa+ulant therapy as

soon as possi"le after the dia+nosis# See4Anticoa+ulant therapy in non.S/ ele!ation acute coronary

syndromes4#-

mportance of dosing) 1;cessi!e dosin+ of antithrom"otic and antiplatelet a+ents is common and

associated ith an increase in "leedin+ risk# /his issue is discussed separately# See4Anticoa+ulant

therapy in non.S/ ele!ation acute coronary syndromes4, section on :Anticoa+ulant re+imens:#-

&otassium and magnesium) Althou+h there are no clinical trials documentin+ the "enefits of

electrolyte replacement in acute M2, the ACC?AHA +uidelines recommend maintainin+ the serum

potassium concentration a"o!e #% me and a serum ma+nesium concentration a"o!e $#% me $#

m+?d> or & mmol?>- 6$,$E7# Much of the e!idence for this recommendation as deri!ed from studies

"efore the routine use of "eta "locker and the use of reperfusion in many patients# See4Clinical features

and treatment of !entricular arrhythmias durin+ acute myocardial infarction4, section on :entricular

fi"rillation:#-

A $%&$ retrospecti!e cohort study found that for patients ith acute M2 the loest mortality as o"ser!ed

in those ith post.admission serum potassium !alues "eteen '# and L# me 6$@7# See49isk

stratification for cardiac e!ents after acute S/ ele!ation myocardial infarction4, section on :Serum

potassium:#-

e su++est that the serum potassium fall ithin the ran+e of '# to # me# Some of our re!ieers

prefer a ti+hter ran+e of #% to # me# 2t may "e difficult to loer the potassium "elo # me in

some patients, such as those ith chronic kidney disease#

!on-steroidal antiinflammatory drugs) 0onsteroidal antiinflammatory dru+s e;cept aspirin- should

"e discontinued immediately due to an increased risk of cardio!ascular e!ents associated ith their use#See 40onselecti!e 0SA2Ds8 Ad!erse cardio!ascular effects4#-

ntravenous glucose-insulin-potassium) e do not recommend the use of intra!enous +lucose.

insulin.potassium G2- to impro!e outcomes in patients ith suspected or dia+nosed acute M2# Much of

the a!aila"le e!idence comes from studies of patients ith S/.ele!ation M2# /he discussion of the

potential use of G2 in these patients is found elsehere# See 45!er!ie of the acute mana+ement of S/

ele!ation myocardial infarction4, section on :2ntra!enous +lucose.insulin.potassium:#-
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73188#H1143773188http://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/25http://www.uptodate.com/contents/measurement-of-serum-lipids-and-lipoproteins?source=see_link&anchor=H24362763#H24362763http://www.uptodate.com/contents/measurement-of-serum-lipids-and-lipoproteins?source=see_link&anchor=H24362763#H24362763http://www.uptodate.com/contents/cholesterol-lowering-after-an-acute-coronary-syndrome?source=see_linkhttp://www.uptodate.com/contents/intensity-of-lipid-lowering-therapy-in-secondary-prevention-of-coronary-heart-disease?source=see_linkhttp://www.uptodate.com/contents/intensity-of-lipid-lowering-therapy-in-secondary-prevention-of-coronary-heart-disease?source=see_linkhttp://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/1,2http://www.uptodate.com/contents/antiplatelet-agents-in-acute-non-st-elevation-acute-coronary-syndromes?source=see_linkhttp://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes?source=see_linkhttp://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes?source=see_linkhttp://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes?source=see_link&anchor=H100954534#H100954534http://www.uptodate.com/contents/anticoagulant-therapy-in-non-st-elevation-acute-coronary-syndromes?source=see_link&anchor=H100954534#H100954534http://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/26,27http://www.uptodate.com/contents/clinical-features-and-treatment-of-ventricular-arrhythmias-during-acute-myocardial-infarction?source=see_link&anchor=H24#H24http://www.uptodate.com/contents/clinical-features-and-treatment-of-ventricular-arrhythmias-during-acute-myocardial-infarction?source=see_link&anchor=H24#H24http://www.uptodate.com/contents/clinical-features-and-treatment-of-ventricular-arrhythmias-during-acute-myocardial-infarction?source=see_link&anchor=H24#H24http://www.uptodate.com/contents/overview-of-the-acute-management-of-unstable-angina-and-non-st-elevation-myocardial-infarction/abstract/28http://www.uptodate.com/contents/risk-stratification-for-cardiac-events-after-acute-st-elevation-myocardial-infarction?source=see_link&anchor=H458465082#H458465082http://www.uptodate.com/contents/risk-stratification-for-cardiac-events-after-acute-st-elevation-myocardial-infarction?source=see_link&anchor=H458465082#H458465082http://www.uptodate.com/contents/risk-stratification-for-cardiac-events-after-acute-st-elevation-myocardial-infarction?source=see_link&anchor=H458465082#H458465082http://www.uptodate.com/contents/aspirin-drug-information?source=see_linkhttp://www.uptodate.com/contents/nonselective-nsaids-adverse-cardiovascular-effects?source=see_linkhttp://www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction?source=see_link&anchor=H1143773188#H1143773188http://www.uptodate.com/contents/overview-of-the-acute-management-of-st-elevation-myocardial-infarction?source=see_link&anchor=H1143773188#H1143773188


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/he 2MM1D2A/1 trial randomly assi+ned @E& patients ith suspected acute coronary syndromes

appro;imately % percent ithout S/.ele!ation on the presentin+ electrocardio+ram- to intra!enous G2

or identical.appearin+ percent +lucose place"o, hich as administered "y paramedics in the out.of.

hospital settin+ and continued for &$ hours 6$7# /here as no difference in the rate of pro+ression to M2

as measured "y "iomarkers and 1CG e!idence- at $ hours or the rate of death at '% days amon+

patients ho recei!ed G2 compared to those ho recei!ed place"o @#E !ersus $# percent3 odds ratio%#@@, I C2 %#.&' and # !ersus #& percent3 odds ratio %#E$, I C2 %#%.$, respecti!ely-#

A""()T('A 'A!A%E'E!T) Both atrial and !entricular arrhythmias can "e seen durin+ and after

the acute phase of an 0S/1M2# /hese include atrial fi"rillation or flutter, hich can cause symptomatic

hypoperfusion due to a rapid rate, and life.threatenin+ !entricular tachycardia or !entricular fi"rillation#

See 4Supra!entricular arrhythmias after myocardial infarction4and4Clinical features and treatment of

!entricular arrhythmias durin+ acute myocardial infarction4#-

Prophylactic intra!enous or intramuscular lidocaineto pre!ent /?F in the acute M2 patient

is notrecommended# 9ecommended prophylactic measures include early administration of a "eta

"locker and treatment of hypokalemia and hypoma+nesemia# /reatment of !entricular tachyarrhythmias in

the settin+ of acute M2 is discussed separately# See 4Clinical features and treatment of !entricular

arrhythmias durin+ acute myocardial infarction4#-

EA"L) "S ST"AT.$ATO!) 1arly risk stratification in patients ith ACS is essential to identify

those patients at hi+hest risk for further cardiac e!ents ho may "enefit from a more a++ressi!e

therapeutic approach 6&,'%,'&7# Clinical trials ha!e identified a num"er of factors predictin+ hi+h risk and a

"enefit from an early in!asi!e strate+y 6'$.'7# /hese include the presence and e;tent of S/ se+ment

depression, ele!ated cardiac "iomarkers, e!idence of hemodynamic insta"ility, and persistent chest pain

despite appropriate medical therapy# /hese !aria"les ha!e "een used to create risk scores such as /2M2,

G9AC1, and P*9S*2/# See 49isk stratification after unsta"le an+ina or non.S/ ele!ation myocardial

infarction4and4/rials of conser!ati!e !ersus early in!asi!e therapy in unsta"le an+ina and non.S/

ele!ation myocardial infarction4#-

2t should "e noted, hoe!er, that indi!idual factors in the se!en.point /2M2 risk score may carry more risk

than others, or "e more specific for acute coronary syndrome than others# As an e;ample, serum troponin

ele!ation and S/ se+ment depression indi!idually are markers of hi+h risk, re+ardless of the other /2M2

risk factors#

T' ris, score) Analysis of data from the /2M2 &&B and 1SS10C1 trials found that se!en !aria"les at

presentation ere independently predicti!e of outcome in patients ith unsta"le an+ina or an 0S/1M23 a

!alue of one as assi+ned hen a factor as present and % hen it as a"sent calculator &- 6'E78

A+e years

Presence of at least three risk factors for CHD hypertension, dia"etes, dyslipidemia, smokin+, or

positi!e family history of early M2-

Prior coronary stenosis of % percent

Presence of S/ se+ment de!iation on admission 1CG

At least to an+inal episodes in prior $ hours
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1le!ated serum cardiac "iomarkers

*se of aspirinin prior se!en days hich is pro"a"ly a marker for more se!ere coronary disease-

6'@7

Patients are considered to "e at lo risk ith a score of % to $3 intermediate risk ith a score of ' to 3and hi+h risk ith a score of to E fi+ure &-#

EA"L) "E&E".#SO! A!D "E/AS$#LA"0ATO!

Avoidance of fibrinolysis) Prospecti!e trials ha!e demonstrated that fi"rinolytic therapy is not

"eneficial in patients ith a non.S/ ele!ation ACS 6&,'$,'7# /he ACC?AHA and ACCP

recommend againstthe routine use of fi"rinolytic a+ents in patients ith a non.S/ ele!ation ACS 6%,&7#

See 4Fi"rinolytic throm"olytic- a+ents in unsta"le an+ina and acute non.S/ ele!ation myocardial

infarction4#-

mmediate angiography and revasculari1ation) Patients ho ha!e a non.S/ ele!ation ACS and one

or more of the folloin+ characteristics are at e;tremely hi+h risk of an ad!erse cardio!ascular e!ent in

the short term8

Hemodynamic insta"ility or cardio+enic shock

Se!ere left !entricular dysfunction or heart failure

9ecurrent or persistent rest an+ina despite intensi!e medical therapy

0e or orsenin+ mitral re+ur+itation or ne !entricular septal defect

Sustained !entricular arrhythmias

e recommend that patients ith any of these fi!e characteristics "e referred for immediatecoronary

arterio+raphy and re!asculari=ation#

For those ithout one of the a"o!e e;tremely hi+h risk characteristics, randomi=ed trials ha!e shon

"enefit of an early in!asi!e approach in hi+h.risk ACS# hile the optimal timin+ is uncertain, the maority

of patients under+o coronary re!asculari=ation early ie, ithin $ hours-# /his early timin+ as shon to

"e of clear "enefit in hi+h.risk patients in the /2MACS trial and su"+roup analyses of maor trials support

this approach in elderly patients as ell as youn+er patients 6&&7# See 4Coronary arterio+raphy and

re!asculari=ation for unsta"le an+ina or non.S/ ele!ation acute myocardial infarction4, section on :/imin+

of early inter!ention:#-

A idely used predicti!e model used to +uide in!asi!e !ersus conser!ati!e strate+y is the /2M2 riskscore, hich is "ased upon se!en !aria"les a!aila"le at presentation 6'E7# Patients ith hi+h.risk /2M2

scores of fi!e to se!en, as ell as intermediate.risk /2M2 scores of three to four, "enefited from early

in!asi!e strate+y in the /AC/2CS./2M2 &@ trial# See :1arly risk stratification:a"o!e and 4Coronary

arterio+raphy and re!asculari=ation for unsta"le an+ina or non.S/ ele!ation acute myocardial infarction4,

section on :/2M2 risk score:#-

Hi+h risk criteria ha!e also "een defined "y the $%%E ACC?AHA +uidelines on unsta"le an+ina and non.

S/ ele!ation M2 and the $%% 1uropean Society of Cardiolo+y +uidelines as cardiac "iomarker ele!ations,
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or=H8#H8http://www.uptodate.com/contents/coronary-arteriography-and-revascularization-for-unstable-angina-or-non-st-elevation-acute-myocardial-infarction?source=see_link&anchor=H8#H8


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S/ se+ment depression, recurrent an+ina, hemodynamic insta"ility, sustained /?F, prior PC2 ithin the

prior si; months or CABG, and dia"etes 6&,$7# See4Coronary arterio+raphy and re!asculari=ation for

unsta"le an+ina or non.S/ ele!ation acute myocardial infarction4#-

/he choice of re!asculari=ation procedure after an+io+raphy depends upon the location and e;tent of

disease# Amon+ patients ith an appropriate lesion, PC2 is most often performed, "ut coronary artery

"ypass +raftin+ CABG- is usually preferred for the treatment of patients ith left main or left maine

overview of the acute management of unstable angina and non

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