Day #133 - Unstable Angina

Today we heard a case of a female patient presenting with typical angina (although atypically described by her on the history) which was escallating in frequency. A diagnosis of unstable angina was made and she was treated according to the guidelines.

(The unstable angina/NSTEMI pocket guideline is here)

Patients should be started on:

• antiplatelet -- i.e. ASA +/-clopidogrel
• anticoagulant -- i.e. IV heparin or LMWH. In high risk patients, consider gpIIaIIIb inhibitor
• statin
• oral beta-blocker within 24 hours for patients without contraindications
• oral calcium channel blocker if contraindication to beta-blocker
• oral ACEi within 24h for patients with heart failure or LVEF less than 40%
• oxygen if hypoxemic
• nitroglycerin 0.4mg SL spray/tablets q5 mins prn (max 3 doses) for symptoms of ischemia

When admitting a patient with UA/NSTEMI, I always find it helpful to estimate their risk of complications (i.e. death/MI) using the TIMI risk score.

Patients with probable ACS of ischemic origin should have (if appropriate) early (<72h) cardiac risk stratification. If high risk patients, they should be considered for early angiography +/- angioplasty (early invasive strategy).

She then went on to have non-invasive risk stratification, which was felt to be positive and then went on to coronary angiography. This showed triple vessel disease, for which she ultimately should consider coronary artery bypass surgery.