Chest Pain & Unstable Angina Eugene Yevstratov MD Based on UCLA protocol of the management of Chest Pain & Unstable Angina

1 ST elevation > 1 mm in 2 or more contiguous limb or precordial leads 2 Left bundle branch block, not known to be old 3 ECG findings useful for establishing the likelihood of coronary artery disease: ST segment depression > 1 mm Inverted T-waves > 1 mm in two or more contiguous leads Diagnostic criteria for acute myocardial infarction

1Chest pain assessment by physician (definite angina, probable angina, probably not angina) 2Prior myocardial infarction or documented coronary artery disease Number of risk factors (diabetes, smoking, hypercholesterolemia, hypertension, post menopausal) 4Age The major factors in the initial history and physical exam that relate to the likelihood of coronary artery disease

Likelihood of significant coronary artery disease in patients with symptoms suggesting unstable angina Low Likelihood: (e.g., ) Chest pain, "probably not angina" in patients with one or no risk factors, but not diabetes. T wave flat or inverted < 1 mm. Normal ECG. Intermediate Likelihood: (e.g., ) "Definite angina" in patients with no risk factors for CAD. High Likelihood: (e.g., ) Known history of prior MI or CAD. "Definite angina" in male > 60 or females > 70. Transient hemodynamic or ECG changes during pain. ST elevation or depression of > 1 mm. Marked symmetrical T wave inversion in multiple leads.

Risk Assessment Low risk: Nonresting angina with increased frequency, severity, or duration. Angina provoked at a lower threshold. New onset angina 2 weeks to 2 months. Normal or unchanged ECG. Intermediate risk: Rest angina now resolved. Rest angina 65 years. Q waves or ST depression on ECG. High risk: Ongoing rest pain > 20 minutes. Angina with pulmonary edema, S3, or rales. Angina with new or worsening mitral regurgitation. Rest angina with dynamic ST changes > 1 mm. Angina with hypotension.

1. Left ventricular function (LVEF) 2. Extent of coronary artery disease 3. Age 4. Co-morbid conditions 5. Unmodified coronary risk factors The most important factors related to short term and long term survival in patients with acute myocardial infarction or unstable angina

1. Activate the CLOT team (CCU fellow) 2. All patients should receive regular ASA 325 mg as soon as possible unless a definite contraindication is present (evidence of ongoing life-threatening hemorrhage or a clear history of severe hypersensitivity to ASA). Have patient chew the aspirin. All patients should receive clopidogrel 300 mg dose in combination with aspirin, unless contraindicated. If aspirin allergic, use clopidigrel 300 mg loading dose alone. The treatment of acute myocardial infarction is detailed in the UCLA Acute Myocardial Infarction Practice

3. Patients in which acute pericarditis or aortic dissection is not suspected, have no evidence of major or lifethreatening hemorrhage, and no significant predisposition to hemorrhage should be given an intravenous bolus of heparin 4. Patients without contraindications should be treated with intravenous followed by oral beta blockers (exclude cardiogenic shock, hypotension, decompensated heart failure prior to treatment) The treatment of acute myocardial infarction is detailed in the UCLA Acute Myocardial Infarction Practice

5. Patients with ongoing chest pain despite SL NTG and beta blockers, with SBP > 90 mmHg should be started on an intravenous nitroglycerine drip 6. The rapid initiation of therapy aimed at reperfusion (direct catheterization or thrombolytic therapy) should not be delayed. Direct catheterization is the preferred treatment strategy

Monitoring: Patients should remain on continuous ECG monitoring for ischemia and arrhythmia detection. Oxygen: Patients with obvious cyanosis, respiratory distress, or high risk features should receive supplemental oxygen. A finger pulse oximeter check should be used to confirm adequate oxygenation. If pulse oximeter sat < 92% full assessment including arterial blood gas determination should be considered prior to initiating oxygen. Routine use of oxygen in all patients is not indicated.. Unstable Angina General Care

Activity: Patients should be placed at bed rest during the initial phase of medical management. Diet: Patients should remain NPO except for meds until clinical stability demonstrated and necessity/timing of cardiac catheterization determined.

Initial Pharmacologic Treatment Antiplatelet Therapy: Intravenous Heparin or Low Molecular Weight Heparin Beta blockers Glycoprotein IIb/IIIa Receptor Antagonists Nitroglycerin Morphine sulfate Calcium channel blockers Thrombolytic therapy Intra-aortic balloon counterpulsation

ECG initially, with ongoing or recurrent symptoms, with relief of chest pain, and 6 hours after admission. CBC with platelets. PT (INR), PTT. Serum creatinine, glucose. Lipid panel on admission (nonfasting) unless patient has had a recent determination. Troponin I q6 x 2 and CK-MB should be measured q8 hours x 3 (omit 2nd/3rd CK- MB if 6 hour troponin is negative). Laboratory Testing

Diagnostic Algorithms

Chest Pain Initial Therapy: ASA: all patients without contraindications should be started on ASA (consider clopidogrel) NTG SL: prescription and instructions on the prn use should be given Appointment for stress testing within 72 hours

Treatment Stratification

Patients with coronary artery disease will live longer when treated with a HMG CoA Reductase Inhibitor. In the 4S trial there was a 34% risk reduction in major cardiac events, a 42% risk reduction in cardiovascular mortality and a 30% reduction in all cause mortality associated with statin treatment. The LIPID trial demonstrated that even patients with "low or normal" levels of total cholesterol and LDL cholesterol (LDL mg/dl) have mortality reduction with statin treatment. Patients should be educated that these medications are for the treatment of atherosclerosis, not because the patient has “failed” dietary treatment and that use of these medications lowers the risk of recurrent events, need for hospitalizations, revascularization, strokes, and mortality.

The HOPE trial demonstrated that in patients with CAD, CVD, PVD or diabetes the use of an ACE inhibitor was associated with a reduction in cardiovascular events, cardiovascular mortality, and all cause mortality. This benefit was seen in patients without hypertension and with normal left ventricular ejection fractions.

Eugene Yevstratov MD Phone: (ARG) Private: / (UKr) Fax: (USA) Link: