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Character
Stable Angina
Unstable angina
Same
Same
Retrosternal area,
Epigastrium (inferior M
Physical exertion
Cold temperatures.
Emotions like
anger or fear or
excitement.
Smoking
Eating a heavy
meal.
Using cocaine
(promote
vasospasm &
thrombosis) or
amphetamines.
Heavy, tight,
griping, squeezing,
crushing
At rest or minimal
exertion 3-5mins
Severe and New
onset of chest pain
At rest
Same
Radiation
Alleviating
factor
Timing
Associated
symptoms
Myocardial infarct
Sublingual Glyceryl
Trinitrate relieve for
a few mins
> 30 minutes
-
Sweating, nause
vomiting, palpita
Anxiety, sense o
impending doom
Collapse/syncope
SOB due to pulm
edema
Underlying
pathology
Vessel
architecture
and
Blood flow
Critical
coronary
artery
stenosis
>70%
caused by
atherosclerot
ic plaque
Blood flow
limited
during
exertion
Ischemia
during
exercise
without
acute
thrombosis
but
transient
platelet
aggregatio
n
Unstable
plaque
rupture
Platelet
thrombus
begins to form
and spasm
limits blood
flow at rest
NSTEMI
- Unstable
platelet
thrombus on
ruptured
plaque
- Transient or
incomplete
vessel
occlusion (lysis
occurs)
-difference
from UA is
that there is
myocardial
necrosis
Non-Q wave/
Subendocardia
l MI
ST
-Plate
throm
on ru
ather
us pla
-Com
vesse
occlu
(no ly
Q wa
Trans
MI
Physical
findings
Diaphoresis
Tachycardia or
bradycardia
- Transient
myocardial
dysfunction
(eg, systolic
blood pressure
< 100 mm Hg
or overt
hypotension,
- elevated
jugular venous
pressure,
dyskinetic
apex, reverse
splitting of S2,
presence of S3
or S4, new or
worsening
apical systolic
murmur, or
rales or
crackles)
Peripheral
arterial
occlusive
disease (eg,
carotid bruit,
supraclavicular
or femoral
bruits, or
diminished
peripheral
pulses or blood
pressure)
Anxious, diaphoretic
S4 Gallop : myocardial noncompliance due to ischemia
S3 Gallop : severe systolic
dysfunction
New apical systolic murmur of MR :
Ischemic papillary muscle
dysfunction
Cardiac
Enzymes
No raised
in CE
Management
Lifestyle
modificatio
n
Mild rise in
troponin
LMWH
double
antiplatel
et
Rise in serum
troponin or CKMB
NSTEMI
LMWH
douple
antiplatelet
GPIIb/IIIa
antagonist
Typically shows a
rise in CE
following the
sequence of
CKMB (every 6-8
hours during the
first 24 hours)
CKMB:CK (2.5/3)
Troponin I, T
AST
LDH
STEMI
thromboly
sis
(streptokin
ase,
alteplase)
primary/pe
rcutaneou
s coronary
interventio
n,
double
antiplatele
t
Localizing MI
ST
Elevations
Reciprocal
STdepressions
Anterior MI
V1-V6
none
LAD
need
Septal MI
V1-V3
none
LAD
need
Inferior MI
I, aVL
RCA (80%)
or
R Cx (20%)
need
Lateral MI
I, aVL, V5,
V6
R Cx, LCX
need
Posterior MI
V7, V8, V9
V1-V3
R Cx
need
Location
Affected
Artery
Exampl
e
ECG
Right Ventricular
MI
V1, V4R
I, aVL
RCA
need
Initial
Elevation
Peak
Elevation
Return to
Baseline
Myoglobin
1-4 h
6-7 h
18-24 h
CK-MB
4-12 h
10-24 h
48-72 h
Cardiac Trop I
3-12 h
10-24 h
3-10 d
Creatinine level
Exercise testing when patients are stable(either exercise or
chemically-induced exertion to look for EKG changes and/or
decreased radionuclide uptake in the ischemic region)
The following imaging studies may be used to assess patients with
suspected unstable angina:
Chest radiography (may show pulmonary edema or other causes
of chest pain)
Echocardiography (usually after admission to look for regional
wall motion abnormality)
Computed tomography angiography
Magnetic resonance angiography
Single-photon emission computed tomography
Magnetic resonance imaging
Myocardial perfusion imaging
Management
Obtain intravenous (IV) access, and provide supplemental oxygen. The
course of unstable angina is highly variable and potentially lifethreatening ; therefore, quickly determine whether the initial
treatment approach should use an invasive (surgical management) or
a conservative (medical management) strategy.
The following medications are used in the management of unstable
angina:
Cardiac catheterization
Revascularization
Those with persistent ST-elevations will need some sort of
revascularization procedure - either pharmacological
(thrombolytic) or an angioplasty in the cardiac catheterization
lab.
Those without ST-elevations should get an angiogram when
appropriately as determined by the interventional cardiologist.