UNSTABLE ANGINA

Introduction
Angina pectoris, commonly known as angina, is
severe chest pain[1] due to ischemia (a lack of blood,
hence a lack of oxygen supply) of the heart muscle,
generally due to obstruction or spasm of the coronary
arteries (the heart's blood vessels). Coronary artery
disease, the main cause of angina, is due
to atherosclerosis of the cardiac arteries. The term
derives from the Latin angina ("infection of the
throat") from the Greek ἀγχόνη ankhone ("strangling"),
and the Latin pectus ("chest"), and can therefore be
translated as "a strangling feeling in the chest".
There is a weak relationship between severity
of pain and degree of oxygen deprivation in the heart
muscle (i.e., there can be severe pain with little or no
risk of a heart attack, and a heart attack can occur
without pain).
Worsening ("crescendo") angina attacks, sudden-onset
angina at rest, and angina lasting more than 15
minutes are symptoms of unstable angina (usually
grouped with similar conditions as the acute coronary
syndrome). As these may herald myocardial
infarction (a heart attack), they require urgent medical
attention and are generally treated as a presumed
heart attack.
Classification of angina pectoris

 Stable angina
 Also known as effort angina, this refers to the more
common understanding of angina related to myocardial
ischemia. Typical presentations of stable angina is that of
chest discomfort and associated symptoms precipitated by
some activity (running, walking, etc.) with minimal or non-
existent symptoms at rest. Symptoms typically abate
several minutes following cessation of precipitating
activities and resume when activity resumes. In this way,
stable angina may be thought of as being similar
to claudication symptoms.
 Unstable angina
Unstable angina (UA) (also "crescendo angina;" this is a
form of acute coronary syndrome) is defined as angina
pectoris that changes or worsens.
 It has at least one of these three features:
 it occurs at rest (or with minimal exertion), usually lasting
>10 min;
 it is severe and of new onset (i.e., within the prior 4–6
weeks); and/or
 it occurs with a crescendo pattern (i.e., distinctly more
severe, prolonged, or frequent than previously).
 What is Unstable Angina?
Angina (chest pain or chest
discomfort produced when
the heart muscle is not
getting enough blood flow)
is considered "unstable"
when it no longer follows the
predictable patterns typical
of "stable angina."
Cont..
Unstable angina is one of the types of "Acute Coronary
Syndrome (ACS)," a series of conditions most
commonly produced by the rupture of a plaque in a
coronary artery. All types of ACS, including unstable
angina, should be considered medical emergencies.
Unstable angina is "unstable" not only because a
plaque has ruptured (a situation which always
threatens to progress to a myocardial infarction), but
also because the symptoms it produces - the angina -
generally occurs much more frequently, often at rest,
lasts much longer, and begins responding poorly to
nitroglycerin.
Unstable Angina
Cont..
Unstable angina is called "unstable" for two reasons.
 First, in contrast to stable angina, symptoms occur in a
more random and unpredictable fashion. While in stable
angina, symptoms typically are brought on by exertion,
fatigue, anger, or some other form of stress, in unstable
angina symptoms can (and often do) occur without any
apparent trigger. In fact, unstable angina often occurs at
rest, and can even wake people from a restful sleep.
Furthermore, in unstable angina, the symptoms often
persist for more than just a few minutes,
and nitroglycerinoften fails to relieve the pain. So:
unstable angina is "unstable" because symptoms may
occur more frequently than usual, without any discernable
trigger, and may persist for a long time.
 Cont..
 Second, and more importantly, unstable angina is "unstable"
because, as with all forms of ACS, it is most often caused by
the actual rupture of aplaque in a coronary artery. In unstable
angina, the ruptured plaque, and the blood clot that is almost
always associated with the rupture, are producing partial
blockage of the artery. The partial blockage may take a
"stuttering" pattern (as the blood clot grows and shrinks),
producing angina that comes and goes in an unpredictable
fashion. If the clot should cause complete obstruction of the
artery (which happens commonly), the heart muscle supplied
by that affected artery is in grave danger of sustaining
irreversible damage. In other words, the imminent risk of a
complete myocardial infarction is very high in unstable angina.
Obviously, such a condition is quite "unstable," and for this
reason is a medical emergency.
Sign and symptoms
When heart is not getting
enough oxygen, a type of
acute chest pain called
unstable angina may
occur. In medical
terminology, acute pain
means the pain comes on
very suddenly and may be
severe. Acute chest pain
may appear, change and
worsen very quickly.
Unstable angina can be a
warning sign that a heart
attack may happen soon.
Cont..
 Chest Pain -
A main symptom of unstable angina is the sudden
onset of chest pain. This pain may be felt in other
areas of the upper body including the arm, shoulder,
back, neck or jaw. Resting will usually not take
reduce the symptoms of an unstable angina.
 Feeling-
Pain from unstable angina may feel crushing, burning,
tight, squeezing, choking or aching. It has also been
described as simply discomfort or heaviness. The pain
associated with the condition will not easily go away
with medicine once the onset has begun.
Cont..
 Nausea & Sweating-
Often times, unstable angina may also bring with it a certain
amount of nausea or even the feeling of indigestion. This
nausea may be accompanied by sweating, though the two
symptoms are not exclusive to one another.
 Shortness of Breath-
You may also begin to experience a shortness of breath with
unstable angina, even when you're at rest.
 Fatigue-
If you're suffering from unstable angina, you may begin to
notice an almost overwhelming feeling of fatigue and
exhaustion.
Cont..
 Dizziness & Lightheadedness-
It isn't uncommon to for someone with unstable
angina to experience a sense of dizziness or
lightheadedness with the chest pain.
Cont..
Other Symptoms-
Other symptoms may include upper stomach pain that
could be mistaken for heartburn. The elderly, diabetics
and women are more likely to have symptoms such as
dizziness, shortness of breath and weakness. You may
have trouble breathing, feel very tired or have nausea
or vomiting.
Risk factors
 Coronary artery disease is the most common cause of
unstable angina.
 Risk factors include:-
 Diabetes
 Aging
 High blood pressure
 High low- density lipoprotein(LDL) cholesterol
 Low high- density lipoprotein(HDL) cholesterol
 Lack of exercises
 Obesity & smoking
 Males and those individuals with a family history of
coronary heart disease before the age of 50 are also at higher
risk for developing the condition.
Daignosis
 ECG
blood tests forcardiac enzyme testing.
Cont..
 The classic symptoms of angina include chest pressure or
pain, sometimes squeezing or “heavy” in character, often
radiating to the jaw or left arm. Unfortunately, many
patients with angina do not have classic symptoms. Their
discomfort may be very mild, and may be localized to the
back, abdomen, shoulders, or either or both arms. Nausea,
breathlessness, or merely a feeling of heartburn may be the
only symptom. What this means, essentially, is that anyone
middle aged or older, especially anyone with one or
more risk factors for coronary artery disease, should be
alert to symptoms that might represent angina.
Diagnosis
 How Is Unstable Angina Diagnosed?
 Symptoms are critically important in making the diagnosis
of unstable angina, or indeed, any form of ACS. In
particular, if you have one or more of the following three
symptoms:-

 Angina at rest, especially if it lasts more than 20 minutes at

a time
 New onset angina that markedly limits the patient's ability
to engage in physical activity
 An increase in prior stable angina, with episodes that are
more frequent, longer lasting, or occur with less exertion
than previously
Cont..
If the portion of the ECG known as "ST segments" are
elevated (which indicates that the artery is completely
blocked), and the cardiac enzymes are increased
(which indicates cardiac cell damage), a "large"
myocardial infarction (MI) is diagnosed (also called an
"ST-segment elevation MI," or STEMI)
If the ST segments are not elevated (so the artery is not
completely blocked), but the cardiac enzymes are
increased (cell damage is present), a "small" MI is
diagnosed (also called a "non-ST segment MI,"
or NSTEMI)
Cont..
 If the ST segments are not elevated and the enzymes are
normal (meaning the artery is not completely blocked and
no cell damage is present), unstable angina is diagnosed.
 Notably, unstable angina and NSTEMI are similar
conditions. In each condition, a plaque rupture has
occurred in a coronary artery, but the artery is not
completely blocked so at least some blood flow remains. In
both of these conditions, the symptoms of unstable angina
are present. The only difference is that in an NSTEMI
enough heart cell damage has occurred to produce an
increase in cardiac enzymes. Because these two conditions
are so similar, their treatment is identical.
Cont..
What Is the Treatment For Unstable Angina (and
NSTEMI)
If you have either unstable angina or NSTEMI, you will
be treated with one of two general approaches: a) treat
aggressively with drugs to stabilize the condition, then
evaluate non-invasively, or b) treat aggressively with
drugs to stabilize the condition, and schedule early
invasive intervention (generally, angioplasty and
stenting).