Chest Pain & Unstable Angina Eugene Yevstratov MD

1. Chest Pain & Unstable AnginaEugene Yevstratov MD Based on UCLA protocol of the management of Chest Pain & Unstable Angina

2. Diagnostic criteria for acute myocardial infarction 1ST elevation > 1 mm in 2 or more contiguous limb or precordial leads 2Left 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

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

4. Likelihood of significant coronary artery disease in patients with symptoms suggesting unstable angina Low Likelihood: (e.g., 0.01-0.14) 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., 0.15-0.84) "Definite angina" in patients with no risk factors for CAD. High Likelihood: (e.g., 0.85-0.99) 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.

5. Risk Assessment • Low risk: Nonresting angina with increased frequency, severity, or duration. Angina provoked at a lowerthreshold. New onset angina 2 weeks to 2 months. Normal or unchanged ECG. • Intermediate risk: Rest angina now resolved. Rest angina < 20 minutes in duration, angina with dynamic T wave changes. New onset angina < 2 weeks at minimal exertion. Age > 65 years. Q waves or ST depressionon ECG. • High risk: Ongoing rest pain > 20 minutes. Angina with pulmonary edema, S3, or rales. Angina with new orworsening mitral regurgitation. Rest angina with dynamic ST changes > 1 mm. Angina with hypotension.

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

7. The treatment of acute myocardial infarction is detailed in the UCLA Acute Myocardial Infarction Practice 1. Activate the CLOT team (CCU fellow) 2. All patients should receive regular ASA 325 mg as soon as possible unless a definite contraindication ispresent (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 withaspirin, unless contraindicated. If aspirin allergic, use clopidigrel 300 mg loading dose alone.

8. 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 bolusof 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)

9. 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) shouldnot be delayed. Direct catheterization is the preferred treatment strategy

10. Unstable Angina General Care 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. .

11. 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 ofcardiac catheterization determined.

12. 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

13. Laboratory Testing •ECG initially, with ongoing or recurrent symptoms, with relief of chest pain, and 6 hours afteradmission. • 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 hourtroponin is negative).

14. Diagnostic Algorithms

15. Diagnostic Algorithms

16. 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

17. Treatment Stratification

18. Patients with coronary artery disease will live longer when treated with a HMG CoA Reductase Inhibitor. Inthe 4S trial there was a 34% risk reduction in major cardiac events, a 42% risk reduction in cardiovascularmortality and a 30%reduction in all cause mortality associated with statin treatment. The LIPID trialdemonstrated that even patients with "low or normal" levels of total cholesterol and LDL cholesterol (LDL 70-170 mg/dl) have mortality reduction with statin treatment. Patients should be educated that these medicationsare for the treatment of atherosclerosis, not because the patient has “failed” dietary treatment and that use ofthese medications lowers the risk of recurrent events, need forhospitalizations,revascularization, strokes, andmortality.

19. The HOPE trial demonstrated that in patients with CAD, CVD, PVD or diabetes the use of an ACE inhibitorwas 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.

20. Eugene Yevstratov MD Phone: 0054111540682712 (ARG) Private: 0030372236344 / 0030372231698 (UKr) Fax: 001 775 796 2780 (USA) Email: ostlandfox@yahoo.de ostlandfox@medscape.com Link: http://myprofile.cos.com/eugenefox