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Unstable Angina

Crescendo Angina

Unstable angina is a cardiac disorder that presents with chest pain and clinical evidence of myocardial ischemia but without any detectable myocardial enzymes in blood.


Presentation

Unstable angina can present with symptoms that mirror those that occur in a patient with myocardial ischemia or myocardial infarction and include the following:

The symptoms often occur at rest and are aggravated by exercise or any type of physical activity. Often the symptoms fail to respond to nitroglycerin. In many cases, the patient may complain of symptoms at rest.

Physical exam may reveal:

Auscultation may reveal:

Over the years several classifications have been developed to grade unstable angina. These include the Braunwald Classification, Canadian Cardiovascular Society Grading System, Acute Coronary Syndrome Risk Assessment and Thrombolysis in Myocardial Infarction Risk Score. In general, all these scoring system grade the angina based on severity of chest pain, the precipitating factor and response to therapy.

Coronary Atherosclerosis
  • About 90 per cent of all cases can be attributed to coronary atherosclerosis. Studies have shown that at least one of the three major coronary arteries usually is stenosed before angina develops.[medical-dictionary.thefreedictionary.com]
  • Four subgroups are recognized. (1) The first is Prinzmetal’s variant angina, with intense focal spasm of a segment of an epicardial coronary artery not involved by coronary atherosclerosis. (2) In the second, also called Prinzmetal’s angina, the spasm[doi.org]
  • Unstable angina and progression of coronary atherosclerosis. N Engl J Med 1983;309:685–689. Google Scholar 3. Théroux P, Lidón RM. Unstable angina: Pathogenesis, diagnosis and treatment. Curr Probl Cardiol 1993;18:157–232. Google Scholar 4.[link.springer.com]
  • atherosclerosis, were initially considered to be quite distinct.[doi.org]
  • A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011 Jan 20. 364(3):226-35. [Medline]. Harrap SB, Zammit KS, Wong ZY, et al. Genome-wide linkage analysis of the acute coronary syndrome suggests a locus on chromosome 2.[emedicine.medscape.com]
Arm Pain
  • A high likelihood of ACS includes any of the following features: History of previous MI, sudden death, or other known history of CAD Chest, neck, jaw, or left arm pain consistent with prior documented angina Transient hemodynamic or ECG changes during[emedicine.medscape.com]
Dyspnea
  • Arm (usually left arm), lower jaw, neck, or shoulder pain Dyspnea, or shortness of breath Sweating Nausea and vomiting Fatigue Lightheadedness Abdominal pain Early morning awakening, about 1-2 hours before normally getting up Diagnosis A physician will[study.com]
  • Associated symptoms of palpitations, dyspnea, nausea, diaphoresis, light-headedness, syncope, or dysphoria can occur.[unboundmedicine.com]
  • Symptoms of unstable angina Symptoms of unstable may include: Chest pain Sweating Dyspnea Nausea Vomiting Fatigue Dizziness Sudden weakness Pain radiating to the back, neck, jaw, abdomen, shoulders, or arms Angina symptoms occurring at rest, often becoming[belmarrahealth.com]
  • Important associated symptoms may be dyspnea, generalized fatigue, diaphoresis, nausea and vomiting, flulike symptoms, and, less commonly, lightheadedness or abdominal pain.[emedicine.medscape.com]
  • Gastric ulcer No Maintenance: 100mg, once a day Ticagrelor Oral loading dose: 180mg Maintenance: 90mg, twice a day 1 year Sinus node disease Ventricular pause (6%) No Keep loading dose if previous clopidogrel Second and third degree atrioventricular block Dyspnea[ncbi.nlm.nih.gov]
Aspiration
  • Thrombus aspiration was also associated with significantly less long-term mortality in unstable angina pectoris patients (adjusted HR: 4.61, 95% CI: 1.16-18.21, P   0.029).Thrombus aspiration in the context of unstable angina pectoris is associated with[ncbi.nlm.nih.gov]
Nausea
  • Unstable angina can present with symptoms that mirror those that occur in a patient with myocardial ischemia or myocardial infarction and include the following: Chest pain Shortness of breath Diaphoresis Dizziness Lightheadedness Fatigue Nausea Vomiting[symptoma.com]
  • Angina symptoms include: chest pain that feels crushing, pressure-like, squeezing, or sharp pain that radiates to your upper extremities (usually on the left side) or back nausea anxiety sweating shortness of breath dizziness unexplained fatigue It’s[healthline.com]
  • Arm (usually left arm), lower jaw, neck, or shoulder pain Dyspnea, or shortness of breath Sweating Nausea and vomiting Fatigue Lightheadedness Abdominal pain Early morning awakening, about 1-2 hours before normally getting up Diagnosis A physician will[study.com]
  • Nausea, breathlessness, or merely a feeling of heartburn may be the only symptom.[verywell.com]
  • Symptoms of unstable angina Symptoms of unstable may include: Chest pain Sweating Dyspnea Nausea Vomiting Fatigue Dizziness Sudden weakness Pain radiating to the back, neck, jaw, abdomen, shoulders, or arms Angina symptoms occurring at rest, often becoming[belmarrahealth.com]
Abdominal Pain
  • Arm (usually left arm), lower jaw, neck, or shoulder pain Dyspnea, or shortness of breath Sweating Nausea and vomiting Fatigue Lightheadedness Abdominal pain Early morning awakening, about 1-2 hours before normally getting up Diagnosis A physician will[study.com]
  • pain The symptoms often occur at rest and are aggravated by exercise or any type of physical activity.[symptoma.com]
  • ., adj an ginal. herpes angina ( angina herpe tica ) herpangina. intestinal angina generalized cramping abdominal pain occurring shortly after a meal and persisting for one to three hours, due to ischemia of the smooth muscle of the bowel. angina pec[medical-dictionary.thefreedictionary.com]
  • There are other diseases that can cause chest pain, abdominal pain, shortness of breath, sweating, and nausea and vomiting. Questions may be asked to determine whether other possibilities other than angina exist.[medicinenet.com]
  • Women may also experience symptoms such as: Nausea Shortness of breath Abdominal pain Discomfort in the neck, jaw or back Stabbing pain instead of chest pressure When to see a doctor If your chest pain lasts longer than a few minutes and doesn't go away[mayoclinic.org]
Chest Pain
  • Unstable angina is chest pain that is sudden and often gets worse over a short period of time.[nlm.nih.gov]
  • However, subclinical hyperthyroidism rarely presents as chest pain in the resting state.[ncbi.nlm.nih.gov]
  • He performed an exercise test on Bruce protocol and exercised up to 12min (13 METs) without chest pain and ST-T changes on the next day.[ncbi.nlm.nih.gov]
  • Unstable angina is a serious heart disorder that often presents with chest pain at rest. When the chest pain does not respond to nitroglycerin, it is highly recommended that the patient be seen in the emergency room.[symptoma.com]
  • It is also classified as a type of acute coronary syndrome (Angina: [crescendo] or [unstable] or [at rest]) or (preinfarction syndrome) or (impending infarction) Angina at rest Anginal chest pain at rest Impending infarction (disorder) Preinfarction angina[wikidata.org]
Heart Disease
  • If you have one or more risk factors for heart disease, talk to your provider about taking aspirin or other medicines to help prevent a heart attack.[nlm.nih.gov]
  • Abstract Although statistical evidence is clear regarding the dangerousness of unstable angina (UA), a form of coronary heart disease (CHD) characterised by high mortality and morbidity globally, it is important to recognise that diagnostic precision[ncbi.nlm.nih.gov]
  • Learn more Women's Heart The region’s only Women’s Heart Program, providing tailored heart care to women with heart disease.[urmc.rochester.edu]
Heart Murmur
  • The provider may hear abnormal sounds, such as a heart murmur or irregular heartbeat, when listening to your chest with a stethoscope.[nlm.nih.gov]
  • Tachycardia or bradycardia Auscultation may reveal: New heart murmur may be heard. Presence of S3 or S4. Rales or crackles. Over the years several classifications have been developed to grade unstable angina.[symptoma.com]
Retrosternal Chest Pain
  • 73 year-old man presented to our emergency department with complaint of retrosternal chest pain since 2 day and admitted with diagnosis of unstable angina.[ncbi.nlm.nih.gov]
  • The patient is a 75-year-old woman who presented with repeated episodes of retrosternal chest pain. She notably had a history of type II diabetes mellitus treated by insulin for several years and complicated by diabetic macro-angiopathy.[ncbi.nlm.nih.gov]
Systolic Murmur
  • murmur due to papillary muscle dysfunction Rales or crackles Findings indicative of peripheral arterial occlusive disease or prior stroke increase the likelihood of associated coronary artery disease (CAD) and are as follows: Carotid bruit Supraclavicular[emedicine.medscape.com]
Shoulder Pain
  • When you engage in physical activity at various levels of intensity, you have come to expect shortness of breath (more common in women than men), chest pressure, neck, jaw or shoulder pain. When you stop the activity, symptoms also cease.[sharecare.com]
  • Arm (usually left arm), lower jaw, neck, or shoulder pain Dyspnea, or shortness of breath Sweating Nausea and vomiting Fatigue Lightheadedness Abdominal pain Early morning awakening, about 1-2 hours before normally getting up Diagnosis A physician will[study.com]

Workup

The most important thing to determine in a patient with unstable angina is the degree of coronary artery disease and how serious it is. Routine workup of a patient with unstable angina requires the following:

  • Complete blood count
  • Lipid profile
  • Renal function
  • Serial cardiac enzymes such as troponin, creatine kinase, C-reactive protein (CRP) and brain (B-type) natriuretic peptide (BNP) [5]
  • Serum electrolytes

ECG is the first line assessment in patients with unstable angina which should be obtained soon after admission to the ER. Any patient with chest pain with ECG evidence of ST-segment elevation or development of a new left bundle branch block needs an urgent cardiology consult. These patients often benefit from immediate revascularization treatment. Subsequent ECGs depend on the symptoms. If there is any clinical or laboratory evidence of worsening of the patient, serial ECGs should be ordered at least every 30 minutes to follow progression of ST-segment changes. It should be noted that primary T-wave changes alone are not sensitive indicators for ischemia.

Imaging

Thrombocytosis
  • Essential thrombocythemia (ET) is a clonal disorder of myeloid stem cells that causes thrombocytosis.[ncbi.nlm.nih.gov]
Hyperviscosity
  • Unstable angina secondary to impaired oxygen delivery can result from anemia, hypoxemia, and hyperviscosity states.[doi.org]
Chlamydia
  • Elevated Chlamydia pneumoniae antibodies, cardiovascular events, and azithromycin in male survivors of acute myocardial infarction. Circulation. 1997 ; 96 :404–407. Crossref Medline Google Scholar[doi.org]
First-Degree Atrioventricular Block
  • atrioventricular block, second- and third-degree atrioventricular block without a pacemaker, asthma, severe left ventricular dysfunction with congestive heart failure, significant chronic obstructive pulmonary disease, and significant sinus bradycardia[aafp.org]
T Wave Inversion
  • ., ST segment depression or transient elevation or new T wave inversion). Since an elevation in troponin may not be detectable for up to 12 hours after presentation, UA and NSTEMI are frequently indistinguishable at initial evaluation.[en.wikipedia.org]
  • In general, patients with new ST-segment changes seen on the initial ECG have a worse prognosis compared to patients with isolated T-wave inversion.[symptoma.com]
  • ECG changes, such as ST-segment depression or T-wave inversions, may be present ( 1 ). Epidemiology Incidence Estimated annual incidence of new and recurrent MI is 605,000 and 200,000, respectively ( 2 ).[unboundmedicine.com]
  • […] disease (peripheral, brachiocephalic, or renal artery atherosclerosis) ST depression of 0.05-1 mm T-wave inversion of 1 mm or greater in leads with dominant R waves A low likelihood of ACS includes the absence of high- or intermediate-likelihood features[emedicine.medscape.com]
  • Two of these 3 disorders, UA and NSTEMI, are usually considered together 14 because they exhibit indistinguishable clinical and ECG features (ST-segment depressions and T-wave inversion) and constitute the non–ST-segment–elevation ACS (NSTE-ACS).[doi.org]

Treatment

The treatment of unstable angina requires admission with bed rest [6] [7]. All patients must be continuously monitored and have at least two intravenous lines. Oxygen is often provided if the patient saturation is below 94%. It is important to realize that unstable angina is a very unpredictable disorder and is life threatening. These patients are best monitored in an ICU setting or a cardiology floor where continuous monitoring is available.

The treatment of unstable angina is guided at the cause of ischemia and reinstitution of blood flow to the heart [8]. Many guidelines have been published about management of unstable angina patients. While some patients will benefit from medical therapy, others may require intensive care admission or emergency revascularization. Patients who are symptomatic despite therapy or are hemodynamically unstable should have emergency revascularization. Patients who respond to treatment still should observed closely with continuous telemetry. The classes of medications that are used to treat unstable angina include:

Aspirin is started on all patients within 30 mins of admission to those who are not at risk for bleeding or have any allergies to the agent. Beta-blockers do relieve ischemic symptoms but are contraindicated in patients with shock or bradycardia. Oral beta blockers are preferred to the IV drugs. Newer anti-platelet agents that can be used to treat unstable angina patients include use of prasugrel, ticagrelor, abciximab, eptifibatide or tirofiban. These agents can decrease symptoms but often do not affect the long-term risk of major adverse events.

During the initial period of admission, the patient should be kept nil per os just in case an invasive procedure or other study is anticipated. For the stable patient, a low sodium and a low cholesterol diet is recommended.

For patients who remain unstable despite maximal therapy, cardiac catheterization is recommended. These include patients with:

So far, there is debate on benefits of non-invasive therapy versus invasive therapy. Not all patients with unstable angina have triple vessel coronary disease and in some cases, there is only minimal disease. In general, coronary artery bypass is recommended for patients with:

  • Left main coronary stenoses > 70%. Patients too ill to undergo open heart surgery may undergo angioplasty with stenting.
  • Low ejection fraction (<25%).
  • Significant triple vessel coronary artery disease.
  • Diabetic patients with significant stenosis in multiple coronary vessels.
  • Presence of any associated severe valvular heart disease.

Prognosis

The prognosis of patients with unstable angina is greatly dependent on comorbidity, response to medication, time to diagnosis and treatment, presence of cardiogenic shock and type of therapeutic intervention. In general, patients with new ST-segment changes seen on the initial ECG have a worse prognosis compared to patients with isolated T-wave inversion. Over the years several negative prognostic factors have been identified for unstable angina patients and include the following:

In many patients with unstable angina who are on intense antianginal therapy, repeat attacks are not rare.

Etiology

Causes and risk factors for unstable angina include the following:

The metabolic syndrome is characterized by abdominal obesity (waist circumference > 40 inches for men and 35 inches in women), decreased HDL <40 mg/dl for men and <50 mg/dl in women, hypertriglyceridemia (> 150mg/dl) and hypertension (>130/85 mmHg). Patients suffering from the metabolic syndrome tend to have a 3-4 fold increased risk for development of coronary artery atherosclerosis and stroke compared to those who do not have this syndrome [4].

Epidemiology

The incidence of unstable angina is on the increase globally based on stats from emergency rooms. In addition, there is a gross underestimate of the real numbers because many cases of unstable angina are not clinically recognized and other are managed in outpatient settings. Unstable angina typically presents in patients aged 60 and over. Women with unstable angina tend to be 5 years older and African Americans tend to presents at a slightly younger age than other races.

Unstable angina in women is frequently associated with comorbid disorders like diabetes, hypertension, congestive heart failure and a family history of coronary artery disease. Men on the other hand, tend to present with a history of prior myocardial infarction and/or coronary revascularization. Overall, unstable angina tends to have the worst outcomes in African Americans compared to other races.

Sex distribution
Age distribution

Pathophysiology

The pathology of unstable angina is related to several factors that include the following:

  • Cyclical flow of blood that does not meet demands of the heart. The cyclical flow of blood is related to episodes of vasospasm which may be triggered by a variety of factors.
  • Disruption or rupture of an atherosclerotic plaque resulting in downstream occlusion or narrowing of a coronary artery.
  • Mismatch in supply and demand of oxygen.
  • Thrombosis in the coronary vessels.
  • Vasoconstriction or spasm of a coronary vessel, in many cases the right coronary artery.

Conditions causing a mismatch of oxygen supply versus demand include the following:

Prevention

Once unstable angina has resolved, preventive steps should be encouraged [9]. It is important to wait at least 4-12 weeks to allow that risk of major adverse event to subside before making any sudden changes in the lives of these patients. Secondary prevention requires changes in lifestyle such as:

  • Healthy diet
  • Participating in exercise
  • Lowering cholesterol
  • Controlling blood sugar
  • Discontinuation of smoking
  • Limiting intake of alcohol
  • Reducing body weight
  • Taking statins
  • Control of hypertension
  • Limiting physical activity like shoveling snow in cold weather

Summary

One of the clinical spectrums of acute coronary syndrome (ACS) is unstable angina. Patients who have unstable angina present exactly like those who have myocardial ischemia or a myocardial infarction but they do not have elevated levels of cardiac enzyme in the blood. When worked up, these patients do not always have severe coronary disease but in fact tend to have coronary artery vasospasm. Often the chest pain is unresponsive to nitroglycerin and patients seek assistance in the emergency room. Even though unstable angina is not associated with elevated levels of cardiac biomarkers, it is a serious disorder that can be life threatening. The treatment involves the use of a variety of cardiac medications and in some cases, interventional therapy [1] [2] [3].

Patient Information

Unstable angina is a serious heart disorder that often presents with chest pain at rest. When the chest pain does not respond to nitroglycerin, it is highly recommended that the patient be seen in the emergency room. Unstable angina is very unpredictable and needs immediate medical attention.

Other common symptoms are: 

Patients may have a varied course in hospital ranging from a heart attack, heart failure or development of abnormal heart rhythm. Once the diagnosis is made, the treatment starts with medications to reduce angina symptoms and improve blood flow. Some patients may need procedure to open up the coronary vessels if there is a blockage. Prevention rests on a healthy low fat diet, discontinuation of smoking, regular exercise and compliance with medications.

References

Article

  1. Makki N, Brennan TM, Girotra S. Acute Coronary Syndrome. J Intensive Care Med. 2013 Sep 18.
  2. Brieger DB, Redfern J. Contemporary themes in acute coronary syndrome management: from acute illness to secondary prevention. Med J Aust. 2013 Aug 5;199(3):174-8.
  3. Hung MJ, Hu P, Hung MY. Coronary artery spasm: review and update. Int J Med Sci. 2014 Aug 28;11(11):1161-71.
  4. Brunori EH, Lopes CT, Cavalcante AM, Santos VB, Lopes Jde L, de Barros AL. Association of cardiovascular risk factors with the different presentations of acute coronary syndrome. Rev Lat Am Enfermagem. 2014 Jul-Aug;22(4):538-46.
  5. Mueller C. Biomarkers and acute coronary syndromes: an update. Eur Heart J. 2014 Mar;35(9):552-6.
  6. Vengoechea F. Management of acute coronary syndrome in the hospital: a focus on ACCF/AHA guideline updates to oral antiplatelet therapy.v Hosp Pract (1995). 2014 Aug;42(3):33-47
  7. Clark MG, Beavers C, Osborne J. Managing the acute coronary syndrome patient: Evidence based recommendations for anti-platelet therapy. Heart Lung. 2015 March - April;44(2):141-149
  8. Roffman DS. Developments in Oral Antiplatelet Agents for the Treatment of Acute Coronary Syndromes: Clopidogrel, Prasugrel, and Ticagrelor. J Pharm Pract. 2015 Feb 8.
  9. Horstick G. Prevention after acute coronary syndrome]. Dtsch Med Wochenschr. 2014 Jan;139 Suppl 1:S43-6.

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Last updated: 2019-07-11 21:49