Clinical Practice Guideline Number 10
Recommendations on the care of patients with unstable angina made in this clinical
practice guideline are based on a combination of evidence obtained through extensive
literature reviews and, in cases where evidence was lacking, on the consensus opinions of the
expert panel. Principal conclusions of this guideline include:
-
Many patients suspected of having unstable angina can be discharged home after adequate
initial evaluation.
- Further outpatient evaluation of patients with symptoms of unstable angina judged at
initial evaluation to be at low risk for complications should be concluded within 72 hours
after initial presentation.
- Patients with unstable angina judged to be at intermediate or high risk of complications
should receive aspirin, heparin, nitroglycerin, and beta-blocker therapy and should be
hospitalized for careful monitoring of their clinical course.
- Intravenous thrombolytic therapy should not be administered to patients without evidence
of acute myocardial infarction.
- Assessment of prognosis by noninvasive testing often aids selection of appropriate
therapy.
- Coronary angiography is appropriate for patients judged to be at high risk for cardiac
complications or death based on their clinical course or results of noninvasive testing.
- Coronary artery bypass surgery should be recommended for almost all patients with left
main disease and many patients with three-vessel disease, especially those with left
ventricular dysfunction.
- The discharge care plan should include continued monitoring of symptoms, appropriate
drug therapy including aspirin and risk factor modification, and counseling.
This document is in the public domain and may be used and reprinted without special
permission, except for those copyrighted materials noted for which further reproduction is
prohibited without the specific permission of the copyright holders. AHCPR and NHLBI will
appreciate citation as to source, using the suggested format:
Braunwald E, Mark DB, Jones RH et al. Unstable Angina: Diagnosis and Management.
Clinical Practice Guideline Number 10. AHCPR Publication No. 94-0602. Rockville, MD:
Agency for Health Care Policy and Research and the National Heart, Lung, and Blood
Institute, Public Health Service, U.S. Department of Health and Human Services. May 1994
(amended).
- Eugene Braunwald, MD
-
- (Panel Chair)
Hersey Professor of the
Theory and Practice of Medicine
Chairman, Department
of Medicine
-
- Harvard Medical School
-
- Brigham & Women's Hospital
-
- Boston, MA
-
- Jay Brown, MD (Deceased)
-
- Chief, Division of Cardiology
-
- Harlem Hospital Center
-
- Clinical Associate Professor
of Medicine
-
- Columbia University
College of Physicians and Surgeons
-
- New York, NY
-
- Leslie Brown, MPH, JD
-
- Deputy Director
-
- Division of Adult Health
Promotion
-
- Department of Environment, Health, and Natural Resources
State of North Carolina
-
- Raleigh, NC
-
- Melvin D. Cheitlin, MD
-
- Chief, Cardiology Division
-
- San Francisco General Hospital
-
- Professor of Medicine
-
- University of California,
San Francisco
School of Medicine
-
- San Francisco, CA
-
- Craig A. Concannon, MD
-
- Chief of Staff
-
- Mitchell County Hospital
-
- Clinical Professor
-
- University of Kansas
School of Medicine, Wichita
-
- Wichita, KS
-
- Marie Cowan, RN, MS, PhD
-
- Associate Dean of Research
and Practice
-
- Professor of Physiological
Nursing
-
- University of Washington
School of Nursing
-
- Seattle, WA
-
- Conan Edwards, PhD
-
- Volunteer
-
- American Association of
Retired Persons
-
- Madison, WI
-
- Valentin Fuster, MD, PhD
-
- Arthur M. and Hilda A. Master
Professor of Medicine
-
- Director, Cardiovascular Institute
Vice Chairman,
-
- Department of Medicine
Mount Sinai Medical Center
-
- New York, NY
-
- Lee Goldman, MD
-
- Professor of Medicine
-
- Harvard Medical School
-
- Chief Medical Officer
-
- Brigham & Women's Hospital
-
- Boston, MA
-
- Lee A. Green, MD, MPH
-
- Assistant Professor
-
- Department of Family Practice
University of Michigan
Medical School
-
- Lecturer in Health Services Management and Policy
-
- University of Michigan School
of Public Health
-
- Ann Arbor, MI
-
- Cindy L. Grines, MD
-
- Director
Cardiac Catheterization
Laboratory
-
- William Beaumont Hospital
-
- Royal Oak, MI
-
- Bruce W. Lytle, MD
-
- Surgeon
Department of Thoracic and Cardiovascular Surgery
-
- Cleveland Clinic Foundation
-
- Cleveland, OH
-
- Kathleen M. McCauley, PhD, RN, CS
-
- Assistant Professor of
Cardiovascular Nursing
-
- University of Pennsylvania
School of Nursing
-
- Cardiovascular Clinical Specialist
-
- Hospital of the
University of Pennsylvania
-
- Philadelphia, PA
-
- Alvin I. Mushlin, MD, ScM
-
- Professor of Community
Medicine and Medicine
-
- University of Rochester
Medical Center
-
- Rochester, NY
-
- Gregory C. Rose, MD
-
- Director, Mobile Cardiac
Care Unit
-
- Wake Medical Center
-
- Raleigh, NC
-
- Earl E. Smith III, MD
-
- Medical Director and Chief Emergency Department
-
- Erlanger Medical Center
-
- Clinical Instructor
Department of Medicine
-
- Chattanooga Unit, University
of Tennessee
College of Medicine
-
- Chattanooga, TN
-
- Julie A. Swain, MD
-
- Chief, Division of
Cardiovascular Surgery
Vice Chairman, Department
of Surgery
-
- University of Nevada
School of Medicine, Las Vegas
-
- Las Vegas, NV
-
- Eric J. Topol, MD
-
- Professor of Medicine
Cleveland Clinic Health Sciences Center,
-
- Ohio State University
-
- Chairman, Department
of Cardiology
-
- Cleveland Clinic Foundation
-
- Cleveland, OH
-
- James T. Willerson, MD
-
- Edward Randall III Professor Chairman, Department of
Internal Medicine
-
- University of Texas
Health Science Center, Houston
-
- Medical Director
-
- Texas Heart Institute
-
- Houston, TX
-
- Angina pectoris:
-
- A clinical syndrome typically characterized by a deep, poorly localized chest or arm
discomfort that is reproducibly associated with physical exertion or emotional stress and
relieved promptly by rest or sublingual nitroglycerin. The discomfort of angina is often hard
for patients to describe, and many patients do not consider it to be "pain." In most but not all
patients, these symptoms reflect myocardial ischemia resulting from significant underlying
coronary artery disease.
- Coronary artery disease (CAD):
-
- While a number of disease processes other than atherosclerosis can involve coronary
arteries, in this guideline the term CAD refers to the atherosclerotic narrowing of the major
epicardial coronary arteries.
- Angiographically significant CAD:
-
- CAD is typically judged "significant" at coronary angiography if there is at least a 70
percent diameter stenosis of one or more major epicardial coronary segments or at least a 50
percent diameter stenosis of the left main coronary artery. The term "significant CAD" used
in this guideline does not imply clinical significance but refers only to an angiographically
significant stenosis.
- Myocardial ischemia:
-
- A condition in which oxygen delivery to and waste removal from the myocardium
falls below normal levels with oxygen demand exceeding supply. As a consequence, the
metabolic machinery of myocardial cells is impaired leading to various degrees of systolic
(contractile) and diastolic (relaxation) dysfunction. Ischemia is usually diagnosed indirectly
through techniques that demonstrate reduced myocardial blood flow or its consequences on
contracting myocardium.
- Ischemic heart disease:
-
- A form of heart disease whose primary manifestations result from myocardial
ischemia due to atherosclerotic CAD. This term encompasses a spectrum of patients ranging
from the asymptomatic preclinical phase to acute myocardial infarction and sudden death.
- Acute myocardial infarction (MI):
-
- An acute process of myocardial ischemia with sufficient severity and duration to
result in permanent myocardial damage.
- Reperfusion-eligible acute MI:
-
- A condition characterized by a clinical presentation compatible with acute MI
accompanied by ST-segment elevation or left bundle branch block on electrocardiogram.
- Non-Q-wave MI:
-
- An MI that is not associated with the evolution of new Q waves on the ECG. The
diagnosis of non-Q-wave MI is often difficult to make soon after the event and is commonly
made only retrospectively on the basis of elevated cardiac enzyme levels.
- Post-MI angina:
-
- Unstable angina occurring from 1 to 60 days after an acute MI.
- Variant angina:
-
- A clinical syndrome of rest pain and reversible ST-segment elevation without
subsequent enzyme evidence of acute MI. In some patients, the cause of this syndrome
appears to be coronary vasospasm alone often at the site of an insignificant coronary plaque,
but a majority of patients with variant angina have angiographically significant CAD.
- Likelihood:
-
- Used in this guideline to refer to the probability of an underlying diagnosis,
particularly significant CAD.
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