Unstable Angina: Diagnosis and Management

Table of Contents

• Purpose
• Process of Guideline Development
• Definition of Unstable Angina
• Diagnosis of Unstable Angina
• Prognosis of Unstable Angina
• Guideline Recommendations
• Patient Counseling
• Initial Evaluation and Treatment of Patients with Unstable Angina
• Outpatient Care
• Intensive Medical Management
• Progression to Nonintensive Medical Management
• Noninvasive Testing
• Cardiac Catheterization and Myocardial Revascularization
• Hospital Discharge and Postdischarge Care

• Definition of Terms and Processes
• Definition of Unstable Angina
• Definition of Care Environments
• Definition of Strength of Evidence Grading
• Background Information on Unstable Angina
• Unstable Angina in the Spectrum of Coronary Artery Disease
• Process of Unstable Angina
• Time-Dependent Mortality Risks of Unstable Angina
• ECG Findings Useful for Establishing the Likelihood of CAD.
• Summary: Estimating the Likelihood of CAD.
• Determination of Prognosis in Patients with Unstable Angina
• Clinical and ECG Findings Related to Short-Term Prognosis in Patients with Unstable Angina
• Factors Affecting Both Short- and Long-Term Prognosis in Unstable Angina
• Computer-Based Risk-Stratification Models in Patients with Acute Ischemic Heart Disease

• Introduction
• Objectives of Care
• Approach to Care Objectives
• Entry into Medical Care Directed by the Guideline
• Telephone Presentation.
• Outpatient Facility or Emergency Presentation.
• Stabilization and Initial Evaluation
• Evaluation of Unstable Angina Patients for Precipitating Noncardiac Causes of Symptoms.
• Initial Evaluation of High-Risk Patients.
• Initial Treatment of Patients with Unstable Angina
• Initial General Care.
• Treatment and Assessment of Relief of Symptomatic Ischemia
• Treatment of Symptomatic Ischemia.
• Patient Counseling
• Conclusion of Initial Evaluation and Treatment Phase
• Medical Record
• Duration of Initial Evaluation and Treatment Phase

• Introduction
• Objectives of Care
• Approach to Care Objectives
• Diagnostic Assessment
• Risk Stratification and Further Management
• Outpatient Treatment of Symptoms
• Patient Counseling
• Medical Record
• Duration of Outpatient Phase

• Introduction
• Objectives of Care
• Approach to Care Objectives
• Pharmacologic Management
• Nitrates.
• Morphine Sulfate.
• Beta Blockers.
• Calcium Channel Blockers.
• Aspirin.
• Ticlopidine and Other Antiplatelet Agents.
• Laboratory Testing
• Assessment of Efficacy of Initial Medical Therapy
• Evaluation and Management of Early Ischemic Complications
• Intra-aortic Balloon Pumping.
• Emergency/Urgent Cardiac Catheterization.
• Preparation for Nonintensive Phase
• Patient Counseling
• Conclusion of Intensive Medical Management Phase
• Medical Record
• Duration of Intensive Medical Management

• Introduction
• Objectives of Care
• Approach to Care Objectives
• Patient Counseling
• Medical Record
• Duration of Nonintensive Medical Management

• Background
• Objectives of Care
• Approach to Care Objectives
• Selection of Noninvasive Tests
• Use of Noninvasive Test Results in Patient Management
• Patient Counseling
• Medical Record

• Introduction
• Objectives of Care
• Approach to Care Objectives
• Cardiac Catheterization
• Revascularization
• Patient Counseling
• Medical Record

• Background
• Objectives of Care
• Approach to Care Objectives
• Discharge Medical Regimen
• Postdischarge Followup
• Patient Counseling
• Use of Medications
• Monitoring Symptoms
• Activity Level and Lifestyle Changes
• Medical Record

• Biosketches: Unstable Angina Guideline Panel
• Biosketches: Duke University Medical Center Authors
• Other Contributors1
• Consultant
• Peer Reviewers
• Pilot Reviewers
• AHCPR Staff
• Publication Design

• Table 1. Three principal presentations of unstable angina
• Table 2. Grading of angina pectoris by the Canadian Cardiovascular Society classification system
• Table 3. Definition of unstable angina care environments
• Table 4. Grading of evidence
• Table 5. Reported mortality of unstable angina
• Table 6. ECG findings useful for establishing the likelihood of coronary artery disease
• Table 7. Likelihood of significant coronary artery disease in patients with symptoms suggesting unstable angina
• Table 8. Short-term risk of death or nonfatal myocardial infarction in patients with unstable angina
• Table 9. Summary of drugs commonly used in the emergency department to treat patients with symptoms suggestive of unstable angina
• Table 10. Noninvasive studies in patients with unstable angina reporting at least 10 cardiac events (cardiac death or myocardial infarction) during followup

• Figure 1: Outcomes of 21,761 medically treated patients at Duke University Medical Center, 1985-1992, grouped by ischemic heart disease diagnosis on admission
• Figure 2: Outcomes of medically treated patients with unstable angina
• Figure 3: Entry of patients into the unstable angina guideline
• Figure 4: Influence of thrombolysis on myocardial infarction in patients presenting with unstable angina
• Figure 5: Relative risk of death or myocardial infarction in unstable angina patients treated with aspirin vs. placebo
• Figure 6: Patient flow: Outpatient care
• Figure 7: Patient flow: Intensive medical management
• Figure 8: Patient flow: Progression to nonintensive medical management
• Figure 9: Patient flow: Noninvasive testing
• Figure 10: Noninvasive testing for risk stratification in patients with unstable angina
• Figure 11: Nomogram of the prognostic relations embodied in the treadmill score
• Figure 12: Patient flow: Cardiac catheterization and myocardial revascularization
• Figure 13: Patient flow: Hospital discharge and postdischarge care

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