Once the diagnosis of unstable angina or an acute non-ST elevation myocardial infarction (NSTEMI) is made, the early management of the patient involves the simultaneous achievement of several goals, including relief of ischemic pain, assessment of the hemodynamic state and correction of abnormalities that are present, determining the optimal timing of cardiac catheterization and potential percutaneous coronary intervention, and initiation of antithrombotic therapy. (See "Initial evaluation and management of suspected acute coronary syndrome in the emergency department" and "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction".)
These early diagnostic and therapeutic interventions are followed by the initiation of short- and long-term interventions aimed at improving in-hospital and long-term outcomes. This topic will summarize the management of patients with unstable angina or acute NSTEMI in the hours and days following reperfusion. The reader will be directed to a more detailed discussion of these issues in other topics.
The management of the patient with an ST elevation MI or with a complication of an acute MI (eg, cardiogenic shock, mitral regurgitation, ventricular septal defect) is discussed separately. (See "Overview of the acute management of ST elevation myocardial infarction" and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction" and "Mechanical complications of acute myocardial infarction".)
FURTHER MEDICAL THERAPY
Following initial therapy as discussed above, further medical therapy includes oral beta blockers (if not already given), statins, and possibly nitrates, aldosterone antagonists, and angiotensin converting enzyme (ACE) inhibitors. There is only a limited role for calcium channel blockers and oral anticoagulation, and no role for hormone replacement therapy in postmenopausal women.
Oral beta blockers — Patients who did not receive a beta blocker during the first 24 hours because of early contraindications should be reevaluated for beta blocker candidacy. An oral cardioselective beta blocker, such as metoprolol (25 to 50 mg twice daily with the short-acting preparation or 100 mg daily with the long-acting XL preparation) or atenolol (50 to 100 mg daily), may be used .