Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction
- Jeffrey A Breall, MD, PhD
Jeffrey A Breall, MD, PhD
- Professor of Clinical Medicine
- Indiana University School of Medicine
- Julian M Aroesty, MD
Julian M Aroesty, MD
- Clinical Associate Professor of Medicine
- Harvard Medical School
- Michael Simons, MD
Michael Simons, MD
- Robert W Berliner Professor of Medicine
- Yale University School of Medicine
- Section Editors
- Christopher P Cannon, MD
Christopher P Cannon, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Harvard Medical School
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
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 (myocardial infarction, unstable angina) 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".)
INPATIENT 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 .
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- INPATIENT MEDICAL THERAPY
- Oral beta blockers
- - Phosphodiesterase-5 inhibitors
- Statin therapy
- Calcium channel blockers
- Red cell transfusion
- Antiarrhythmic drugs
- Venous thromboembolism prophylaxis
- Glycemic control
- Gastrointestinal prophylaxis
- RECURRENT CHEST PAIN
- Recurrent ischemia and reinfarction
- - Management
- Infarction pericarditis
- PREPARING FOR DISCHARGE
- Chronic anticoagulation
- Long-term risk stratification
- - Stress testing
- - Evaluation of LV function
- Pharmacologic therapy
- - Antiplatelet therapy
- - Nitrates
- - ACE inhibitors
- - Angiotensin II receptor blockers
- - Mineralocorticoid receptor antagonists
- Ventricular arrhythmias
- Return to activities
- RISK FACTOR MODIFICATION
- Glycemic control
- Smoking cessation
- Stress management
- Cardiac rehabilitation
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS