Overview of the non-acute management of unstable angina and non-ST elevation myocardial infarction
- 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 .
- Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 130:2354.
- Gibson RS, Hansen JF, Messerli F, et al. Long-term effects of diltiazem and verapamil on mortality and cardiac events in non-Q-wave acute myocardial infarction without pulmonary congestion: post hoc subset analysis of the multicenter diltiazem postinfarction trial and the second danish verapamil infarction trial studies. Am J Cardiol 2000; 86:275.
- The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group. N Engl J Med 1988; 319:385.
- Gibson RS, Boden WE, Theroux P, et al. Diltiazem and reinfarction in patients with non-Q-wave myocardial infarction. Results of a double-blind, randomized, multicenter trial. N Engl J Med 1986; 315:423.
- Held PH, Yusuf S, Furberg CD. Calcium channel blockers in acute myocardial infarction and unstable angina: an overview. BMJ 1989; 299:1187.
- Sabatine MS, Morrow DA, Giugliano RP, et al. Association of hemoglobin levels with clinical outcomes in acute coronary syndromes. Circulation 2005; 111:2042.
- Hébert PC, Fergusson DA. Do transfusions get to the heart of the matter? JAMA 2004; 292:1610.
- Cooper HA, Rao SV, Greenberg MD, et al. Conservative versus liberal red cell transfusion in acute myocardial infarction (the CRIT Randomized Pilot Study). Am J Cardiol 2011; 108:1108.
- Chatterjee S, Wetterslev J, Sharma A, et al. Association of blood transfusion with increased mortality in myocardial infarction: a meta-analysis and diversity-adjusted study sequential analysis. JAMA Intern Med 2013; 173:132.
- Salpeter SR, Buckley JS, Chatterjee S. Impact of more restrictive blood transfusion strategies on clinical outcomes: a meta-analysis and systematic review. Am J Med 2014; 127:124.
- Wu WC, Rathore SS, Wang Y, et al. Blood transfusion in elderly patients with acute myocardial infarction. N Engl J Med 2001; 345:1230.
- Hébert PC, Yetisir E, Martin C, et al. Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases? Crit Care Med 2001; 29:227.
- Carson JL, Brooks MM, Abbott JD, et al. Liberal versus restrictive transfusion thresholds for patients with symptomatic coronary artery disease. Am Heart J 2013; 165:964.
- Qaseem A, Humphrey LL, Fitterman N, et al. Treatment of anemia in patients with heart disease: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2013; 159:770.
- Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37:267.
- Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB*. Ann Intern Med 2012; 157:49.
- Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399.
- Mukherjee D, Fang J, Chetcuti S, et al. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes. Circulation 2004; 109:745.
- Ambrosioni E, Borghi C, Magnani B. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. The Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators. N Engl J Med 1995; 332:80.
- Søgaard P, Nøgaard A, Gøtzsche CO, et al. Therapeutic effects of captopril on ischemia and dysfunction of the left ventricle after Q-wave and non-Q-wave myocardial infarction. Am Heart J 1994; 127:1.
- Ho PM, Spertus JA, Masoudi FA, et al. Impact of medication therapy discontinuation on mortality after myocardial infarction. Arch Intern Med 2006; 166:1842.
- Anderson J, Adams C, Antman E, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 2002 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College or Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2007; 50:e1 www.acc.org/qualityandscience/clinical/statements.htm (Accessed on September 18, 2007).
- Latini R, Tognoni G, Maggioni AP, et al. Clinical effects of early angiotensin-converting enzyme inhibitor treatment for acute myocardial infarction are similar in the presence and absence of aspirin: systematic overview of individual data from 96,712 randomized patients. Angiotensin-converting Enzyme Inhibitor Myocardial Infarction Collaborative Group. J Am Coll Cardiol 2000; 35:1801.
- Pfeffer MA, McMurray JJ, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med 2003; 349:1893.
- Pitt B, White H, Nicolau J, et al. Eplerenone reduces mortality 30 days after randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. J Am Coll Cardiol 2005; 46:425.
- Beygui F, Cayla G, Roule V, et al. Early Aldosterone Blockade in Acute Myocardial Infarction: The ALBATROSS Randomized Clinical Trial. J Am Coll Cardiol 2016; 67:1917.
- Meine TJ, Patel MR, Washam JB, et al. Safety and effectiveness of transdermal nicotine patch in smokers admitted with acute coronary syndromes. Am J Cardiol 2005; 95:976.
- 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