(Acute coronary insufficiency, Präinfarktangina, Intermediärsyndrom)
Unstable angina results from acute obstruction of a coronary artery without myocardial infarction. Symptoms include discomfort in the chest area with or without dyspnea, nausea and sweating and cold sweats. The diagnosis results from the ECG and the presence or absence of serological markers. Treatment is with anticoagulant drugs, anticoagulants, nitrates, statins and beta blockers. Coronary angiography with percutaneous intervention or coronary artery bypass surgery is often necessary.
(See also Procedure for acute coronary syndromes.)
Unstable angina results from acute obstruction of a coronary artery without myocardial infarction. Symptoms include discomfort in the chest area with or without dyspnea, nausea and sweating and cold sweats. The diagnosis results from the ECG and the presence or absence of serological markers. Treatment is with anticoagulant drugs, anticoagulants, nitrates, statins and beta blockers. Coronary angiography with percutaneous intervention or coronary artery bypass surgery is often necessary. (. See also procedure for acute coronary syndromes) Unstable angina is a type of acute coronary syndrome, which is defined by one or more of the following features in patients whose cardiac biomarkers do not meet the criteria for acute myocardial infarction (MN): Longer prolonged angina at rest (usually> 20 min) emerging angina with symptoms that at least grade 3 CCS (Canadian Cardiac Society-) classification equivalent (see table: classification system of the Canadian cardiovascular Society for angina) crescendo angina, d. H. a previously diagnosed angina (increasing z. B. ?1 to CCS degrees or until at least CCS grade 3) with pectoris now noticeably more frequent and more serious symptoms of longer duration or a lesser load threshold. This unstable angina pectoris is clinically unstable and often the harbinger of a myocardial infarction or arrhythmia, or, but less frequently, sudden cardiac death. Symptoms and complaints patients have symptoms of angina (chest pain or discomfort, typically). However, the discomfort or pain here are usually more, take longer to show up at even lower loads, occur spontaneously at rest on (as angina decubitus) take progressively increased in intensity (Crescendo) or occur in any kind of combination , Unstable angina is on severity and clinical situation classified based (see table: Braunwald classification of unstable angina *). It is also considered whether the unstable angina occurs during treatment of chronic stable angina and whether temporary changes present in ST-T wave during angina. If the angina occurred within 48 hours and there are no contributing extra-cardiac conditions that troponin levels can be measured to aid in assessing the prognosis. Troponin-negative results indicate a better prognosis as troponin-positive. Braunwald classification of unstable angina * Classification Designation Severity 1 new onset of severe angina or worsening angina No angina at rest – II angina at rest last month, but not in the last 48 hours Subacute angina at rest IIII Angina at rest in the last 48 h Acute angina at rest Clinical Situation A develops secondary to an extracardiac condition that myocardial ischemia worsens Secondary unstable angina B develops when not contributing extracardiac condition exists Primary unstable angina pectoris C develops within 2 Where after acute MI Post-MI unstable angina * The basic classification consists of a Roman number and a letter. angina is more common, is heavier, lasts longer or is triggered by less effort. In patients with class IIIB, troponin status is determined (negative or positive) to estimate the prognosis. Adapted from Hamm CW, Braunwald E: APACHE II: A classification of unstable angina revisited. Circulation 102: 118-122, 2000. Diagnostic Serial ECGs Serial cardiac markers Immediate coronary angiography in patients with complications (. Eg persistent chest pain, hypotension, unstable arrhythmias) Delayed angiography (24-48 h) (for stable patient approach unstable angina pectoris.) The analysis begins with start and serial ECG and serial measurements of cardiac markers to (between unstable angina and acute myocardial infarction MI) to distinguish non-either-ST-segment elevation myocardial infarction (NSTEMI) or ST segment elevation myocardial infarction (STEMI). This decision is the trend for the next steps. Fibrinolysis can help with STEMI may, while increasing the risk in NSTEMI and unstable angina. In addition, an urgent cardiac catheterization in patients with acute STEMI is indicated, but not generally in those with NSTEMI or unstable angina. (Editor’s note: The Kutkoronarangiographie is also not used, it is the Revaskularisationsstrategie the first choice The Akutkoronarangiographie is indicated in patients with acute STEMI, but not in those with NSTEMI!.) ECG The ECG is the most important test and should be within the first 10 minutes are carried out. During the attack, unstable angina pectoris ECG changes, such as ST-segment depression, ST-segment elevation or an inversion of the T wave may occur. However, these changes are temporary. Clinical Calculator: M.I. “Prediction Decision TreeCalc” Cardiac Marker patients with suspected unstable angina pectoris should have a highly sensitive assay for cardiac troponin (hs CTN) at presentation and 3 h later (at 0 and 6 h using a standard TN assays). Among the cardiac markers CK is not increased, but cardiac troponin, especially when measured with highly sensitive troponin test (hs-cTn) may be slightly higher, but do not match the criteria of myocardial infarction in line (above the 99th percentile of the upper reference limit or URL). Coronary angiography patients with unstable angina whose symptoms have improved, will angiography usually within the first 24-48 hours of hospitalization to locate lesions require treatment. Coronary angiography is often a combination of diagnostic and percutaneous coronary intervention ((PCI-z. B. angioplasty, stent insert). After initial diagnosis and treatment, a coronary angiography in patients with evidence of ongoing ischemia (ECG or because of symptoms ), recurrent ventricular tachyarrhythmias and other deviations that indicate recurrent ischemic events, be with hemodynamic instability performed. Prognosis the prognosis after an episode of unstable angina depends on how many coronary arteries are diseased which arteries are affected and how strong they are affected. For example, a stenosis of the left main coronary trunk or equivalent thereto have (proximal LAD stenosis plus RCX), a worse prognosis than distal Stenosis or stenosis in a smaller arterial branch. Left ventricular function also has a large influence on the prognosis. Patients with significant left ventricular dysfunction (including those with 1- or 2-vessel Erkan Kung) more likely to benefit from a revascularization. Overall, about 30% of patients suffer with unstable angina within 3 months after the onset of a myocardial instability. Less common is the sudden cardiac death. Significant ECG abnormalities in combination with chest pain represent an increased risk of a subsequent myocardial infarction or fatal outcome represents Clinical Calculator:. Prediction Unstable angina pectoris results therapy Preclinical supply: oxygen, aspirin, nitrates and / or opioids for pain and performance in an appropriate medical facility drug treatment: antiplatelet drugs, antianginal drugs, anticoagulants, and in some cases, other medications) angiography to evaluate the anatomy of the coronary artery reperfusion: Pperkutane coronary intervention or coronary artery bypass surgery After discharge, rehabilitation bilitation and continuous medical treatment of coronary heart disease Preclinical supply oxygen aspirin, nitrates and / or opioids Triage to appropriate medical center There must be a reliable i.v. Access are placed, the patient receives oxygen (usually 2 l via a nasogastric tube), the connection to an ECG monitoring provides continuous monitoring of heart function. Preclinical measures of rescue teams (including ECG monitoring, administration of aspirin to kauendem [325 mg], pain treatment with opioids or nitrates) may reduce the risk of mortality and the risk of complications. Early diagnosis data and response to treatment can help the need and timing of revascularization to bestimmen.Stationäre hospitalization risk assessment of the patient and select the time of reperfusion strategy Drug therapy with platelet inhibitors, anticoagulants and other medicines based reperfusion strategy On arrival in the emergency room, the patient’s diagnosis is confirmed. Drug therapy and timing of revascularization depend on the clinical picture. In clinically unstable patients (patients with persistent symptoms, hypotension or sustained arrhythmias), angiography is an urgent need to revascularization. In clinically stable patients angiography can be pushed (batch for unstable angina.) With revascularization for 24 to 48 h. Approach for unstable angina. * Complexity means that the hospital stay by recurrent angina or heart attack, heart failure or persistent recurrent ventricular arrhythmias was complicated. The absence of these events is called uncomplicated. CABG is generally for patients with the following PCI preferred: left main or left main disease-like illness left ventricular dysfunction treated diabetes too long lesions or lesions in the vicinity of vascular bifurcations are often not reached by a PCI. CABG = coronary artery bypass surgery; GP = glycoprotein; LDL = low density lipoprotein; NSTEMI = non-ST-segment elevation MI; PCI = percutaneous Kornarintervention; STEMI = ST-segment elevation MI. Drug treatment of unstable angina All patients should antiplatelet drugs and anticoagulants and chest pain antianginals. The medications specifically used depend on the reperfusion strategy, and other factors; their selection and use is discussed in drugs in acute coronary syndrome. Other drugs, such as beta-blockers, ACE inhibitors and statins should be started during recording (see table: drugs for coronary heart disease *). Patients with unstable angina should (not contraindicated any) will be given anti-platelet drugs following: aspirin, clopidogrel, or both (prasugrel or ticagrelor are alternatives to Clopidogrel) anticoagulants: A heparin (unfractionated or low molecular weight heparin) or bivalirudin glycoprotein IIb / IIIa inhibitors for some high-risk patients Antianginal therapy, usually nitroglycerin beta blockers, ACE inhibitors statin Unless contraindicated, all patients received aspirin at admission 160-325 mg (not dünndarmlöslich) and then 81 mg / day indefinitely. The first dose is rapidly absorbed when the tablet is chewed. (Editor’s note:. Gift also possible iv) Aspirin reduces short and long term mortality risk. In patients who are subjected to PCI, improves a loading dose of clopidogrel (300-600 mg p.o. 1 time), prasugrel 60 mg p.o. 1 times) or ticagrelor (180 mg p.o. 1) times the results, especially when administered 24 h in advance. (Editor’s note: For prasugrel and ticagrelor, there is no changing doses, there is only each approved loading dose prasugrel 60 mg po, ticagrelor is 180 mg po There is no data, the advantage the prior administration over administration in HK lab. can appear, especially for prasugrel one knows when NSTEMI the opposite. in STEMI, the question settled, because you can not treat one day in advance.) for urgent PCI are prasugrel and ticagrelor faster achieve the effect and should be preferred over clopidogrel. As long as no contraindication exists (eg. As active bleeding), is routinely either a low molecular weight heparin administered (LMWH) or an unfractionated heparin (UFH) or bivalirudin in patients with unstable angina. Unfractionated heparin is more complex in its application because it frequent (every 6 h) dosage adjustments required to achieve the goal activated PTT (aPTT). The LMWHs have better bioavailability are given as a simple weight-based dose without monitoring of aPTT and dose titration and have a lower risk of heparin-induced thrombocytopenia. Bivalirudin is recommended for those with a known or suspected history of heparin-induced thrombocytopenia. Drag glycoprotein IIb / IIIa inhibitor for high risk patients (patients with recurrent ischemia, dynamic ECG changes or hemodynamic instability) into consideration. Abciximab, tirofiban and eptifibatide seem to have an equivalent efficacy, and the choice of the drug should be from other factors (eg. As cost, availability, familiarity). Patients with chest pain can be treated with morphine or nitroglycerine. Morphine 2-4 mg iv, repeated every 15 minutes if necessary, is very effective, but can cause respiratory depression and impair myocardial contractile force. Furthermore, morphine is a potent venous vasodilator. A morphine-induced hypotension and bradycardia can be solved usually by immediate raising of the legs. Nitroglycerin is initially sublingual, then administered as needed in a continuous infusion. Standard therapy for all patients with unstable angina include beta-blockers, ACE inhibitors and statins. Beta blockers are recommended if there are no contraindications (eg., Bradycardia, conduction block, hypotension or bronchial asthma) are present, v. a. in high risk patients. Beta-blockers decrease the heart rate, the arterial pressure and the contractility and thereby reduce the cardiac work and the O2 demand. ACE inhibitors may protect the heart in the long term by improving endothelial function. If an ACE inhibitor is not tolerated because of side effects such as cough or rash (but angioedema or renal dysfunction not), instead, an angiotensin II receptor antagonist can be given. Statins are also standard therapy and should be continued indefinitely werden.Reperfusionstherapie in unstable angina pectoris fibrinolytic drugs that can be helpful with STEMI in patients who do not help patients with unstable angina pectoris. Angiography is typically carried out during the recording-within 24 to 48 hours after the recording, if the patient is stable or unstable patients immediately upon (for example, with current symptoms, hypotension, persistent arrhythmia). Angiographic results help determine whether PCI or CABG is displayed. Choice of reperfusion strategy is discussed further in revascularization in acute coronary syndrome. Tips and risks Although fibrinolytic drugs can help with STEMI patients, they are in unstable angina not beneficial rehabilitation and treatment after hospitalization Functional evaluation lifestyle changes: Regular exercise, diet, weight loss, smoking cessation drugs: continuation of blood-platelet-inflammatory drugs, beta-blockers, ACE inhibitors and statins patients receiving no coronary angiography at the instruction that do not show signs of high-risk (z. B. heart failure, recurrent angina, VT or VF after 24 h, mechanical complications as new noise, shock) and the ejection fraction of> 40% have, should carry out usually before or shortly after release stress tests of some kind. The acute illness and treatment unstable angina should be used to make a material encourage the patient is to reduce the risk factors. The evaluation of the physical and emotional condition and a conversation about it with the patient, advising on a suitable lifestyle (eg. Smoking, diet, work, leisure habits, sports) and a massive reduction of risk factors can help to improve the prognosis , At discharge, all patients should take appropriate anticoagulant drugs, statins, and other antianginals based on comorbidities drugs on. Important points Unstable angina pectoris is new, or resting angina worsens in patients whose cardiac biomarkers do not meet the criteria for a heart attack. The symptoms of unstable angina are new or worsening chest pain or chest pain occurring at rest. Diagnosis is based on ECG and cardiac markers. Immediate treatment includes oxygen, antianginals, antiplatelet drugs and anticoagulants. In patients with persistent symptoms, hypotension or sustained arrhythmias, immediate angiography. Run with a stable patient by angiography within 24 to 48 hours of hospitalization. After recovery anticoagulant drugs, beta blockers, ACE inhibitors and statins should be initiated or continued.