What is the approach to management in patients with unstable angina?

Unstable angina is a potentially dangerous condition, and management should be tailored to prevent adverse outcomes. Patients should be admitted to the cardiac care unit, placed at bedrest,

and begun on antianginal therapy with either P-blockers or calcium channel blockers, aspirin, and intravenous nitrates. (J-Blockers, when added to nitrates, have been shown to reduce symptoms of recurrent ischemia and the occurrence of myocardial infarction. Intravenous heparin should be added to the regimen of patients who present with rest angina within 48 hours or those with chest pain and ischemic ECG changes on admission. Heparin significantly reduces in-hospital cardiac events, including myocardial infarction. Aspirin also decreases recurrent ischemia and infarctions in patients with unstable angina, although neither aspirin nor heparin taken as sole therapy appears to be better than the other. Long-term aspirin therapy should be given to all patients with unstable angina without contraindications, because it reduces the incidence of nonfatal myocardial infarction and death. Most patients with unstable angina will stabilize on this regimen of medical therapy.

A small percentage of patients will develop medically refractory rest angina. Treatment with intraaortic balloon counterpulsation is usually effective in stabilizing patients with refractory symptoms or poor hemodynamic profiles. This technique is useful to stabilize patients before and during cardiac catheterization.

Although most patients with unstable angina have nonocclusive intracoronary thrombi, to date the use of thrombolytic agents has not demonstrated a benefit in recurrent ischemia, myocardial infarction, or mortality when compared to heparin or aspirin. A large-scale randomized trial addressing this issue is in progress.

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