Unstable angina exhibits 1 or more of 3 principal presentations: (1) rest angina (usually lasting >20 minutes), (2) new-onset (<2 months previously) severe angina, and (3) a crescendo pattern of occurrence (increasing in intensity, duration, frequency, or any combination of these factors). In contrast, the patient is considered to have experienced UA if no such biomarker can be detected in the bloodstream hours after the initial onset of ischemic chest pain. A diagnosis of NSTEMI can be made when the ischemia is sufficiently severe to cause myocardial damage that results in the release of a biomarker of myocardial necrosis into the circulation (cardiac-specific troponins T or I, or muscle and brain fraction of creatine kinase ). Unstable angina and NSTEMI are closely related conditions: their pathophysiologic origins and clinical presentations are similar, but they differ in severity. The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and covers the spectrum of clinical conditions ranging from unstable angina (UA) to non-ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI). This article summarizes the evidence and provides the clinician with the latest information about the pathophysiology, clinical presentation, and risk stratification of ACS and the management of UA/NSTEMI.ĪCC = American College of Cardiology ACE = angiotensin-converting enzyme ACS = acute coronary syndrome ADP = adenosine diphosphate AHA = American Heart Association BNP = B-type natriuretic peptide CABG = coronary artery bypass grafting CAD = coronary artery disease CHF = congestive heart failure CI = confidence interval CK-MB = muscle and brain fraction of creatine kinase CRP = C-reactive protein CURE = Clopidogrel in Unstable Angina to Prevent Recurrent Events ECG = electrocardiography ED = emergency department GP = glycoprotein HR = hazard ratio IV = intravenous LDL = low-density lipoprotein LMWH = low-molecular-weight heparin LV = left ventricular MI = myocardial infarction NSTEMI = non-ST-segment elevation MI PCI = percutaneous coronary intervention STEMI = ST-segment elevation MI TIMI = Thrombolysis in Myocardial Infarction UA = unstable angina UFH = unfractionated heparin Thus, clinicians are frequently faced with the problem of determining which drug or therapeutic strategy will achieve the best results. Evidence-based guidelines provide recommendations for the management of ACS however, therapeutic approaches to the management of ACS continue to evolve at a rapid pace driven by a multitude of large-scale randomized controlled trials. Clinical outcomes can be optimized by revascularization coupled with aggressive medical therapy that includes anti-ischemic, antiplatelet, anticoagulant, and lipid-lowering drugs. High-risk patients with UA/NSTEMI are often treated with an early invasive strategy involving cardiac catheterization and prompt revascularization of viable myocardium at risk. A quick but thorough assessment of the patient's history and findings on physical examination, electrocardiography, radiologic studies, and cardiac biomarker tests permit accurate diagnosis and aid in early risk stratification, which is essential for guiding treatment. These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).
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