Unstable angina / non ST elevation myocardial infarction immediate management


 * Associate Editors-In-Chief: ; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.;

Overview
Initial management of acute coronary syndorme (ACS) begins with differentiating between the spectrum of ACS which includes STEMI, Unstable Angina and Non-ST Elevation Myocardial Infarction.

Because the symptoms for all these can be similar, a medical evaluation is necessary as mentioned in earlier sections (see Pre-hospital Care and  Initial Therapy). Information from the history, physical examination, 12-lead ECG, and initial cardiac biomarker tests can help in differentiating between the above three categories as well as categorize the patient into probable or definite ACS, chronic stable angina or non-cardiac cause of chest pain.


 * Patients with STEMI must be evaluated for immediate reperfusion therapy (see Reperfusion Therapy (Overview of Fibrinolysis and Primary PCI)).
 * Patients with Unstable angina/NSTEMI, recurrent symptoms suggestive of ACS and/or electrocardiogram ST-segment deviations, or positive cardiac biomarkers who are hemodynamically stable should be admitted to an inpatient unit for bed rest with continuous rhythm monitoring and careful observation for recurrent ischemia and managed with either an invasive or conservative strategy(see Initial conservative versus initial invasive strategies).

Risk stratification
Risk Stratification and Prognosis early in the course of admission is important so that patients who are classified as intermediate to high risk, including those with ongoing ischemia and evidence of hemodynamic instability should be admitted to a critical care unit, whenever possible.

Once a patient with documented high-risk ACS is admitted, standard medical therapy is indicated which includes Oxygen, ASA, Beta Blockers,  Anticoagulant Therapy,  Antiplatelet Therapy with a GP IIb/IIIa inhibitor, and a thienopyridine(for example clopidogrel), unless contraindicated.

Immediate Management

 * You can read in greater detail about each of the therapies below in greater detail by clicking on the link for that therapy.

Oxygen | Nitrates | Analgesics |  Beta Blockers |  Calcium Channel Blocker |  Inhibitors of Renin-Angiotensin-Aldosterone axis


 * You can also read the ACC/AHA Guidelines for immediate managament here