How stable is unstable?
50 yo F with NSTEMI (s/p PCI stents, about 4 years ago) admitted with unstable angina (UA), TIMI risk score of 3 (intermediate risk) with persistent angina despite aggressive medical therapy meeting criteria for early invasive management with cardiac catheterization.
Definition: Angina at rest or new/worsening angina with no elevation of cardiac enzymes.
Goals of discussion: How to choose medical management strategies, risk stratification and criteria for early invasive treatment.
Teaching points:
– UA can be differentiated from NSTEMI by checking cardiac enzymes
– 20% of NSTEMI patients have no EKG abnormalities
– STE >0.5 mm in aVR implies a a possibility of left main or 3 vessel disease
– Some of the indications for early invasive therapy (cath +/- PCI) are hemodynamic/ arrhythmic instability, high TIMI score 5 to 7, refractory angine despite aggressive medical therapy, PCI within past 6 mos/ prior CABG, new CHF, new/ worsening MR, EF<40%
– Risk stratification using TIMI score (most commonly used), Braunwald’s classification and others