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

Review article Unstable Angina, NEJM.