Unstable angina

• What is unstable angina primarily caused by?

  Disruption of atherosclerotic plaque in CA -> thrombus formation -> partial or transient occlusion = imbalance between myocardial O2 demand and supply
• What are some risk factors for developing unstable angina?

  Age - men 45+ and women 55+

  Smoking

  Dyslipidaemia

  Hypertension

  Diabetes

  Obesity

  Lifestyle

  Family history
• What are some underlying causes of unstable angina?

  Atherosclerotic plaque disruption

  Vasospasm

  Cocaine use
• How is unstable angina classified (3 categories)?

  New-onset severe

  Increasing or crescendo

  Rest or nocturnal
• What is new-onset severe angina?

  Angina that has developed in the past month - immediate evaluation and treatment due to high risk of MI
• What is Braunwald Class I in terms of unstable angina?

  Secondary to increased oxygen demand e.g. fever, tachycardia, thyrotoxicosis or anaemia
• What is Braunwald Class II in terms of unstable angina?

  Secondary to decreased oxygen supply e.g. hypoxia, anaemia or hypotension
• What is Braunwald Class III in terms of unstable angina?

  At rest

  A - Not previously treated

  B - Treated but recurrent

  C - Post-infarction
• What are some clinical features of unstable angina?

  Anginal pain

  Radiation

  Dyspnoea

  Syncope

  Nausea and vomiting

  Sweating
• What is anginal pain in regards to unstable angina?

  Occurs at rest/minimal exertion/ inc frequency
• How is anginal pain characterised?

  Pressure, heaviness or squeezing located centrally in the chest behind the sternum
• Where does the pain from unstable angina refer to?

  Neck

  Jaw

  Epigastrium

  Arms (left is more common)
• What are some atypical presentations of unstable angina mostly seen in elderly patients, women and those with diabetes?

  Dyspnoea and fatigue (as primary symptom, not chest pain)
• How is unstable angina investigated?

  Troponin test

  ECG

  Echo

  CXR
• What is the main reasoning behind the investigations done for unstable angina?

  Establish the presence of myocardial ischaemia
• What are some risk stratification scoring systems used for unstable angina?

  GRACE

  TIMI risk score for unstable angina/NSTEMI
• What does GRACE risk score estimate?

  Admission to 6 months mortality for patients with ACS
• What does GRACE risk score take into account?

  Age

  HR

  BP (systolic)

  Creatinine

  Cardiac arrest at admission

  ST deviation?

  Abnormal cardiac enzymes?

  Killip class (signs/symptoms)
• What does TIMI risk score for Unstable Angina/Non-ST elevation MI estimate?

  Mortality for patients with unstable angina and NSTEMI
• What invasive investigation can be done for high-risk patients with unstable angina?

  Coronary angiography
• How is unstable angina managed?

  Risk stratification

  Pharm management

  PCI

  CABG

  Lifestyle modification
• What drugs are used in the pharm management of unstable angina?

  Dual antiplatelet therapy - aspirin + P2Y12 inhibitor (clopidogrel)

  Nitroglycerin for immediate relief

  Beta-blocker/CCB

  Statins