The management of unstable angina and non-ST-segment elevation myocardial infartion.
Patients presenting with unstable angina and non-ST elevation myocardial infarction (UA/NSTEM) have a highly variable course. Optimal management is critical because of the high risk of death or myocardial infarction (MI) in the ensuing 30 days. In this article, we review the therapeutic options available to clinicians. Anti-ischemic therapy with beta-blockers and nitrates should be considered in all patients without contraindications. Aspirin remains a cornerstone of antiplatelet therapy and has been shown to substantially reduce the risk of death or MI. Although the data are less robust, unfractionated heparin (UFH) also appears to be efficacious, and the low-molecular-weight heparin (LMWH) enoxaparin appears to be superior to UFH. The GP IIb/IIIa inhibitors, highly beneficial in the setting of percutaneous coronary intervention (PCI), should be considered in patients with continuing ischemia or other high-risk features. The ADP receptor blocker clopidogrel has been shown to be beneficial in patients who are managed conservatively and in those who undergo PCI. Lastly, a strategy of early angiography should be considered in patients with recurrent ischemia or in those who present with high-risk features such as elevated troponins or ST deviation. Thus, early risk stratification using clinical features, electrocardiographic data, and biomarkers allows identification of subgroups of patients who are not only at high risk but also enjoy the greatest benefits from these aggressive therapies and thereby enables clinicians to target these interventions most effectively.
Chen
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Cardiology Division, Massachusetts General Hospital, Boston, MA 02115, USA. msabatine@partners.org
Sabatine
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D000789:Angina, Unstable / Q000628:therapy*; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D009203:Myocardial Infarction / Q000503:physiopathology / Q000628:therapy*; D017202:Myocardial Ischemia / Q000188:drug therapy; D018570:Risk Assessment; D013997:Time Factors
D005343:Fibrinolytic Agents