Angina (unstable) March 2018 | by EMauthor Angina is due to myocardial ischaemia (without necrosis) and presents as a central chest tightness or heaviness. It may radiate to one or both arms, the neck, jaw or teeth. Angina can be stable (exertional) or unstable. It is actually rare for stable angina to present to the ED: normally patients will disclose their symptoms in primary care and be referred on to a chest pain clinic. Therefore this section will focus on unstable angina which is a much more serious diagnosis. Pearls and pitfalls •Negative cardiac biomarkers (troponin) and normal ECG’s do not rule-out unstable angina. •Unstable angina requires inpatient management unless a reviewing consultant says otherwise (e.g. significant ceiling of care). •The definition of UA = prolonged (>20 minutes) angina at rest; new onset of severe angina; angina that is increasing in frequency, longer in duration, or lower in threshold; or angina that occurs after a recent episode of MI. •Therefore if these symptoms are present the patient will likely need admission and ACS treatment: your job is to rule out features of MI particularly those requiring PCI and ensure the patient is stable. oThere is no need to wait for a troponin result BUT there is a need to add value to the patient’s care, e.g. good analgesia, treatment administered, chest radiograph has a normal mediastinum / no gross abnormalities. oThe patient must also be adequately counselled on the differential diagnosis and his / her treatment. Investigations and treatment for UA •Chest radiograph to rule out other causes •At least 2 x ECGs prior to referral •After screening for contraindications, give aspirin 300 mg and clopidogrel 300 mg oIf suspected MI, CXR normal and ongoing pain consider fondaparinux 2.5 mg. •Pain can be controlled by GTN infusion (50 mg in 50 mL saline 0-10 mL per hour) •Patients are referred to the medical team
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