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HWN Suggests

Unstable Angina Is It Time for a Requiem?

It appears that we have now come full circle in our definition of symptomatic ischemic heart disease. Before the 1930s, 2 manifestations, stable angina and AMI, were recognized. Patients in the gray zone between stable angina and AMI that we now call UA were described 75 years ago and at first appeared to be quite rare. Over the next half-century, they were recognized with increasing frequency, and by 25 years ago, about one half of all patients with NSTE-ACS were considered to have UA. However, use of ever more sensitive biomarkers of myocardial necrosis, especially cTn, has steadily chipped away at the fraction of patients with NSTE-ACS without MI who therefore are still considered…

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 Unstable Angina

...high sensitivity troponins may completely change how we think about classifying ACS. But we’re not ready to get rid of unstable angina just yet. Just know that most patients who previously would have had UA are now getting reclassified as NSTEMIs.

Articles of Interest

Unstable angina: trends and characteristics associated with length of hospitalization in the face of diminishing frequency—an evidence of a paradigm shift

Unstable angina (UA) belongs to a spectrum of ischemic heart disease that is called acute coronary syndrome (ACS) or more recently non-ST-elevation acute coronary syndrome (NSTE-ACS). The other major component of NSTE-ACS is non-ST-elevation myocardial infarction (NSTEMI). The difference between UA and NSTEMI is the detection of a cardiac biomarker, as an evidence of myocardial damage and necrosis, despite the absence of electrocardiographic changes. Chest pain remains one of the most common presenting symptoms in the patients presenting with unstable angina. According to the most recent estimate, unstable angina is responsible for 550,000 hospital admissions in the United States each year

Angina Can Be Stable or Unstable

Stable angina can become unstable. For instance, if you usually have chest discomfort every time you walk two blocks, that would be considered stable angina. However, if that pattern of chest discomfort changes over the course of a short period of time, then the angina has become unstable

Critical review of unstable angina and non-ST elevation myocardial infarction

Within the coronary vasculature the progression of a stable atherosclerotic plaque into a vulnerable and ultimately unstable lesion leads to a cascade of events culminating in the clinical presentation of unstable angina or acute myocardial infarction.

Critical review of unstable angina and non-ST elevation myocardial infarction

Incidence of UA is low (12.5% of all ACS) but with a 1-year incidence of major cardiac events high (26.2%), mainly related to new acute coronary event. UA is therefore not a benign disease and secondary prevention has probably to be improved.

Does Observation for ACS Make Sense? Part 2: Identifying ACS

What is unstable angina? Is it even real? Probably not. Look at it this way: the person who created the first guidelines for the diagnosis and treatment of unstable angina (UA) no longer believes it to be a real entity. The definition was created at a time when we were still using CK-MB as evidence of myocardial necrosis. As mentioned earlier, troponin is far more sensitive and specific than CK-MB. By 2000, AHA guidelines estimated that more than one-third of patients previously thought to have UA would be reclassified as NSTEMI, given they would have had a positive troponin.

Is That Chest Pain Unstable Angina or Acute Coronary Syndrome?

One of the more expensive questions any emergency physician can ask is: Does the patient complaining of chest pain have unstable angina (UA) or non-ST-segment elevation myocardial infarction (NSTEMI)?

Resources

StatPearls

Unstable angina falls along a spectrum under the umbrella term acute coronary syndrome. This public health issue that daily affects a large portion of the population remains the leading cause of death worldwide. Distinguishing between this and other causes of chest pain that include stable angina is important regarding the treatment and disposition of the patient.

StatPearls

Unstable angina is a clinical syndrome characterized by myocardial ischemia without sustained ST-segment elevation or biochemical evidence of myocardial necrosis. This condition falls within the spectrum of acute coronary syndromes, along with ST-elevation myocardial infarction and non–ST-elevation myocardial infarction. Unstable angina typically presents as chest pain that is new in onset, occurs at rest, or exhibits a worsening pattern. The condition is associated with an increased risk of myocardial infarction and requires prompt recognition and management.