UNSTABLE ANGINA

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DEFINITION
See Acute Coronary Syndromes

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MANAGEMENT
Initial Management
See ACS iCARD.

Post-Stratification Management
Review regularly.
Serial Trop Ts.
Ensure pt stable.
Keep giving them aspirin. Forever.

Further Management
Assurance. Annual mortality less than 2%.
These pts need a treadmill test.
If cardiologists deem +ve / high risk pt -> angiography +/- revascularisation.
If -ve, manage as for chronic stable angina.

Secondary Prevention
Beta-blocker
Metoprolol is agent of choice.
20% reduction in sudden death (VF and cardiac rupture).
Also decreases myocardial O2 demand and decreased BP)
ACEi
(HOPE Trial).
Consider, especially if for blood pressure control.
Independent vessel protection and prevents remodelling.
Aspirin
Low dose.
Statin If high lipids.
Target <4.00 (AVERT trial).
Aim low 3s.
RRR 28% of death over 5 yrs (4S trial).
Blood Pressure
If needed further to the above agents.
Want target of 125/85 (be vigorous - WHOISH recommendations).
Benefit down to 120/80.
Beware J-shaped curve of increasing mortality below this.
NB - Thiazides are losing favour as they leach K+, and have no independent advantage, unlike ACEi, Beta-blockers.
Diet
Accounts 10-15% of cholesterol levels.
Increase fruit and vegetable intake - NHF recommends 7+ a day in those with cardiac disease.
Antioxidants (anthracidins in grapes, strawberries, cruesetin in tomatoes).
Vegetables bind to fat in the gut decreasing absorption.
Decrease saturated fats.
Exercise
30-40 minutes 3-4 times per week - bare minimum.
Slight further benefit 1 hr.
Excessive exercise beyond this, especially vigorous sports should be avoided because of the risk of intimal tears.
Sex ok if pt can get heart rate above 115bpm/ walk 20mins and then swiftly climb a decent flight of stairs.
Other
Modify other risk factors.
Don't smoke or you're a death waiting to happen.

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