Unstable anginaMANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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478 items

☷ Legend

01Approach to the Critical Patient/attcp34

Initial stabilization and monitoring

›Time-critical priorities

›Hemodynamic and respiratory targets

›SpO2 94-98%

›If SpO2 <90% or respiratory distress, supplemental oxygen

›Monitoring and access

›Cardiac monitor

›Defibrillator pads if ongoing ischemia or instability

›IV access x2

›If shock or vasoactive infusions, arterial line

›Immediate ECG pathway

›12-lead ECG within 10 minutes

›Repeat ECG for recurrent pain or clinical change

›Serial ECGs at 15-30 minute intervals if high suspicion

›Early contraindication screen

›Recent phosphodiesterase-5 inhibitor use

›Suspected aortic dissection features

›Active bleeding or major bleeding risk

›Team activation triggers

›Persistent or recurrent ischemic pain despite initial therapy

›Dynamic ST depression or transient ST elevation

›Hemodynamic instability

›Ventricular arrhythmia

›Heart failure or pulmonary edema

Working diagnosis and immediate decision points

›Unstable angina definition framework

›Ischemic symptoms at rest or minimal exertion

›New onset severe angina

›Crescendo pattern

›No persistent ST elevation on ECG

›ST depression or T wave inversion possible

›Normal ECG possible early

›Cardiac troponin not above assay 99th percentile on serial testing

›If troponin rises above 99th percentile, NSTEMI pathway

›High early risk of MI without treatment

›Treat as NSTE-ACS until proven otherwise

02History/hx48

Symptom characterization and timeline

›Chest pain phenotype

›Pressure, tightness, squeezing

›Radiation

›Arm

›Jaw

›Back

›Associated symptoms

›Diaphoresis

›Dyspnea

›Nausea or vomiting

›Syncope or presyncope

›Temporal profile

›Onset time

›Duration of episodes

›Rest pain

›Increasing frequency or severity

›Response to nitroglycerin

›Partial relief

›No relief does not exclude ACS

Risk factors and prior cardiac history

›Atherosclerotic risk

›Diabetes

›Hypertension

›Dyslipidemia

›Tobacco

›Chronic kidney disease

›Family history premature CAD

›Known CAD

›Prior MI

›Prior PCI

›Prior CABG

›Prior stress test results

›Current medications and adherence

›Antiplatelets

›Anticoagulants

›Beta blockers

›Statins

›Nitrates

›Bleeding risk elements

›Prior intracranial hemorrhage

›Recent major bleed

›Recent surgery

›Anemia history

›Alternative diagnosis cues

›Pleuritic pain

›Positional pain

›Fever or viral prodrome

›Leg swelling or hemoptysis

›Tearing back pain

03Physical Exam/exam29

Cardiovascular and pulmonary

›Hemodynamic status

›Blood pressure in both arms if concern for dissection

›Heart rate and rhythm

›Signs of shock

›Cool clammy skin

›Altered mentation

›Oliguria

›Cardiac exam

›New murmur

›Mitral regurgitation

›Aortic regurgitation

›S3 gallop

›Jugular venous pressure

›Pulmonary exam

›Rales

›Wheeze

›Increased work of breathing

›Perfusion findings

›Peripheral edema

›Cyanosis

High-risk findings and PITFALLS

›High-risk exam features

›Pulmonary edema

›Hypotension

›New hypoxia

›Ventricular arrhythmia

›Pitfalls

›Normal exam does not exclude UA

›Elderly and diabetic atypical symptoms

›Women more often non-chest-pain presentations

04Differential Diagnosis/ddx24

Life-threatening causes of chest pain

›Immediate threats

›Acute coronary syndrome

›Unstable angina (ICD-10 I20.0)

›NSTEMI (ICD-10 I21.4)

›STEMI (ICD-10 I21.3)

›Aortic dissection (ICD-10 I71.0)

›Pulmonary embolism (ICD-10 I26.99)

›Tension pneumothorax (ICD-10 J93.0)

›Pericardial tamponade (ICD-10 I31.4)

›Esophageal rupture (ICD-10 K22.3)

Mimics and alternative diagnoses

›Non-ACS cardiac

›Pericarditis (ICD-10 I30.9)

›Myocarditis (ICD-10 I40.9)

›Hypertrophic cardiomyopathy (ICD-10 I42.2)

›Tachyarrhythmia-related demand ischemia

›Pulmonary

›Pneumonia (ICD-10 J18.9)

›Asthma or COPD exacerbation (ICD-10 J45.901, J44.1)

›GI and chest wall

›GERD or esophagitis (ICD-10 K21.9)

›Biliary colic (ICD-10 K80.20)

›Costochondritis (ICD-10 M94.0)

›Psychiatric and functional

›Panic disorder (ICD-10 F41.0)

05Laboratory Tests/lt31

Cardiac biomarkers

›Troponin strategy

›High-sensitivity troponin

›0 hour value

›Repeat at 1-3 hours per assay pathway

›Repeat at 3-6 hours if ongoing concern

›If rise and or fall with at least one value above 99th percentile, MI pathway

›Interpretation pitfalls

›Chronic elevation in CKD

›Myocarditis and PE as alternative causes

Baseline labs and risk stratification

›Safety labs

›Complete blood count

›Hemoglobin baseline before antithrombotics

›Platelet count before P2Y12 or anticoagulation

›Electrolytes and renal function

›Sodium mmol/L

›Potassium mmol/L

›Creatinine and eGFR

›Magnesium mmol/L

›Liver enzymes if statin initiation concerns

›Coagulation

›INR

›If on warfarin or liver disease

›aPTT baseline

›If UFH planned

›Metabolic and secondary prevention

›HbA1c

›Lipid profile

›Optional tests by phenotype

›BNP or NT-proBNP for heart failure phenotype

›D-dimer if PE pathway and low risk

›Pregnancy test in pregnancy-capable patients

06Diagnostic Tests/dt62

Scoring Systems

›Risk stratification tools

›HEART score

›History category

›ECG category

›Age category

›Risk factors category

›Troponin category

›TIMI risk score for UA or NSTEMI

›Age 65 years or older

›At least 3 CAD risk factors

›Known CAD stenosis 50% or more

›Aspirin use in prior 7 days

›At least 2 angina episodes in 24 hours

›ST deviation 0.5 mm or more

›Elevated cardiac biomarkers

›GRACE score

›Age

›Heart rate

›Systolic blood pressure

›Creatinine

›Killip class

›Cardiac arrest at presentation

›ST segment deviation

›Cardiac biomarkers

›Tool use principles

›Risk tool supports but does not replace clinical judgment

›Dynamic ECG changes or refractory symptoms override low score

MRI

›Cardiac MRI roles

›Diagnostic clarification

›Myocarditis pattern

›Takotsubo pattern

›Microvascular disease signals

›Stress perfusion MRI

›Functional ischemia evaluation when available

›Practical limitations

›Access and timing constraints in ED

›Device and implant contraindications

›CT strategies in chest pain workup

›Coronary CT angiography

›Low to intermediate risk acute chest pain with nondiagnostic ECG and negative serial troponins

›Anatomic CAD evaluation and plaque burden

›Contraindications and limits

›Significant renal dysfunction

›Iodinated contrast allergy

›Very high coronary calcium limiting accuracy

›CT aorta

›Dissection phenotype features

›Pulse deficit or new AR murmur

›Neuro deficits with chest pain

Ultrasound

›POCUS applications

›Cardiac views

›Pericardial effusion and tamponade physiology

›Gross LV systolic function

›Regional wall motion abnormality support

›Lung ultrasound

›B lines for pulmonary edema

›Pneumothorax signs

›DVT ultrasound

›Proximal DVT support for PE pathway

›Limitations

›Normal POCUS does not exclude UA

›RWMA sensitivity operator and window dependent

07Disposition/dispo19

Level of care and consultation

›Admission framework

›Unstable angina working diagnosis

›Telemetry admission

›Cardiology consultation

›High-risk features

›ICU or step-down consideration

›Ongoing ischemic symptoms

›Hemodynamic instability

›Ventricular arrhythmia

›Heart failure or pulmonary edema

›Invasive strategy triggers

›Early angiography and possible PCI

›Recurrent ischemia despite medical therapy

›Dynamic ST depression

›High risk scores or high clinical concern

›Discharge rare for true UA

›If UA excluded and low risk chest pain pathway met

›Outpatient testing plan within 72 hours where system allows

›Rapid follow-up arranged

08Treatment/t137

Anti-ischemic and symptom control

›Oxygen and monitoring

›Oxygen therapy

›If SpO2 <90% or respiratory distress, initiate oxygen

›Avoid routine oxygen if normoxic

›Analgesia strategy

›Acetaminophen

›650-1000 mg PO or PR q6h

›Maximum 4000 mg per 24 hours

›Opioid use

›Morphine IV 2-4 mg

›Titrate 2 mg every 5-15 minutes to pain control

›Hypotension and respiratory depression monitoring

›Avoid routine morphine if possible

›Potential interaction with P2Y12 absorption

›NSAIDs avoidance

›Increased cardiovascular risk in ACS context

›Nitrates

›Nitroglycerin SL

›Initiate 0.4 mg SL

›Repeat every 5 minutes up to 3 doses

›Hold if SBP <90 mmHg or 30 mmHg drop from baseline

›Contraindications

›Phosphodiesterase-5 inhibitor use

›Sildenafil or vardenafil within 24 hours

›Tadalafil within 48 hours

›Suspected right ventricular infarct

›Severe aortic stenosis

›Nitroglycerin IV

›Initiate 5-10 micrograms per minute

›Titrate by 5-10 micrograms per minute every 3-5 minutes

›Target symptom relief and blood pressure tolerance

›Headache and hypotension monitoring

›Beta blocker

›Metoprolol

›If ongoing ischemia and no contraindications, initiate 25-50 mg PO q6-12h

›Target heart rate 50-60 beats per minute

›Hold for bradycardia or hypotension

›If severe hypertension or refractory ischemia, IV option

›5 mg IV q5 minutes up to 15 mg

›Transition to oral dosing when stable

›Contraindications

›Acute decompensated heart failure

›Cardiogenic shock risk

›Severe asthma with active bronchospasm

›High-grade AV block without pacing

Antithrombotic therapy

›Antiplatelet therapy

›Aspirin

›Initiate loading

›162-325 mg chew once

›If true allergy, avoid and use P2Y12 alone

›Maintenance

›81 mg PO daily

›GI protection if high bleeding risk

›P2Y12 inhibitor

›Ticagrelor

›Initiate loading

›180 mg PO once

›If history intracranial hemorrhage, avoid

›Maintenance

›90 mg PO twice daily

›Dyspnea and bradyarrhythmia monitoring

›Clopidogrel

›Initiate loading

›600 mg PO once

›If high bleeding risk, consider 300 mg per local protocol

›Maintenance

›75 mg PO daily

›CYP2C19 interaction awareness

›Prasugrel

›Use considerations

›For PCI strategy with known coronary anatomy

›Avoid if prior stroke or TIA

›Initiate loading

›60 mg PO once

›If age 75 years or older, generally avoid

›Maintenance

›10 mg PO daily

›If weight <60 kg, 5 mg PO daily

›DAPT duration planning

›Default 12 months in ACS unless bleeding risk predominates

›Shorter duration consideration if high bleeding risk

›Anticoagulation for NSTE-ACS strategy

›Unfractionated heparin

›Initiate bolus

›60 units per kg IV

›Maximum bolus 4000 units

›Initiate infusion

›12 units per kg per hour

›Maximum initial rate 1000 units per hour

›Titration and monitoring

›aPTT target per local protocol

›Platelet monitoring for HIT

›Enoxaparin

›Initiate dosing

›1 mg per kg SC q12h

›If eGFR <30 mL/min, 1 mg per kg SC q24h

›Transition cautions

›Avoid switching anticoagulants when possible

›Anti-Xa monitoring rarely required

›Fondaparinux

›Initiate dosing

›2.5 mg SC daily

›Avoid if eGFR <30 mL/min

›PCI caution

›If PCI performed, add UFH due to catheter thrombosis risk

›Bivalirudin

›PCI setting

›Per cath lab protocol dosing

›Bleeding reduction strategy in selected patients

Disease-modifying and secondary prevention initiation

›High-intensity statin

›Atorvastatin

›Initiate 80 mg PO daily

›Baseline liver enzymes if concern

›Myopathy symptom monitoring

›Rosuvastatin

›Initiate 20-40 mg PO daily

›Renal dosing considerations

›Drug interaction review

›ACE inhibitor or ARB

›Early start considerations

›Hypertension

›Diabetes

›Reduced LVEF

›Contraindications

›Pregnancy

›Hyperkalemia

›Acute kidney injury

›Smoking cessation support

›Nicotine replacement option

›Patch dosing per baseline use

›Short-acting nicotine for cravings

What not to do

›Fibrinolysis

›Not indicated without STEMI criteria

›Harm risk with misdiagnosis such as dissection

›Routine GP IIb/IIIa inhibitor

›Reserved for select high thrombus burden or bailout PCI scenarios

›Bleeding risk review

09Special Populations/sp35

Pregnancy

›Pregnancy considerations

›Diagnosis and risk

›ACS in pregnancy rare but higher maternal risk

›Preeclampsia and SCAD considerations

›Medication safety

›Aspirin low dose generally acceptable when indicated

›Heparin preferred anticoagulation

›UFH or LMWH use

›Avoid warfarin in pregnancy

›Statins generally avoided in pregnancy

›Imaging considerations

›ECG and troponin interpretation still applicable

›Radiation minimization strategies for CT

›Consultation triggers

›Obstetrics and cardiology early co-management

Geriatric

›Older adult considerations

›Presentation

›Dyspnea, weakness, confusion instead of chest pain

›Higher baseline troponin prevalence

›Treatment balance

›Higher bleeding risk with DAPT and anticoagulation

›Renal dosing for LMWH and contrast studies

›Disposition

›Lower threshold for admission

›Early goals-of-care discussion in frail patients

Pediatrics

›Pediatric considerations

›Epidemiology

›True unstable angina extremely rare

›Alternative diagnoses

›Myocarditis

›Anomalous coronary artery

›Hypertrophic cardiomyopathy

›Management pathway

›Pediatric cardiology consultation

›Weight-based medication dosing if ACS-like scenario

10Background/b28

Epidemiology

›Disease frequency and trends

›Unstable angina as part of NSTE-ACS spectrum

›Decreasing proportion in era of high-sensitivity troponin

›Many prior UA now classified as NSTEMI with hs-troponin

›Major risk contributors

›Atherosclerotic disease burden

›Smoking and diabetes prevalence effects

Pathophysiology

›Mechanisms

›Plaque disruption and non-occlusive thrombosis

›Subtotal coronary obstruction

›Intermittent platelet-rich thrombus

›Supply-demand mismatch contributions

›Tachycardia

›Severe hypertension

›Anemia or hypoxemia

›ECG changes without necrosis

›Subendocardial ischemia patterns

›Troponin negative on serial testing

Therapeutic Considerations

›Treatment rationale

›Antiplatelet therapy reduces thrombus propagation

›Aspirin foundational in ACS

›P2Y12 inhibitor adds event reduction in ACS

›Anticoagulation reduces recurrent ischemic events in NSTE-ACS

›UFH or LMWH standard options

›Fondaparinux bleeding benefit with PCI UFH add-on

›Early invasive strategy benefits in higher-risk NSTE-ACS

›Symptom control and ischemia reduction

›Risk-stratified selection

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Discharge instructions

›Diagnosis status

›Unstable angina ruled out or alternative diagnosis established

›If UA remains suspected, discharge not appropriate

›Medications

›Continue aspirin if prescribed

›Continue P2Y12 inhibitor if prescribed

›Avoid NSAIDs unless directed

›Activity

›Avoid strenuous exertion until cleared

›Follow-up

›Primary care or cardiology within 72 hours if arranged

›Stress testing or CT coronary angiography plan if arranged

›Return to ED now

›Chest pain at rest or worsening pattern

›New dyspnea

›Syncope

›Palpitations with dizziness

›New weakness or neurologic symptoms

12References/r12

Clinical guidelines and evidence sources

›Guideline sources

›2025 ACC AHA ACEP NAEMSP SCAI Guideline for the Management of Patients With Acute Coronary Syndromes

›https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309

›https://pubmed.ncbi.nlm.nih.gov/40014670/

›2023 ESC Guidelines for the management of acute coronary syndromes

›https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Acute-Coronary-Syndromes-ACS-Guidelines

›https://pubmed.ncbi.nlm.nih.gov/37622654/

›2021 AHA ACC Chest Pain Guideline

›https://www.ahajournals.org/doi/10.1161/CIR.0000000000001029

›https://www.jacc.org/pb-assets/documents/guidelines/chest-pain/guidelines-made-simple-chest-pain-1635445148113.pdf

›2016 ACC AHA Focused Update on Duration of Dual Antiplatelet Therapy

›https://www.ahajournals.org/doi/10.1161/cir.0000000000000404

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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