Management of unstable angina and nonSTsegment elevation myocardial infarction

These conditions are managed similarly; the aims of management are to provide supportive care and pain relief during the acute attack and to prevent further cardiac events and death. For advice on the management of patients with acute ST-segment elevation myo-cardial infarction (STEMI), see below.

Initial management Oxygen (section 3.6) should be administered if there is evidence of hypoxia, pulmonary oedema, or continuing myocardial ischaemia; hyperoxia should be avoided and particular care is required in patients with chronic obstructive airways disease.

Nitrates (section 2.6.1) are used to relieve ischaemic pain. If sublingual glyceryl trinitrate is not effective, intravenous or buccal glyceryl trinitrate or intravenous isosorbide dinitrate is given. If pain continues, diamor-phine or morphine (section 4.7.2) can be given by slow intravenous injection; an antiemetic such as metoclo-pramide should also be given (section 4.6).

Aspirin (chewed or dispersed in water) is given for its antiplatelet effect in a dose of 300 mg (section 2.9). If aspirin is given before arrival at hospital, a note saying that it has been given should be sent with the patient. Clopidogrel in a dose of 300 mg (or 600 mg [unlicensed] if used prior to percutaneous coronary intervention) should also be given (see section 2.9). Prasugrel, in a dose of 60 mg, is an alternative to clopidogrel in certain patients undergoing percutaneous coronary intervention (see NICE guidance, p. 150). Patients should also receive either unfractionated heparin, a low molecular weight heparin, or fondaparinux (section 2.8.1).

Patients without contra-indications should receive beta-blockers (section 2.4) which should be continued indefinitely. In patients without left ventricular dysfunction and in whom beta-blockers are inappropriate, diltiazem or verapamil can be given (section 2.6.2).

The glycoprotein IIb/IIIa inhibitors eptifibatide and tirofiban (section 2.9) can be used (with aspirin and unfractionated heparin) for unstable angina or for non-ST-segment elevation myocardial infarction in patients at a high risk of either myocardial infarction or death.

In intermediate- and high-risk patients, abciximab, epti-fibatide, or tirofiban can also be used with aspirin and unfractionated heparin in patients undergoing percutaneous coronary intervention, to reduce the immediate risk of vascular occlusion. In intermediate- and high-risk patients in whom early intervention is planned, bivalir-udin (section 2.8.1) can be considered as an alternative to the combination of a glyocprotein IIb/IIIa inhibitor plus a heparin.

Revascularisation procedures are often appropriate for patients with unstable angina or non-ST-segment elevation myocardial infarction (NSTEMI); see section 2.9 for the use of antiplatelet drugs in patients undergoing coronary stenting.

Long-term management The need for long-term angina treatment or for coronary angiography should be assessed. Most patients will require standard angina treatment (see management of stable angina, above) to prevent recurrence of symptoms.

Prevention of cardiovascular events Patients with stable and unstable angina should be given advice and treatments to reduce their cardiovascular risk. The importance of life-style changes, especially stopping smoking, should be emphasised. Patients should take aspirin indefinitely in a dose of 75 mg daily. In patients with non-ST-segment elevation acute coronary syndrome, a combination of aspirin and clopidogrel (section 2.9) is given for up to 12 months; most benefit occurs during the first 3 months. An ACE inhibitor (section 2.5.5.1) and a statin (section 2.12) should also be given.

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