Patients presenting within 24 hours of suspected NSTE-ACS – defined by ECG changes or elevated cardiac biomarkers – were randomized to receive aspirin plus a loading dose of 300 mg clopidogrel, and then 75 mg daily thereafter, compared to control receiving just aspirin. The CURE trial established the benefit of clopidogrel, with aspirin, given immediately on patient presentation with ACS (33). One of these subsets was patients with unstable angina.Ģ014 AHA Guidelines recommend giving 162 to 325 mg non-enteric coated aspirin, chewed, to all patients with suspected ACS (11). They found that aspirin at initial presentation, and then low dose daily, reduced serious vascular events in every subset of patients. In 2002, the Antithrombotic Trialists Group performed a meta-analysis of aspirin use in various cardiovascular disorders including acute stroke and acute MI (32). ( JM note: This topic might need its own deep dive at some point.) Aspirin The studies in this review used IV nitrates, primarily IV nitroglycerin.Ģ014 AHA guidelines recommend sublingual nitroglycerin to be administered to all patients with chest pain concerning for ACS, followed by IV nitroglycerin if the pain is refractory to sublingual medication (11). NitroglycerinĪ 2009 Cochrane Review concluded that nitrates reduce short-term mortality in patients with ACS (31). Of note, unstable angina is often grouped with NSTEMI and called NSTE-ACS. The following is a brief, up to date review of the literature on treating unstable angina. Should we be sending unstable angina to obs? What is the appropriate treatment of unstable angina?īy definition, patients with unstable angina are patients with ACS, and they should presumably be treated aggressively for ACS. Add a negative troponin and that seems like the patients who we would typically see in an observation unit. They used their own clinical algorithm to determine low risk, which they defined as 1 mm and 0.5 mm) or TWI (>3 mm) in at least 2 contiguous leads OR in a patient with known CAD (as diagnosed by angiography or prior MI) (29, 30).Īs you can see from this definition, a patient with chest pain, known CAD, and no ECG changes could technically have UA. In 1991, ED doctors at Brigham and Women’s Hospital published a study describing a “coronary observation unit” in which patients with low risk chest pain were monitored in an ED observation unit to rule out MI rather than being admitted to the hospital (9). Yet still, these patients were being admitted to the CCU for this observation period. It was determined that 12-24 hours was an acceptable observation period for ruling out MI (7, 8). Researchers developed decision aids to help identify low risk patients in the ED (5, 6), and ran studies to find the shortest amount of time in which MI could be ruled out. Admission of these “rule out MI” patients to an intensive care unit was costly, leading hospitals to seek ways of distinguishing the low risk patients earlier. Over half the patients admitted to the CCU with acute chest pain were eventually “ruled out” for myocardial infarction (4). ![]() However, the majority were low risk patients admitted simply to monitor for the development of acute MI with serial ECGs and cardiac enzyme measurement (CK-MB at that time). Some of these patients had acute MI and were treated accordingly. Up until the late 1980s, most patients presenting to the emergency department (ED) with acute chest pain were simply admitted to a coronary care unit (CCU) (3). Chest pain is the second most common reason for emergency department visits in the United States, and coronary artery disease is the leading cause of death (1,2). Part 1: A History of Observation for Chest PainĪccurate and expeditious diagnosis of acute myocardial infarction (MI) is one of the key charges of emergency departments and emergency providers. When not in the hospital he can be found surfing out on Rockaway Beach. Charles is a PGY-4 EM resident at Kings County Hospital/SUNY Downstate Medical Center with an academic interest in evidence-based medicine.
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