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Treating Unstable Angina and NSTEMI

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Updated November 13, 2011

Written or reviewed by a board-certified physician. See About.com's Medical Review Board.

Unstable angina and Non-ST Segment Elevation Myocardial infarction (NSTEMI) are both treated as medical emergencies. These two closely related conditions are forms of Acute Coronary Syndrome (ACS), which means that both are caused by a ruptured plaque in a coronary artery.

In any kind of ACS, it is important to rapidly stabilize the cardiac ischemia being produced by the plaque rupture, then to take steps to stabilize the plaque. Furthermore, in both unstable angina and NSTEMI, it is important to decide whether to schedule early cardiac catheterization (generally, with the idea of placing a stent), or to attempt to use non-invasive management.

Stabilization

If you have unstable angina or NSTEMI, the doctor will immediately begin intensive medical therapy to stabilize your heart. The goals of this stabilization effort are to protect the jeopardized heart muscle, and to prevent further growth of the blood clot that accompanies plaque rupture, and that obstructs blood flow.

Stopping cardiac ischemia -- which should also stop chest pain -- most often involves the use of oxygen, morphine (if pain is intense or continuous), nitroglycerin (to reduce the workload of the heart by lowering tension on the heart muscle), and beta blockers (which reduce the effect of adrenalin on the heart muscle). These steps usually will relieve most of the cardiac ischemia within minutes.

To prevent the blood clot from growing, aspirin is given along with Plavix, and in many cases, one of the IIb/IIIa inhibitors (either Integrilin or Reopro) is given as well. All these drugs together powerfully inhibit the blood platelets. Finally, most doctors also add a drug (either heparin, Lovenox, or Arixtra) to inhibit the thrombin clotting system. These measures, taken together, strongly reduce the risk of further blood clotting.

Importantly, in unstable angina and NSTEMI the use of powerful "clot-busting" drugs such as Streptase, to attempt to dissolve the clot that already has formed, appears to increase risk without adding measurable benefit. These drugs, therefore, are not used. (They are used used only in patients who have complete blockage in a coronary artery, which produces a classic myocardial infarction.)

You will also be started on statin therapy, most likely with with Lipitor, as soon as possible. While statins are commonly used to reduce cholesterol, in the case of ACS, their primary benefit is apparently to help stabilize ruptured plaques and to reduce the inflammation that is a component of plaque rupture. Hence, statins are now generally given as soon as possible after the diagnosis of unstable angina or NSTEMI is made, and regardless of your cholesterol levels. Lipitor, in particular, is given because this is the drug used in the clinical trials showing a significant reduction in death, heart attack, and other cardiac complications when statins are used in unstable angina and NSTEMI.

Page 2: Deciding Between the Conservative and the Invasive Approaches to Treatment.

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