History

Fact Explanation
Chest pain This is the most common mode of presentation.[1] Acute onset retro-sternal chest pain is described as pressure or heaviness over the area or sometimes as a non-specific discomfort. Patients often complain of radiation of the pain to the left arm, or the left side of the neck, or jaw. Pain is usually intermittent or persistent and last more than 20 minutes. [2] Patients with cardiac autonomic neuropathy may not feel the chest pain. [3,4,5] The chest pain may be accompanied by excessive sweating, nausea, abdominal pain, dyspnoea, and syncope. [1]
Recent worsening of existing stable angina Acute plaque rupture causes sudden reduction of the coronary perfusion. This causes worsening symptoms of stable angina. [1]
Acute onset shortness of breath This is due to left heart failure and pulmonary edema. [1]
Non-specific symptoms Some patients present with non-specific symptoms like epigastric pain, indigestion, or increasing dyspnoea. [6]
References
  1. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  2. CHRISTOPHER P. CANNON, ALEXANDER G.G. TURPIE. Unstable Angina and Non–ST-Elevation Myocardial Infarction. Circulation. [online] 2003; 107: 2640-2645 [viewed 24 March 2014]. Available from: doi: 10.1161/01.CIR.0000072246.69344.2D
  3. CHICO A, TOMAS A, NOVIALS A. Silent myocardial ischemia is associated with autonomic neuropathy and other cardiovascular risk factors in type 1 and type 2 diabetic subjects, especially in those with microalbuminuria. Endocrine. [online] 2005;27(3):213–217. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16230776
  4. MANZELLA D, PAOLISSO G. Cardiac autonomic activity and type II diabetes mellitus. Clinical Science. [online] 2005;108:93–99. [viewed 24 March 2014].
  5. VINIK AI, FREEMAN R, ERBAS T. Diabetic autonomic neuropathy. Seminars in Neurology. [online] 2003;23(4):365–372. [viewed 24 March 2014].
  6. CANTO JG, FINCHER C, KIEFE CI, ALLISON JJ, LI Q, FUNKHOUSER E, CENTOR RM, SELKERHP, WEISSMAN NW. Atypical presentations among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol [online] 2002;90:248-253. [viewed 24 March 2014].

Examination

Fact Explanation
Blood pressure Increased blood pressure increases the afterload and increases the workload of the heart. Patients with hypertension are more susceptible for the development of myocardial ischemia. [1,2] Hypotension may result as a complication of NSTEMI. [3]
Features of heart failure [1] Left heart failure results in pulmonary edema. Prompt diagnosis and management of heart failure is necessary. [1] The examination findings that suggest right heart failure are distended jugular veins, tender hepatomegaly and peripheral edema. Pulmonary crepitations are suggestive of left heart failure. Tachycardia and gallop rhythm can also be detected. [3]
Tachycardia [1] Due to autonomic disturbances.
Fever Fever is a known precipitant of myocardial ischemia in susceptible individuals. [1]
Pulse Presence of tachycardia or bradycardia indicates increased risk of death or fatal myocardial infarction.[3] Presence of arrhythmia like atrial fibrillation, ventricular tachycardia can also be detected. These indicates poor prognosis. [4]
None Physical examination can be completely normal in some patients.[1]
References
  1. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  2. TOFLER GH, MULLER JE. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation [online] 2006;114:1863-1872. [viewed 24 March 2014].
  3. Practical Implementation of the Guidelines for Unstable Angina/Non–ST-Segment Elevation Myocardial Infarction in the Emergency Department. Circulation. [online] 2005; 111: 2699-2710. [viewed 25 March 2014]. Available from: doi: 10.1161/​01.CIR.0000165556.44271.BE
  4. PERRON AD, SWEENEY T. Arrhythmic complications of acute coronary syndromes. Emerg Med Clin North Am. [online] 2005 Nov;23(4):1065-82. [viewed 25 March 2014]

Differential Diagnoses

Fact Explanation
Pericardial effusion [3] Pleuritic type of chest pain which is relieved by bending forwards is suggestive of pericardial effusion. Pericardial friction rub heard over the left lower sternal border further suggests the diagnosis. [10]
Hypoglycemia [1] Palpitations, tremor, anxiety and sweating occurs in both conditions. [2]
ST elevation MI (STEMI) STEMI and Non-STEMI have similar clinical presentations. NSTEMI is commoner than STEMI. [12]
Angina Pectoris Stable and unstable angina both have similar type of chest pain but autonomic disturbances are not detected in angina pectoris.
Aortic Dissection [3,12] Patients with acute dissection presents with severe tearing type of chest pain which radiates to the back. [4]
Aortic Stenosis [13] Patients with aortic stenosis can present with recurrent ischemic type chest pain. [5,12]
Musculoskeletal pain The pain typically increases with breathing and movements. [9]
Peptic ulcer disease (PUD) Burning type of epigastric pain occurs in PUD. Inferior MI is a possible differential diagnosis. [6]
Pancreatitis [9] upper abdominal (epigastric or paraumbilical) pain, with associated nausea and vomiting. Abdominal pain radiates to the back typically, but may radiates to the chest, flanks, and lower abdomen as well. [11]
Pneumonia Patients with fever, cough, pleuritic type of chest pain are characteristic. [7,9]
Pneumothorax An emergency. The diagnosis is made by clinical examination. Patient with sudden onset shortness of breath, rapid deterioration, tracheal deviation away from the lesion, hyper-resonant percussion note over the affected side and engorged neck veins provide clues to the diagnosis.
Pulmonary Embolism [3,12] Patients present with dyspnea, pleuritic chest pain and haemoptysis. [8,9]
Apical ballooning (Tako-Tsubo syndrome) A type of cardiomyopathy. Characteristically it causes reversible ventricular apical balooning. [14]
Radicular pain due to Herpes zoster Herpes zoster in the thoracic dermatomes also produces chest pain, itching, paresthesia and dysesthesia over the affected dermatome. Examination will reveal the vesicles in the affected dermatome. [10]
References
  1. HOLLI A. DEVON, SUE PENCKOFER, KAREN LARIMER. The Association of Diabetes and Older Age With the Absence of Chest Pain During Acute Coronary Syndromes. West J Nurs Res. [online] Feb 2008; 30(1): 130-144. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2247416/#!po=3.57143
  2. BULPITT CJ, PALMER AJ, BATTERSBY C, FLETCHER AE. Association of symptoms of type 2 diabetic patients with severity of disease, obesity, and blood pressure. Diabetes Care. [online] 1998;21(1):111–115. [viewed 24 March 2014].
  3. LENGYEL M. The role of transesophageal echocardiography in the management of patients with acute and chronic pulmonary thromboembolism. Echocardiography. [online] 1995;12:359–366. [viewed 24 March 2014].
  4. ALAN C. BRAVERMAN. Acute Aortic Dissection. Circulation. [online] 2010; 122: 184-188. [viewed 24 March 2014]. Available from: doi: 10.1161/ CIRCULATIONAHA.110.958975.
  5. BARBARA K. JULIUS, MARTIN SPILLMANN, GIUSEPPE VASSALLI, BRUNO VILLARI, FRANZ R. EBERLI, OTTO M. HESS. Angina Pectoris in Patients With Aortic Stenosis and Normal Coronary Arteries. Circulation. 1997; 95: 892-898. [viewed 24 March 2014]. Available from: doi: 10.1161/01.CIR.95.4.892
  6. KURKCIYAN I, SCHIRMAIER E, FROSSARD M, SCHREIBER W, LANGLE F, HUEMER G, STERZ F. Concomitant perforated ulcer and acute myocardial infarct--a diagnostic challenge in emergency medicine. Wien Klin Wochenschr. [online] 1994;106(20):660-3. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7810150
  7. LEE TH, CANNON CP. Approach to the patient with chest pain. In: Zipes DP, Libby P, Bonow RO, Braunwald E, eds. Braunwald's heart disease: a textbook of cardiovascular medicine. [online] Philadelphia, PA: Elsevier Saunders; 2005:1129-39. [viewed 24 March 2014].
  8. MARTIN RIEDEL. Acute pulmonary embolism 1: pathophysiology, clinical presentation, and diagnosis. Heart. [online] 2001;85:229-240 doi:10.1136/heart.85.2.229. [viewed 24 March 2014].
  9. KRISTIAN THYGESEN, JOSEPH S. ALPERT HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  10. NIKLAUS H. MUELLER, DONALD H. GILDEN, MARIA A. NAGEL. Varicella Zoster Virus Infection: Clinical Features, Molecular Pathogenesis of Disease, and Latency. Neurol Clin. [online] Aug 2008; 26(3): 675-viii. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2754837/
  11. JENNIFER K. CARROLL, BRIAN HERRICK, TERESA GIPSON, SUZANNE P. LEE. Acute Pancreatitis: Diagnosis, Prognosis, and Treatment. Am Fam Physician. [online] 2007 May 15;75(10):1513-1520. [viewed 24 March 2014]. Available from: http://www.aafp.org/afp/2007/0515/p1513.html
  12. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  13. TOFLER GH, MULLER JE. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation [online] 2006;114:1863-1872. [viewed 24 March 2014].
  14. SALIM S. VIRANI, NASSER K. A, EDUARDO DE M, Takotsubo Cardiomyopathy, or Broken-Heart Syndrome. Tex Heart Inst J. [online] 2007; 34(1) 76-79. [viewed 24 March 2014]

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram (ECG) This is the first line investigation. Usually there is ST segment depression either persistent or transient. It may be accompanied by the T-wave changes, like inversion, flattening, or pseudo-normalization of T-waves. [3,4] There may be no ECG changes at presentation. [1,5,6]
Troponin (I or T) The differentiation of NSTEMI (Non-ST Elevation Myocardial Infarction) from unstable angina is based on the assessment of cardiac bio markers. [1,2] Troponin levels peak 6 to 9 hours after the onset of clinical symptoms and remain elevated for 7 to 14dasys.[1,8]These enzymes are more cardio specific than CK-MB and have high specificity. [1,9] Troponin is the best predictor of short term prognosis. [10]
Coronary angiography Detects the site of the lesion.[7]
2D Echocardiogram This investigation helps to estimate the left ventricular ejection fraction. Also useful in excluding the possible differential diagnoses like aortic stenosis, aortic dissection, pulmonary embolism, and hypertrophic cardiomyopathy. [1]
Heart-type fatty acid-binding protein (H-FABP) This is a newer cardiac biomarker with early diagnostic and prognostic value and can be used with in the first 6 hours of onset of symptoms. [12]
Creatinine Kinase MB (CK-MB) [9] This is less cardio specific when compared to troponin and it has very limited value in diagnosing the NSTEMI.
References
  1. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  2. ALPERT JS, THYGESEN K, ANTMAN EM, BASSAND JP. Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. Eur Heart J [online] 2000;21:1502-1513. [viewed 24 March 2014].
  3. SAVONITTO S, ARDISSINO D, GRANGER CB, MORANDO G, PRANDO MD, MAFRICI A, CAVALLINI C, MELANDRI G, THOMPSON TD, VAHANIAN A, OHMAN EM, CALIFF RM, VAN DE WERF F, TOPOL EJ. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA [online] 1999;281:707-713. [viewed 24 March 2014].
  4. CANNON CP, MCCABE CH, STONE PH, ROGERS WJ, SCHACTMAN M, THOMPSON W, PEARCE DJ, DIVER DJ, KELLS C, FELDMAN T, WILLIAMS M, GIBSON RS, KRONENBERG MW,GANZ LI, ANDERSON HV, BRAUNWALD E. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol [online] 1997;30:133-140. [viewed 24 March 2014].
  5. MCCARTHY BD, WONG JB, SELKER HP. Detecting acute cardiac ischemia in the emergency department: a review of the literature. J Gen Intern Med [online] 1990;5:365-373. [viewed 24 March 2014].
  6. ROUAN GW, LEE TH, COOK EF, BRAND DA, WEISBERG MC, GOLDMAN L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol [online] 1989;64:1087-1092. [viewed 24 March 2014].
  7. MIZUNO K, SATOMURA K, MIYAMOTO A, ARAKAWA K, SHIBUYA T, ARAI T, KURITA A, NAKAMURA H, AMBROSE JA. Angioscopic evaluation of coronary-artery thrombi in acute coronary syndromes. N Engl J Med [online] 1992;326:287-291. [viewed 24 March 2014]
  8. MACRAE AR, KAVSAK PA, LUSTIG V, BHARGAVA R, VANDERSLUIS R, PALOMAKI GE,YERNA M-J, JAFFE AS. Assessing the requirement for the six-hour interval between specimens in the American Heart Association classification of myocardial infarction in epidemiology and clinical research studies. Clin Chem. [online] 2006;52:812-818. [viewed 24 March 2014].
  9. JAFFE AS, RAVKILDE J, ROBERTS R, NASLUND U, APPLE FS, GALVANI M, KATUS H. It's time for a change to a troponin standard. Circulation. [online] 2000;102:1216-1220. [viewed 24 March 2014].
  10. ANTMAN EM, TANASIJEVIC MJ, THOMPSON B, SCHACTMAN M, MCCABE CH, CANNONCP, FISCHER GA, FUNG AY, THOMPSON C, WYBENGA D, BRAUNWALD E. Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes. N Engl J Med [online] 1996;335:1342-1349. [viewed 24 March 2014].
  11. CHEITLIN MD, ARMSTRONG WF, AURIGEMMA GP, BELLER GA, BIERMAN FZ, DAVIS JL, DOUGLAS PS, FAXON DP, GILLAM LD, KIMBALL TR, KUSSMAUL WG, PEARLMAN AS, PHILBRICKJT, RAKOWSKI H, THYS DM, ANTMAN EM, SMITH SC JR, ALPERT JS, GREGORATOS G,ANDERSON JL, HIRATZKA LF, HUNT SA, FUSTER V, JACOBS AK, GIBBONS RJ, RUSSELL RO.ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation [online] 2003;108:1146-1162. [viewed 24 March 2014].
  12. NAKATA T, HASHIMOTO A, HASE M, TSUCHIHASHI K, SHIMAMOTO K. Human heart-type fatty acid-binding protein as an early diagnostic and prognostic marker in acute coronary syndrome. Cardiology. [online] 2003;99(2):96-104. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12711885

Investigations - Followup

Fact Explanation
Pulse oxymetry Measures oxygen saturation. [1]
ECG Patient should be subjected to serial ECG monitoring. [2] There can be transient episodes of ST-segment changes in ECG. [3,4]
Stress ECG Only the patients who are asymptomatic should undergo stress ECG testing. [5] Stress ECG provides prognostic information. [6]
2D Echocardiogram Myocardial remodeling can be assessed. Presence of mural thrombi or complications like valve lesions and aneurysm formation can be detected. [9]
Chest X-ray (CXR) [1] CXR aids in diagnosing heart failure.
MRI Helps in detecting the myocardial viability. [7]
Lipid profile Total cholesterol, LDL and HDL cholesterol levels and fasting triglyceride levels should be measured. [1]
Serum electrolytes [1] Electronic disturbances occur due to autonomic disturbance [8] If not corrected persistent electrolyte imbalance might lead to the development of arrhythmias. [1]
References
  1. Management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal. [online] Volume 24, Issue 1. Pp. 28-66. [viewed 24 March 2014]. Available from: doi: 10.1016/S0195-668X(02)00618-8
  2. NORRISRM, CAUGHEY DE, MERCER CJ, et al. Prognosis after myocardial infarction. Six-year follow-up. Br Heart J. [online] 1974;36:786–790. [viewed 24 March 2014].
  3. AKKERHUIS KM, KLOOTWIJK PA, LINDEBOOM W, UMANS VA, MEIJ S, KINT PP, SIMOONSML. Recurrent ischaemia during continuous multilead ST-segment monitoring identifies patients with acute coronary syndromes at high risk of adverse cardiac events; meta-analysis of three studies involving 995 patients. Eur Heart J [online] 2001;22:1997-2006. [viewed 24 March 2014].
  4. JERNBERG T, LINDAHL B, WALLENTIN L. The combination of a continuous 12-lead ECG and troponin T; a valuable tool for risk stratification during the first 6 h in patients with chest pain and a non-diagnostic ECG. Eur Heart J [online] 2000;21:1464-1472. [viewed 24 March 2014].
  5. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  6. NYMAN I, WALLENTIN L, ARESKOG M, ARESKOG NH, SWAHN E. Risk stratification by early exercise testing after an episode of unstable coronary artery disease. The RISC Study Group. Int J Cardiol [online] 1993;39:131-142. [viewed 24 March 2014].
  7. KWONG RY, SCHUSSHEIM AE, REKHRAJ S, ALETRAS AH, GELLER N, DAVIS J, CHRISTIAN TF,BALABAN RS, ARAI AE. Detecting acute coronary syndrome in the emergency department with cardiac magnetic resonance imaging. Circulation [online] 2003;107:531-537. [viewed 24 March 2014].
  8. S. W. WEBB, A. A. J. ADGEY, J. F. PANTRIDGE. Autonomic Disturbance at Onset of Acute Myocardial Infarction. Br Med J. [online] Jul 8, 1972; 3(5818): 89–92. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1785615/
  9. FRANK A. FLACHSKAMPF, MICHAEL SCHMID, CHRISTIAN R, STEPHAN A, ANTHONY N. DEMARIA, WERNER G.D. Cardiac imaging after myocardial infarction. Eur Heart J [online] 2010. [viewed 25 March 2014]. Available from: doi: 10.1093/eurheartj/ehq446

Management - General Measures

Fact Explanation
Basic life support [3,4] In an unconscious patient management of airway, breathing and circulation (ABC) should be given the priority.
Analgesics [5,6] Narcotic analgesics are the drug of choice.
Oxygen Given in a rate of 2–4l/min. The effectiveness of the reperfusion therapy depends on the arterial oxygen concentration as well. [6]
Pharmacological management of heart failure [7] Mild heart failure can be treated with slow intravenous infusion of furosemide 20–40mg and repeated 1 to 4 hourly. However severe heart failure may need higher doses. Titrating doses of intravenous nitroglycerine (0.25μg/kg/min titrate the dose every 5minutes) or oral nitrates can be administered if there is no response to diuretics.
Life style modifications Quit smoking. Nicotine replacement therapy if necessary. Smoking is a well-recognized cardiovascular risk factor and it is responsible for the development of thrombotic complications. [1,2]
References
  1. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  2. SMITH SC JR, ALLEN J, BLAIR SN, BONOW RO, BRASS LM, FONAROW GC, GRUNDY SM, HIRATZKA L, JONES D, KRUMHOLZ HM, MOSCA L, PASTERNAK RC, PEARSON T, PFEFFER MA, TAUBERT KA. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation [online] 2006;113:2363-2372. [viewed 24 March 2014].
  3. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. [online] 2000;102:I-22–I-59. [viewed 24 March 2014].
  4. Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. [online] 2000;102:I-82–I-166. [viewed 24 March 2014].
  5. REMETZ MS, Analgesic therapy in acute myocardial infarction. Cabin HS. Cardiol Clin. [online] 1988 Feb;6(1):29-36. [viewed 24 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2901910
  6. SIMON MAXWELL. Emergency management of acute myocardial infarction. Br J Clin Pharmacol. [online] Sep 1999; 48(3): 284–298. [viewed 24 March 2014]. Available from: doi: 10.1046/j.1365-2125.1999.00998.x
  7. NICODP, GILPIN E, DITTRICH H, et al. Influence on prognosis and morbidity of left ventricular ejection fraction with and without signs of left ventricular failure after myocardial infarction. Am J Cardiol. [online] 1988;61:1165–1171. [viewed 24 March 2014].

Management - Specific Treatments

Fact Explanation
Aspirin [13,17] Aspirin is an antiplatelet drug. It is proven that thrombosis is the critical component of the obstruction of the coronary arteries in NSTEMI. [1,2,3] Aspirin inhibits the platelet activity and prevent thrombosis.
Clopidogrel This is a glycoprotein IIb/IIIa inhibitor and belongs to antiplatelet group. It reduces the risk of myocardial infarction. [14]
Lipid-lowering agents Controlled serum lipid levels significantly reduce the risk of re-infarction. [19,20,21]
Beta blockers [4] Beta blockers reduces the blood pressure and heart rate. They also have anti-arrhythmic properties.
Intravenous or oral nitrates Nitrates have vasodilation properties. [5]
Calcium channel blockes Reduces the vasospasm. [6] Also it reduces the conduction of electricle impulse from the sino-atrial node to atrio-ventricular node and reduces the heart rate. [7] The use of CCB in the management of MI remains contravertial. [8]
Angiotensin converting enzyme inhibitors (ACEIs) Patient should be prescribed an ACEI within the first 24 hours, unless there is any contraindication or hypotension. [22]
Percutaneous coronary interventions (PCI) Re-establish the patency of the coronary vessels. [7,15]
Coronary artery bypass graft This re-establish the vessel patency. This method of treatment is preferred if more than one vessel is affected. [16]
Sub cutaneous low molecular weight heparin (LMWH) [9,10,18] Although there is relative increased risk of bleeding LMWH is proven to reduce the mortality. [11]
Vitamin K antagonists Although there is a considerable increase in the risk of bleeding combination of the aspirin and warfarin is proven to reduce the risk of reinfarction. [12]
References
  1. DAVIES MJ. The pathophysiology of acute coronary syndromes. Heart . [online] 2000;83:361-366 [viewed 24 March 2014].
  2. LIBBY P. Current concepts of the pathogenesis of the acute coronary syndromes.Circulation [online] 2001;104:365-372. [viewed 24 March 2014].
  3. FITZGERALD DJ, ROY L, CATELLA F, FITZGERALD GA. Platelet activation in unstable coronary disease. N Engl J Med [online] 1986;315:983-989. [viewed 24 March 2014].
  4. FREEMANTLEN, CLELAND J, YOUNG P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ. [online] 1999;318:1730–1737 [viewed 24 March 2014].
  5. YUSUFS, COLLINS R, MACMAHON S, PETO R. Effect of intravenous nitrates on mortality in acute myocardial infarction: an overview of the randomised trials. Lancet. [online] 1988;1:1088–1092. [viewed 24 March 2014].
  6. TOPOLEJ, YADAV JS. Recognition of the importance of embolization in atherosclerotic vascular disease. Circulation. [online] 2000;101:570–580. [viewed 24 March 2014].
  7. KRISTIAN THYGESEN, JOSEPH S. ALPERT, HARVEY D. Universal definition of myocardial infarction. Eur Heart J. [online] 2007; 28 (20): 2525-2538. [viewed 24 March 2014]. Available from: doi: 10.1093/eurheartj/ehm355
  8. SMITH NL, REIBER GE, PSATY BM, HECKBERT SR, SISCOVICK DS, RITCHIE JL, EVERY R, KOEPSELL TD. Health outcomes associated with beta-blocker and diltiazem treatment of unstable angina. J Am Coll Cardiol [online] 1998;32:1305-1311. [viewed 24 March 2014].
  9. HARRINGTON RA, BECKER RC, EZEKOWITZ M, MEADE TW, O'CONNOR CM, VORCHHEIMERDA, GUYATT GH. Antithrombotic therapy for coronary artery disease: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest [online] 2004;126:513S-548S. [viewed 24 March 2014].
  10. Fragmin During Instability in Coronary Artery Disease (FRISC) Study Group. Low-molecular-weight heparin during instability in coronary artery disease. Lancet [online] 1996;347:561-568. [viewed 24 March 2014].
  11. GURFINKEL EP, MANOS EJ, MEJAIL RI, CERDA MA, DURONTO EA, GARCIA CN, DAROCAAM, MAUTNER B. Low molecular weight heparin versus regular heparin or aspirin in the treatment of unstable angina and silent ischemia. J Am Coll Cardiol [online] 1995;26:313-318. [viewed 24March 2014].
  12. HURLEN M, ABDELNOOR M, SMITH P, ERIKSSEN J, ARNESEN H. Warfarin, aspirin, or both after myocardial infarction. N Engl J Med [online] 2002;347:969-974. [viewed 24March 2014].
  13. THEROUX P, OUIMET H, MCCANS J, LATOUR JG, JOLY P, LEVY G, PELLETIER E, JUNEAU M,STASIAK J, DEGUISE P, PELLETIER GB, RINZLER D, WATERS DD. Aspirin, heparin, or both to treat acute unstable angina. N Engl J Med [online] 1988;319:1105-1111. [viewed 24 March 2014].
  14. BUDAJ A, YUSUF S, MEHTA SR, FOX KA, TOGNONI G, ZHAO F, CHROLAVICIUS S, HUNT D,KELTAI M, FRANZOSI MG. Benefit of clopidogrel in patients with acute coronary syndromes without ST-segment elevation in various risk groups. Circulation [online] 2002;106:1622-1626. [viewed 24March 2014].
  15. HOCHMANJS, SLEEPER LA, WHITE HD, et al. One-year survival following early revascularization FOR CARDIOGENIC SHOCK. JAMA. [online] 2001;285:190–192 [viewed 24March 2014].
  16. CHU MW, WILSON SR, NOVICK RJ, STITT LW, QUANTZ MA. Does clopidogrel increase blood loss following coronary artery bypass surgery? Ann Thorac Surg [online] 2004;78:1536-1541. [viewed 24 March 2014].
  17. THEROUX P, OUIMET H, MCCANS J, et al. Aspirin, heparin or both to treat unstable angina. N Engl J Med. [online] 1988; 319: 1105–1111. [viewed 24March 2014].
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