Early invasive treatment of unstable angina

Early invasive treatment of unstable angina

Early invasive treatment of unstable angina is recommended in high risk patients with:

Recurrent angina at rest or low level activity despite maximum medical therapy, indicating an unstable plaque or critical coronary narrowing
Elevated troponin suggesting ongoing myocardial damage
New ST segment depression at presentation
Recurrent angina with heart failure
High risk findings on noninvasive stress testing (in relatively stable patients)
Depressed LV systolic function with ejection fraction less than 40%
Hemodynamic instability
Angina at rest with hypotension
Sustained ventricular tachycardia
History of percutaneous coronary intervention within the past 6 months
Prior coronary artery bypass grafting

Relative contraindications for cardiac catheterisation / percutaneous coronary intervention:

Uncontrolled hypertension, heart failure or arrhythmia – to be stabilised prior shifting to cath lab if feasible. Sometimes stabilization may not be possible without revascularization.
Recent cerebrovascular accident (within 3/6 months)
Infection
Electrolyte abnormalities (K, Mg)
Acute gastrointestinal bleed or anemia of unknown etiology
Acute renal failure
Coagulopathy
Pregnancy
Medication toxicity (digoxin)
Uncooperative patient

Role of coronary artery bypass grafting in unstable angina:

Coronary artery bypass grafting in unstable angina is recommended if there is significant left main coronary artery disease, three vessel disease or two vessel disease with significant proximal LAD disease (left anterior descending coronary artery) and either ejection fraction less than 50% or ischemia on noninvasive testing. Many of these cases are now managed with percutaneous coronary intervention with availability of better hardware and operator expertise.