Differences between Stable angina & Acute coronary syndrome

(Unstable angina, NSTEMI, STEMI)

Features
Site
Onset
&
Precipitating
factor

Character

Stable Angina

Unstable angina

Same

Same

Retrosternal area,
Epigastrium (inferior M

Physical exertion
Cold temperatures.
Emotions like
anger or fear or
excitement.
Smoking
Eating a heavy
meal.
Using cocaine
(promote
vasospasm &
thrombosis) or
amphetamines.
Heavy, tight,
griping, squeezing,
crushing

At rest or minimal
exertion 3-5mins
Severe and New
onset of chest pain

At rest

Same

More severe than angi

Radiation
Alleviating
factor

Timing
Associated
symptoms

Myocardial infarct

Lower jaw, neck, left a

unchanged
exertional pain
lasting 5-15
minutes and
relieved by rest or
nitroglycerin
Short
No sweating

Sublingual Glyceryl
Trinitrate relieve for
a few mins

Not relieved by rest or

nitrate.
Only relieved by opiate

Short, usually a few

mins
No sweating
Mild or No anxiety

> 30 minutes
-

Sweating, nause
vomiting, palpita
Anxiety, sense o
impending doom
Collapse/syncope
SOB due to pulm
edema

Underlying
pathology
Vessel
architecture
and
Blood flow

Critical
coronary
artery
stenosis
>70%
caused by
atherosclerot
ic plaque
Blood flow
limited
during
exertion
Ischemia
during
exercise
without
acute
thrombosis
but
transient
platelet
aggregatio
n

Unstable
plaque
rupture
Platelet
thrombus
begins to form
and spasm
limits blood
flow at rest

NSTEMI
- Unstable
platelet
thrombus on
ruptured
plaque
- Transient or
incomplete
vessel
occlusion (lysis
occurs)
-difference
from UA is
that there is
myocardial
necrosis
Non-Q wave/
Subendocardia
l MI

ST
-Plate
throm
on ru
ather
us pla
-Com
vesse
occlu
(no ly
Q wa
Trans
MI

Physical
findings

Diaphoresis
Tachycardia or
bradycardia
- Transient
myocardial
dysfunction
(eg, systolic
blood pressure
< 100 mm Hg
or overt
hypotension,
- elevated
jugular venous
pressure,
dyskinetic
apex, reverse
splitting of S2,
presence of S3
or S4, new or
worsening
apical systolic
murmur, or
rales or
crackles)
Peripheral
arterial
occlusive
disease (eg,
carotid bruit,
supraclavicular
or femoral
bruits, or
diminished
peripheral
pulses or blood
pressure)

Anxious, diaphoretic
S4 Gallop : myocardial noncompliance due to ischemia
S3 Gallop : severe systolic
dysfunction
New apical systolic murmur of MR :
Ischemic papillary muscle
dysfunction

Cardiac
Enzymes

No raised
in CE

Management

Lifestyle
modificatio
n

Mild rise in
troponin

LMWH
double
antiplatel
et

Rise in serum
troponin or CKMB

NSTEMI
LMWH
douple
antiplatelet
GPIIb/IIIa
antagonist

Typically shows a
rise in CE
following the
sequence of
CKMB (every 6-8
hours during the
first 24 hours)
CKMB:CK (2.5/3)
Troponin I, T
AST
LDH
STEMI

thromboly
sis
(streptokin
ase,
alteplase)
primary/pe
rcutaneou
s coronary
interventio
n,
double

antiplatele
t

Notes: In patient >70 years/ who is diabetic, transplanted heart,

female acute MI maybe painless and a/w only vague discomfort,
but maybe heralded by sudden onset of dyspnea, pulmonary
edema, or ventricular arrhythmias.
Early death in AMI are due to ventricular fibrillation
Process of infarction takes more than 8 hours and most patient present
when it is still possible to salvage myocardium and improve outcome
Diagnosis
Diagnosis of acute MI is made by finding at least 2 of the following
features:

Typical chest pain > 30 mins

Typical ECG findings
Elevated cardiac enzyme levels
ST-elevations of 1 mm or more in two contiguous limb leads (high
lateral: I, aVL; inferior: II, III, aVF) or 2 mm elevations in the
precordial leads (anterior: V1, V2, V3; lateral: V4, V5, V6).

Localizing MI
ST
Elevations

Reciprocal
STdepressions

Anterior MI

V1-V6

none

LAD

need

Septal MI

V1-V3

none

LAD

need

Inferior MI

II, III, aVF

I, aVL

RCA (80%)
or
R Cx (20%)

need

Lateral MI

I, aVL, V5,
V6

II, II, aVF

R Cx, LCX

need

Posterior MI

V7, V8, V9

V1-V3

R Cx

need

Location

Affected
Artery

Exampl
e
ECG

Right Ventricular
MI

V1, V4R

I, aVL

RCA

need

The following laboratory studies are recommended within the first 24

hours in the evaluation of a patient with unstable angina:

Serial cardiac biomarker assays (eg, creatine kinase MB

isoenzyme [CK-MB], troponins, C-reactive protein [CRP], and brain
natriuretic peptide [BNP])
Complete blood count (CBC) with hemoglobin level
Serum chemistry panel (including magnesium and potassium)
Lipid panel
electrolyes, BUN and creatinine (may effect treatment regimens)
Cardiac markers
Marker

Initial
Elevation

Peak
Elevation

Return to
Baseline

Myoglobin

1-4 h

6-7 h

18-24 h

CK-MB

4-12 h

10-24 h

48-72 h

Cardiac Trop I

3-12 h

10-24 h

3-10 d

Cardiac Trop T 3-12 h

12-48 h
5-14 d
The troponin I is the most sensitive cardiac marker, detectable in
serum 3-6 hours after an MI, and its level remains elevated for 14 days.
Other tests that may be used to assess patients include the following:

Creatinine level
Exercise testing when patients are stable(either exercise or
chemically-induced exertion to look for EKG changes and/or
decreased radionuclide uptake in the ischemic region)
The following imaging studies may be used to assess patients with
suspected unstable angina:
Chest radiography (may show pulmonary edema or other causes
of chest pain)
Echocardiography (usually after admission to look for regional
wall motion abnormality)
Computed tomography angiography
Magnetic resonance angiography
Single-photon emission computed tomography
Magnetic resonance imaging
Myocardial perfusion imaging

Management
Obtain intravenous (IV) access, and provide supplemental oxygen. The
course of unstable angina is highly variable and potentially lifethreatening ; therefore, quickly determine whether the initial
treatment approach should use an invasive (surgical management) or
a conservative (medical management) strategy.
The following medications are used in the management of unstable
angina:

Antiplatelet agents (eg, aspirin and clopidogrel)

Lipid-lowering statin agents (eg, simvastatin, atorvastatin,
pitavastatin, and pravastatin)
Cardiovascular antiplatelet agents (eg, tirofiban, eptifibatide, and
abciximab)
Beta blockers (eg, atenolol, metoprolol, esmolol, nadolol, and
propranolol)
Anticoagulants (eg, heparin)
Low-molecular-weight heparins (eg, enoxaparin, dalteparin, and
tinzaparin)
Thrombin inhibitors (eg, bivalirudin, lepirudin, desirudin, and
argatroban)
Angina nitrates (eg, nitroglycerin IV)
Angiotensin-converting enzyme inhibitors (eg, captopril,
lisinopril, enalapril, and ramipril)
Surgical intervention in unstable angina may include the following:

Cardiac catheterization
Revascularization
Those with persistent ST-elevations will need some sort of
revascularization procedure - either pharmacological
(thrombolytic) or an angioplasty in the cardiac catheterization
lab.
Those without ST-elevations should get an angiogram when
appropriately as determined by the interventional cardiologist.