Management of NSTEMI/unstable angina

Diagram showing the simplified management of NSTEMI/unstable angina according to NICE guidelines. A number of assumptions (listed at the bottom) are made.

The management of NSTEMI/unstable angina is complicated and depends on individual patient factors and a risk assessment. The summary below provides an overview but the full NICE guidelines should be reviewed for further details.

Further drug therapy

• antithrombin treatment
  • fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately
  • if immediate angiography is planned or a patients creatinine is > 265 µmol/L then unfractionated heparin should be given

Risk assessment

The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors:

• age
• heart rate, blood pressure
• cardiac (Killip class) and renal function (serum creatinine)
• cardiac arrest on presentation
• ECG findings
• troponin levels

This results in the patient being risk stratified as follows:

Based on this risk assessment key decisions are made regarding whether a patient has coronary angiography (with follow-on PCI if necessary) or has conservative management. The detailed pros/cons of this decision are covered in other notes.

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?

• immediate: patient who are clinically unstable (e.g. hypotensive)
• within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk