What is the treatment for unstable angina (UA)?

From the Guidelines

Unstable angina treatment should prioritize an early invasive strategy, with coronary angiography and angiographically directed revascularization if possible, as it has been shown to improve outcomes in patients with acute coronary syndrome 1. The initial treatment of unstable angina involves a combination of medications, including:

• Aspirin (325 mg chewed) and sublingual nitroglycerin (0.4 mg every 5 minutes for up to 3 doses) for symptom relief
• Antiplatelet therapy with P2Y12 inhibitors like clopidogrel (300-600 mg loading dose, then 75 mg daily)
• Anticoagulation with unfractionated heparin or low molecular weight heparin (enoxaparin 1 mg/kg twice daily)
• Beta-blockers, such as metoprolol (25-50 mg orally twice daily), which should be started promptly, unless contraindicated, as recommended by the American Heart Association 1
• High-intensity statins, such as atorvastatin (40-80 mg daily) Patients should be hospitalized for monitoring and evaluation for cardiac catheterization, which is often performed within 24-48 hours to assess coronary anatomy and determine if revascularization (PCI or CABG) is needed. Following the acute phase, long-term management includes:
• Dual antiplatelet therapy for 6-12 months
• Continued beta-blockers, ACE inhibitors, and statins
• Lifestyle modifications, including smoking cessation, regular exercise, and a heart-healthy diet It is essential to note that the management of unstable angina should be individualized, taking into account the patient's specific clinical characteristics and risk factors, as outlined in the European Heart Journal 1.

From the FDA Drug Label

If angina markedly worsens or acute coronary insufficiency develops, metoprolol administration should be reinstated promptly, at least temporarily, and other measures appropriate for the management of unstable angina should be taken. The treatment for unstable angina with metoprolol involves:

• Reinstating metoprolol administration promptly if angina worsens
• Taking other measures appropriate for the management of unstable angina Key considerations:
• Gradual dose reduction is recommended when discontinuing metoprolol in patients with coronary artery disease
• Careful monitoring is necessary when discontinuing metoprolol, especially in patients with coronary artery disease 2

From the Research

Unstable Angina Treatment

• The treatment of unstable angina involves early risk stratification and aggressive medical therapy, supplemented by coronary angiography in appropriately selected patients 3.
• An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients 3.
• Adjunctive medical therapy with acetylsalicylic acid, clopidogrel or another adenosine diphosphate antagonist, glycoprotein IIb/IIIa inhibitors, and either low-molecular-weight heparin or unfractionated heparin, in the appropriate setting, further reduces the risk of ischemic events secondary to thrombosis 3.
• For elderly patients, treatment should include hospitalization, identification and correction of precipitating factors, electrocardiogram monitoring, and administration of aspirin, clopidogrel, and heparin 4.
• Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be given and continued indefinitely, and statins should be used if the serum low-density lipoprotein (LDL) cholesterol is >or=100 mg/dl 4.
• High-risk patients should have an early invasive strategy with coronary artery bypass graft surgery (CABGS) or percutaneous coronary intervention (PCI) performed depending on the coronary artery anatomy, left ventricular function, presence or absence of diabetes, and findings on noninvasive testing 4.

Medical Therapy

• Aspirin should be given as soon as possible and continued indefinitely 4.
• Clopidogrel should be given for up to 9 months in patients in whom an early noninterventional approach is planned or in whom a percutaneous coronary intervention (PCI) is planned 4.
• A platelet glycoprotein IIb/IIIa inhibitor should also be given in addition to aspirin, clopidogrel, and heparin in patients in whom cardiac catheterization and PCI are planned 4.
• Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be given and continued indefinitely 4.
• Statins should be used if the serum low-density lipoprotein (LDL) cholesterol is >or=100 mg/dl and continued indefinitely 4.

Invasive Strategy

• High-risk patients should have an early invasive strategy with CABGS or PCI performed depending on the coronary artery anatomy, left ventricular function, presence or absence of diabetes, and findings on noninvasive testing 4.
• An early-invasive-treatment strategy is of most benefit to high-risk patients, whereas an early-conservative strategy is recommended for low-risk patients 3.