From the Guidelines
Crescendo angina is a medical emergency that requires immediate hospitalization and aggressive treatment to prevent myocardial infarction, with a standard approach including aspirin, anticoagulation, high-intensity statin therapy, beta-blockers, and nitroglycerin, as well as dual antiplatelet therapy and cardiac catheterization with possible percutaneous coronary intervention or coronary artery bypass grafting. The condition is characterized by chest pain that increases in frequency, intensity, and duration over time, often occurring with minimal exertion or at rest, indicating worsening coronary artery disease and high risk for myocardial infarction 1.
Key Components of Treatment
- Aspirin (325mg loading dose, then 81mg daily)
- Anticoagulation with heparin or low molecular weight heparin
- High-intensity statin therapy (such as atorvastatin 80mg daily)
- Beta-blockers (like metoprolol 25-50mg twice daily)
- Nitroglycerin for acute symptom relief (0.4mg sublingual as needed or IV infusion in hospital)
- Dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel 600mg loading, then 75mg daily; ticagrelor 180mg loading, then 90mg twice daily; or prasugrel 60mg loading, then 10mg daily)
Importance of Cardiac Catheterization
Cardiac catheterization is crucial in the management of crescendo angina, as it allows for the identification of coronary anatomy and the determination of the best revascularization strategy, whether it be percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) 1.
Revascularization Modalities
The choice of revascularization modality depends on the coronary anatomy and the clinical presentation of the patient. In patients with single-vessel disease, PCI with stenting of the culprit lesion is the first choice. In patients with multivessel disease, the decision for PCI or CABG must be made individually, taking into account factors such as the extent of disease, the presence of diabetes, and the patient's overall clinical condition 1.
Medical Therapy for Patients Without Options for Revascularization
In patients who do not have options for revascularization due to the extent of their coronary disease or poor distal run-off, medical therapy is the mainstay of treatment. This includes intensified medical therapy to achieve freedom from angina at rest, as well as secondary preventive measures to reduce the risk of future cardiovascular events 1.
From the FDA Drug Label
Nitroglycerin sublingual tablets can relieve this pain. Angina feels like a pressing or squeezing pain, usually in your chest under the breastbone. One tablet should be dissolved under the tongue or in the oral cavity at the first sign of chest pain.
Crescendo angina is not directly addressed in the provided drug label. The FDA drug label does not answer the question.
From the Research
Definition and Characteristics of Crescendo Angina
- Crescendo angina is a type of unstable angina characterized by increasing frequency, severity, and duration of angina attacks 2.
- It is often associated with a high risk of death and myocardial infarction 2.
- Patients with crescendo angina typically have more extensive coronary disease and lower ejection fractions compared to those with recent onset angina 2.
Diagnosis and Treatment of Crescendo Angina
- The diagnosis of unstable angina, including crescendo angina, is clinical and requires immediate hospital admission to a coronary care unit due to the risk of myocardial infarction and/or sudden death 3.
- Medical management of unstable angina includes triple anti-ischemic therapy (nitrate derivatives, beta-blockers, calcium antagonists), anticoagulants, and platelet antiagregants 3.
- Treatment for refractory angina, including crescendo angina, may involve enhanced external counterpulsation, transmyocardial revascularization, and stem cell therapy 4.
Comparison with Other Types of Angina
- Crescendo angina is distinct from stable effort angina, which is characterized by a predictable pattern of angina attacks triggered by exertion or emotional stress 5.
- Variant angina, also known as Prinzmetal's angina, is caused by coronary vasospasm and is typically treated with calcium channel blockers and organic nitrates 5.
Management Strategies
- Patients with crescendo angina may require emergency coronary angiography and revascularization procedures, such as coronary angioplasty or aorto-coronary bypass 3.
- Medical therapy, including aspirin, beta-blockers, and calcium channel blockers, is aimed at reducing the risk of myocardial infarction and improving symptoms 5, 3, 6.