What is the management approach for a patient presenting with crescendo (increasing) angina?

From the Guidelines

Crescendo angina should be managed with urgent hospitalization, aggressive medical therapy, and early coronary angiography within 48 hours, with revascularization via percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) as indicated by coronary anatomy. The management approach for a patient presenting with crescendo angina involves several key components, including:

• Initial pharmacotherapy with aspirin, anticoagulation with low molecular weight heparin (LMWH), and anti-ischemic medications, including nitrates and beta-blockers, as tolerated 1.
• Administration of a GPIIb/IIIa receptor inhibitor, such as abciximab, tirofiban, or eptifibatide, for 12-24 hours after the procedure if angioplasty is performed 1.
• Early coronary angiography, which should be planned as soon as possible, but without undue urgency, unless the patient has severe ongoing ischemia, major arrhythmias, or hemodynamic instability 1.
• Revascularization via PCI or CABG, based on coronary anatomy, with PCI being the first choice for single-vessel disease and CABG being the recommended procedure for left main or triple-vessel disease, particularly in patients with left ventricular dysfunction 1.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as clopidogrel, for patients undergoing PCI 1. The goal of this aggressive approach is to prevent progression to myocardial infarction and reduce morbidity and mortality in patients with crescendo angina.

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 management approach for a patient presenting with crescendo (increasing) angina involves:

• Reinstating metoprolol administration promptly, at least temporarily, if it was previously discontinued
• Implementing other measures suitable for managing unstable angina Key considerations include:
• Close monitoring of the patient's condition
• Adjusting the treatment plan as needed to prevent further exacerbation of angina
• Collaboration with a physician to determine the best course of action 2

From the Research

Management Approach for Crescendo Angina

The management approach for a patient presenting with crescendo angina involves a combination of medical therapy, invasive procedures, and lifestyle modifications.

• Medical management comprises triple anti-ischemic therapy (nitrate derivatives, beta-blockers, calcium antagonists), anticoagulants, and platelet antiaggregants 3.
• The diagnosis of unstable angina, which includes crescendo angina, is clinical and justifies immediate hospital admission to a coronary care unit because of the risk of myocardial infarction and/or sudden death 3.
• When unstable angina is refractory to maximal medical therapy, emergency coronary angiography should be performed 3.
• Myocardial revascularisation by coronary angioplasty or aorto-coronary bypass should be proposed whenever possible, depending on the coronary lesion 3.

Invasive Procedures

• Coronary angiography can be performed several days after the acute event, and the outcome is usually favourable 3.
• Surgical treatment has been shown to be more effective (symptomatic relief, improved survival) than medical therapy in patients with triple vessel disease 3.
• Prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death in high-risk patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) 4.

Risk Factors and Prognosis

• Persistence of pain after admission to the hospital is a significant indicator of an adverse prognosis in patients with unstable angina 5.
• The incidence rate of nonfatal myocardial infarction is 9 percent during the first 28 days and a further 3 percent for the 1st year in patients with unstable angina 5.
• High-sensitivity troponin measurements are the preferred test to evaluate for non-ST-segment elevation myocardial infarction (NSTEMI) 4.

Antiplatelet Therapy

• Prasugrel and ticagrelor are next-generation antiplatelet agents that provide a rapid and more potent inhibition of platelet P2Y12 receptor than clopidogrel 6.
• These new P2Y12 inhibitors are now the first-line treatments for patients with acute coronary syndrome, in combination with aspirin 6.