From the Guidelines
Crescendo angina should be managed with urgent coronary angiography and revascularization, as it is a high-risk condition that can rapidly progress to myocardial infarction. The management approach for a patient presenting with crescendo angina involves several key components, including:
- Dual antiplatelet therapy, although the specific agents and dosages are not detailed in the provided evidence 1
- Anticoagulation with low molecular weight heparin (LMWH) while waiting for angiography, and administration of a GPIIb/IIIa receptor inhibitor such as abciximab, tirofiban, or eptifibatide 1
- Coronary angiography 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 percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) should be performed based on the extent and characteristics of the lesions, with PCI being the first choice for single-vessel disease and CABG being the recommended procedure for left main or triple-vessel disease 1
- Patients with suitable lesions for PCI will receive clopidogrel, while those planned for CABG will have clopidogrel stopped, except if the operation is deferred 1
The goal of this management approach is to reduce the risk of myocardial infarction and improve outcomes in patients with crescendo angina, which is a condition characterized by increasing frequency, severity, and duration of angina episodes. By providing urgent and aggressive treatment, including coronary angiography and revascularization, clinicians can help to prevent the progression of this condition and improve patient outcomes.
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.
- The coronary lesion responsible for unstable angina is often "complex", an eccentric, irregular, severe stenosis or appearances of thrombosis 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.