What is the full inpatient management for a patient with angina?

Inpatient Management of Angina

The comprehensive inpatient management of angina requires immediate symptom control with nitroglycerin, bed rest with continuous ECG monitoring, and initiation of beta-blockers as first-line therapy, followed by a structured approach to risk stratification and targeted medical therapy. 1, 2

Initial Management (First 24-48 Hours)

Immediate Interventions

• Bed rest with continuous ECG monitoring for ischemia and arrhythmia detection in patients with ongoing rest pain 1
• Nitroglycerin (NTG):
  • Sublingual tablet or spray for immediate relief, followed by intravenous administration if needed 1
  • Avoid NTG within 24 hours of sildenafil (Viagra) use 1
• Supplemental oxygen for patients with:
  • Cyanosis or respiratory distress
  • Arterial oxygen saturation (SaO₂) <90% 1
• Morphine sulfate intravenously when:
  • Symptoms not immediately relieved with NTG
  • Acute pulmonary congestion present
  • Severe agitation present 1

Early Pharmacologic Therapy

• Beta-blockers (first-line therapy):
  • First dose administered intravenously if ongoing chest pain
  • Followed by oral administration (e.g., metoprolol)
  • Target heart rate: 50-60 bpm 2, 3
  • Caution: May precipitate heart failure in susceptible patients 3
• Calcium channel blockers (when beta-blockers are contraindicated):
  • Non-dihydropyridine agents (verapamil or diltiazem) preferred
  • Avoid immediate-release dihydropyridines without beta-blockers 1
• ACE inhibitors when:
  • Hypertension persists despite NTG and beta-blockers
  • Left ventricular dysfunction or heart failure present
  • Patient has diabetes 1, 2

Risk Stratification and Further Management

Antiplatelet/Anticoagulant Therapy

• Aspirin: 75-300 mg daily for all patients without contraindications 1, 2
• Consider dual antiplatelet therapy for high-risk patients 2

Additional Pharmacologic Interventions

• Statins: Initiate for all patients to target LDL-C <70 mg/dL 2
• Long-acting nitrates: For recurrent ischemia, with a nitrate-free interval to prevent tolerance 2
• Intra-aortic balloon pump counterpulsation for:
  • Severe ischemia continuing despite intensive medical therapy
  • Hemodynamic instability before or after coronary angiography 1

Revascularization Considerations

• Coronary angiography for:
  • Refractory symptoms despite medical therapy
  • High-risk features (recurrent ischemia, hemodynamic instability)
• Revascularization options:
  • PCI: Effective for symptom relief when medical therapy fails
  • CABG: Preferred for complex 3-vessel disease, left main disease, or proximal LAD stenosis, especially with impaired left ventricular function 1, 2

Discharge Planning and Transition of Care

Medication Regimen

• Continue inpatient anti-ischemic regimen (except IV NTG) after discharge 1
• Use the ABCDE mnemonic to guide treatment:
  • A: Aspirin, antianginals, ACE inhibitors
  • B: Beta-blockers and blood pressure control
  • C: Cholesterol management and smoking cessation
  • D: Diet and diabetes management
  • E: Education and exercise 1

Patient Education

• Provide clear instructions about:
  • Medication type, purpose, dose, frequency, and side effects
  • Recognition of worsening symptoms
  • When to seek emergency care 1
• Specific instructions for angina episodes:
  • Discontinue physical activity if angina lasts >2-3 minutes
  • Take 1 dose of sublingual NTG if pain doesn't subside immediately
  • Call 911 if pain is unimproved/worsening 5 minutes after NTG
  • May take additional NTG doses (at 5-minute intervals, up to 2 more times) while awaiting EMS 1

Follow-up Care

• Arrange multidisciplinary team support (nurses, dietitians, pharmacists, rehabilitation specialists)
• Schedule telephone follow-up (e.g., weekly for first 4 weeks)
• Enroll in cardiac rehabilitation program 1

Common Pitfalls and Caveats

1. Abrupt discontinuation of beta-blockers can cause severe exacerbation of angina, MI, or ventricular arrhythmias - taper gradually over 1-2 weeks if needed 3

2. Nitrate tolerance can develop with continuous use - ensure a daily nitrate-free interval of 10-12 hours 2

3. Dihydropyridine calcium channel blockers should not be used without beta-blockers in patients with angina 1

4. Sildenafil (Viagra) use within 24 hours of nitrates can cause severe hypotension 1

5. Overlooking secondary prevention - aggressive risk factor modification is essential for long-term outcomes 2

By following this comprehensive approach to inpatient management of angina, clinicians can effectively control symptoms, identify and treat underlying causes, and establish an appropriate long-term management plan to improve patient outcomes and quality of life.