Cardiology · USMLE Step 1 and Step 2

Unstable Angina song

Unstable Angina - Diagnosis & Management, as a song. Hear the short teaser here. The full song is on YouTube and Spotify.

Unstable Angina

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Key points in this song10

Unstable angina is part of the acute coronary syndrome spectrum, defined as angina at rest, new-onset severe angina, or crescendo angina without troponin elevation, distinguishing it from NSTEMI.
The underlying mechanism is partial occlusion of a coronary artery by a non-occlusive thrombus forming on a ruptured or eroded atherosclerotic plaque, causing demand-supply mismatch without myocyte necrosis.
ECG findings typically show ST depression or transient ST elevation and T-wave inversions; a normal ECG does not exclude the diagnosis.
Biomarkers are negative by definition — serial troponins (at 0 and 3–6 hours) must be normal to differentiate unstable angina from NSTEMI.
Initial management follows the MONA framework plus anticoagulation: aspirin, P2Y12 inhibitor (clopidogrel, ticagrelor), heparin (UFH or LOXMWH), and nitrates for pain relief; beta-blockers reduce myocardial oxygen demand.
Risk stratification using the TIMI score (0–7 points) guides the decision between early invasive strategy (cardiac catheterization within 24–48 hours) versus conservative medical management.
High-risk features mandating urgent invasive strategy include recurrent ischemia at rest, hemodynamic instability, elevated troponin, new ST depression ≥0.5 mm, or TIMI score ≥3.
GP IIb/IIIa inhibitors (eptifibatide, tirofiban) are reserved for high-risk patients undergoing PCI or those with refractory ischemia despite dual antiplatelet therapy.
Long-term secondary prevention includes dual antiplatelet therapy for at least 12 months post-ACS, high-intensity statin therapy, ACE inhibitor, and beta-blocker regardless of EF.
Cocaine-induced unstable angina is managed with benzodiazepines and nitrates; beta-blockers are contraindicated due to unopposed alpha-adrenergic stimulation causing paradoxical vasospasm.