Accelerating Angina

Overview

Accelerating angina (also called crescendo angina) is a form of unstable angina, characterized by:

• Increasing frequency, duration, or severity of angina episodes.

• Angina occurring with less exertion than before or even at rest.

• Often a warning sign of impending myocardial infarction due to worsening coronary artery disease or plaque instability.

It is a medical emergency that requires urgent evaluation and management.

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Treatment Options

1. Immediate/Emergency Management

• Hospital admission with cardiac monitoring.

• Oxygen: if SpO₂ < 90%.

• Aspirin: 160–325 mg PO chewed immediately.

• Nitroglycerin:

  • Sublingual: 0.3–0.6 mg every 5 min as needed (max 3 doses in 15 min).

  • IV infusion: 5 mcg/min, titrate every 5–10 min if persistent pain.

• Morphine: 2–4 mg IV PRN for uncontrolled pain.

• Antiplatelet therapy:

  • Clopidogrel: 300–600 mg PO loading dose, then 75 mg PO daily.

• Anticoagulation:

  • Enoxaparin: 1 mg/kg SC every 12 hours.

  • Alternative: Unfractionated heparin IV bolus 60 U/kg (max 4000 U), then infusion 12 U/kg/hr.

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2. Secondary Medical Therapy

• Beta-blockers (unless contraindicated):

  • Metoprolol tartrate: 25–50 mg PO every 6–12 hours; titrate to HR 55–60 bpm.

• Statins:

  • Atorvastatin 40–80 mg PO daily (high-intensity therapy).

• ACE inhibitors (if LV dysfunction, diabetes, hypertension):

  • Ramipril 2.5–5 mg PO BID.

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3. Definitive/Revascularization Therapy

• Early invasive strategy (preferred):

  • Coronary angiography within 24–48 hours.

  • Percutaneous coronary intervention (PCI) with stenting if culprit lesion identified.

• Coronary artery bypass grafting (CABG):

  • For multi-vessel disease, left main disease, or failed PCI.

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Supportive & Monitoring Measures

• Continuous ECG monitoring for arrhythmias.

• Serial ECGs and troponins to exclude evolving MI.

• Lifestyle counseling: smoking cessation, diet, exercise.

• Cardiac rehabilitation after stabilization.

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Key Notes

• Accelerating angina is considered part of acute coronary syndrome (ACS).

• Requires urgent hospital admission and aggressive treatment.

• Do not discharge until MI has been ruled out and patient is stabilized.

• Early intervention reduces risk of myocardial infarction and death.