Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room

Prata, Mateus Arantes; Ohe, Louis Nakayama; Vilalva, Kelvin Henrique; Lemos, Lucas Ferreira Marcondes; Smanio, Paola Emanuela Poggio

doi:10.36660/abc.20230049i

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Original Article • Arq. Bras. Cardiol. 121 (3) • 2024 • https://doi.org/10.36660/abc.20230049i copy

Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background:

The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices.

Objectives:

This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results.

Methods:

This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level.

Results:

A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated.

Conclusion:

The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

Keywords:
Unstable Angina; Chest Pain; Acute Coronary Syndrome

Variable			Stratification Method		p-value
Variable			Invasive (N=596)	Non-invasive (N=133)	p-value
Medical History
	Age, years (median, [Q1; Q3])		63 [56;69]	63 [55;71]	0.966
	Male gender		64.4%	65.4%	0.909
	BMI > 30 kg/m²		28.4%	30.8%	0.643
	SAH		82.4%	81.2%	0.845
	DM		45.6%	50.4%	0.371
	DM ID		10.9%	15.0%	0.357
	DLP		59.4%	51.9%	0.136
	CKD		18.8%	18.8%	1.000
	Active smoking		13.6%	8.27%	0.001
	Previous CAD		62.2%	60.2%	0.725
Chest Pain
	Type (classification):				<0.001
		A	25.1%	11.5%
		B	48.5%	48.1%
		C	26.4%	40.5%
	Rest / Effort				0.127
		Effort	34.0%	26.6%
		Rest	66.0%	73.4%
	'Crescendo'		26.8%	15%	0.006
Scores
	GRACE (median, [Q1; Q3])		92.5 [75;110]	92 (24)	0.881
	TIMI (median, [Q1; Q3])		4 [3;4]	3 [2;4]	0.006
	HEART (median, [Q1; Q3])		5 [5;6]	5 [4;6]	0.011
ECG normal			108 (18.1%)	28 (21.1%)	0.508
DVAR			166 (27.9%)	36 (27.1%)	0.940
EIA			93 (15.6%)	18 (13.5%)	0.640
Isquemia			72 (12.1%)	9 (6.77%)	0.107
ST Dep (mm)					0.660
	0		584 (98.0%)	133 (100%)
	0.5		1 (0.17%)	0 (0.00%)
	1		9 (1.51%)	0 (0.00%)
	2		2 (0.34%)	0 (0.00%)

Variable	Category	OR	CI 95%	p-value
Smoking	Active	2.23	1.13-4.80	0.028
	Stopped < 6m	0.84	0.41-1.85	0.646
	Former	2.19	1.39-3.53	0.001
Type of Pain	A	3.39	1.83-6.66	<0.001
Type of Pain	B	1.48	0.97-2.27	0.070

Variable			Obstructive CAD or Ischemia		p-value
Variable			No (N = 209)	Yes (N = 520)	p-value
Medical History
	Age, years (median, [Q1; Q3])		63 [55.0;70.0]	63 [56.0;70.0]	0.399
	Male gender		58.4%	67.1%	0.032
	BMI > 30 kg/m²		30.1%	28.3%	0.678
	SAH		84.7%	81.2%	0.307
	DM		48.3%	45.8%	0.587
	DM ID		9.57%	12.5%	0.277
	DLP		60.8%	56.9%	0.386
	CKD		14.8%	20.4%	0.103
	Active smoker		11%	13.3%	0.439
	Previous CAD		57.9%	63.5%	0.188
Chest Pain
	Type (classification)				0.105
		A	17.4%	24.7%
		B	51.7%	47.1%
		C	30.9%	28.2%
	Rest / Effort				0.037
		Effort	26.7%	35.1%
		Rest	73.3%	64.9%
	`Crescendo’		20.6%	26.3%	0.124
Scores
	GRACE (median, [Q1; Q3])		91 [74;111]	92 [75;109]	0.494
	TIMI (median, [Q1; Q3])		3 [2;4]	4 [3;4]	0.001
	HEART (median, [Q1; Q3])		5 [4;6]	5 [4;6]	0.542
ECG normal			16.7%	19.4%	0.463
DVAR			30.6%	26.5%	0.307
EAI			11.5%	16.7%	0.095
Isquemia			8.13%	12.3%	0.136
ST Dep					0.646
	0		99.5%	97.9%
	0.5		0.00%	0.19%
	1		0.48%	1.54%
	2		0.00%	0.38%

Variable	Category	OR	CI 95%	p-value
Type of Pain	B	0.60	0.38-0.93	0.026
	C	0.61	0.37-1.00	0.051
Previous CAD	Yes	1.42	1.01-2.00	0.048
LOS		1.13	1.08-1.19	<0.001

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