Treatment
ÎÎFibrinolytic therapy is useful in patients with ischemic chest
discomfort after cocaine use if ST segments remain elevated despite
NTG and calcium channel blockers, if there are no contraindications,
and if coronary angiography is not possible. (I-C)
ÎÎAdministration of NTG or oral calcium channel blockers can be
beneficial for patients with normal ECGs or minimal ST-segment
deviation suggestive of ischemia after cocaine use. (IIa-C)
ÎÎConsider coronary angiography, if available, for patients with ischemic
chest discomfort after cocaine use with ST-segment depression or
isolated T-wave changes not known to be previously present and who
are unresponsive to NTG and calcium channel blockers. (IIa-C)
ÎÎManagement of UA/NSTEMI patients with methamphetamine use is
similar to that of patients with cocaine use. (IIa-C)
ÎÎAdministration of combined alpha- and beta-blocking agents (eg,
labetalol) may be reasonable for patients after cocaine use with
hypertension (systolic blood pressure >150 mm Hg) or those with
sinus tachycardia (pulse >100 beats/min) provided that the patient
has received a vasodilator, such as NTG or a calcium channel blocker,
within close temporal proximity (ie, within the previous hour). (IIb-C)
ÎÎCoronary angiography is NOT recommended in patients with chest
pain after cocaine use without ST-segment or T-wave changes and with
a negative stress test and cardiac biomarkers. (III-C)
Variant (Prinzmetal's) Angina
Variant angina (Prinzmetal's angina, periodic angina) is a form of UA that usually occurs
spontaneously and is characterized by transient ST-segment elevation that resolves spontaneously or with NTG use without progression to MI.
ÎÎDiagnostic investigation is indicated in patients with a clinical picture
suggestive of coronary spasm, with investigation for the presence of
transient myocardial ischemia and ST-segment elevation during chest
pain. (I-A)
ÎÎCoronary angiography is recommended in patients with episodic chest
pain accompanied by transient ST-segment elevation. (I-B)
ÎÎTreatment with nitrates and calcium channel blockers is recommended
in patients with variant angina whose coronary angiogram shows no
or nonobstructive coronary artery lesions. Risk factor modification is
recommended for patients with atherosclerotic lesions considered to
be at higher risk. (I-B)
ÎÎPCI may be considered in patients with chest pain and transient STsegment elevation and a significant coronary artery stenosis. (IIb-B)
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