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Medicine (MD/DO)
Ischemic Heart Disorders
Unstable Angina

Master Unstable Angina for the USMLE

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Unstable Angina

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Unstable Angina

Unstable-ground Angel with Chest Pain-bolts
Unstable angina is chest pain that is irregular, occurs at rest, has new onset, or has a worsening pattern. Chronic stable angina can progress to unstable angina. And unlike chronic stable angina, unstable angina is unpredictable and is an emergency. This can occur at rest or exertion and limits a patient’s ADL’s. Typically this pain lasts greater than 15 minutes, and is not relieved by nitroglycerin. ECG can show ST depression and possible T wave inversion.
Chest Pain with Rest or Exertion
Chest Pain-bolt with Bed or Exertion

The pattern of unstable angina is irregular, and can occur at rest, or with minimal exertion. This pain is described as crushing, squeezing, or a pressure that is choking in the substernal area.

Limits ADLs
Limit Tools for Daily Living

Because this pain appears with minimal activity or rest, patients’ activities of daily living (ADL’s) are limited, as any activity can precipitate chest pain.

> 15 Minutes
Timer > 15 Minutes

Unstable anginas can last greater than 15 minutes, but usually last less than 20 minutes. It is described by patients as increasing in intensity over the course of days or weeks.

Less Likely Relieved by Nitroglycerin
Not Relieved by Nitro-glacier

The chest pain experienced in unstable angina does not respond well to nitroglycerin administration, distinguishing it from chronic stable angina. It often requires the addition of morphine for symptomatic pain control and ultimately surgical intervention to correct the underlying problem.

ST Depression
Depression St.

A 12 lead ECG can show ST depression and possible T wave inversion. Up to 50% of patients with unstable angina can have myocardial necrosis. CK-MB and troponins should be followed, as they may have non-ST elevation myocardial infarction (NSTEMI).


The most prominent symptom of this disease is fatigue, and women seek medical attention for symptoms of unstable angina more often than men. Other symptoms include shortness of breath, indigestion and anxiety.

Acute Coronary Syndrome (ACS) Treatment
Acute-angle Crown-heart

Because of the severity of unstable angina, patients should undergo treatment for acute coronary syndrome, which is a precursor to myocardial infarction. The protocol to rule out myocardial infarction should be followed, including ECG, cardiac markers CK-MB, and troponins.

Emergency Treatment

Unstable angina is an emergency, thus patients should seek emergency treatment. There is a serious risk of unstable angina progressing to myocardial infarction.


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