The coronary care unit (CCU) with unstable angina

A 79-year-old woman is admitted to the coronary care unit (CCU) with unstable angina. She is started on appropriate medication to reduce her cardiac risk. She is hypertensive, fasting glucose is normal and cholesterol is 5.2. She is found to be in atrial fibrillation. What is the most appropriate treatment?

  1. Aspirin and clopidogrel
  2. Digoxin
  3. Cardioversion
  4. Aspirin alone
    5) Warfarin

View Explanation

Ideally this patient should be started on antihypertensives, a beta blocker and a statin. There is no indication for hypoglycaemics at present. There is no indication that this is acute atrial fibrillation and she does not seem to be compromised in a female of this age, cardioversion © is unlikely to be successful. She should be rate-controlled but the beta blockade is more appropriate in light of her ischaemic heart disease. Whether to start anticoagulation (A) is a decision that has to be tailor-made for each individual patient. The CHAD2 score is a quick and dirty but very useful way of predicting risk of subsequent stroke as a result of atrial fibrillation and helps guide the prescription of prophylactic antiplatelets or anticoagulants. Other factors, such as ease of taking and monitoring warfarin, risk of falls and important risk factors, such as vascular disease, should be taken into account.

C Congestive heart failure 1

H Hypertension: blood pressure consistently above 140/90 mmHg (or treated hypertension on medication) 1

A Age ≥75 years 1

D Diabetes mellitus 1

S2 Previous stroke or TIA 2

A score of 0 is low risk (2 per cent of patients/year will have a stroke without treatment), aspirin is considered adequate. A score of 1 is moderate risk (3 per cent annual stroke risk) and either warfarin or aspirin (D) is indicated according to the individual. A score of two or above (>4 per cent annual stroke risk) is classified as high risk and warfarin (E) should be started unless there are clear contraindications. A patient with a full-house of risk factors (scores 6) has an almost 20 per cent chance of stroke/year.