不稳定型心绞痛

虽然 ST 段抬高型心肌梗死患者的管理以急诊血运重建为主，但非 ST 段抬高型急性冠脉综合征 (NSTE-ACS) 患者的治疗主要是评估和力争将心血管事件复发风险降到最低。

不稳定型心绞痛患者（肌钙蛋白阴性），如果无反复发作或持续症状，并且心电图正常，可以在普通病房接受监测，但 NSTE-ACS 患者应当接受心律监测。[1]Roffi M, Patrono C, Collet JP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:267-315.http://eurheartj.oxfordjournals.org/content/37/3/267.longhttp://www.ncbi.nlm.nih.gov/pubmed/26320110?tool=bestpractice.com

低风险患者定义为无复发性胸痛、无ECG改变、无血清心脏标记物升高以及未发现心力衰竭。[92]Schechtman KB, Capone RJ, Kleiger RE, et al. Risk stratification of patients with non-Q wave myocardial infarction. The critical role of ST segment depression. The Diltiazem Reinfarction Study Research Group. Circulation. 1989;80:1148-1158.http://www.ncbi.nlm.nih.gov/pubmed/2805257?tool=bestpractice.com这些患者出院前应接受无创检查（使用运动或药物负荷，超声或核素显像），需要积极改善危险因素。

最初接受保守治疗的患者应当在出院后 2 至 6 周接受再次评估。应当根据症状和无创检测来评估这些患者是否能够接受心导管插管和血运重建。[1]Roffi M, Patrono C, Collet JP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37:267-315.http://eurheartj.oxfordjournals.org/content/37/3/267.longhttp://www.ncbi.nlm.nih.gov/pubmed/26320110?tool=bestpractice.com[3]Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64:e139-e228.http://content.onlinejacc.org/article.aspx?articleid=1910086http://www.ncbi.nlm.nih.gov/pubmed/25260718?tool=bestpractice.com

为心脏病患者提供临床治疗的医生需重视此人群有较高的严重抑郁障碍发生率，其与心血管结局恶化相关。[93]Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation. 1995;91:999-1005. [Erratum in: Circulation. 1998;97:708.]http://circ.ahajournals.org/content/91/4/999.fullhttp://www.ncbi.nlm.nih.gov/pubmed/7531624?tool=bestpractice.com因此，应对患者进行抑郁症状的筛查并给予治疗，包括药物治疗。[94]Lichtman JH, Bigger JT Jr, Blumenthal JA, et al. Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association. Circulation. 2008;118:1768-1775.http://circ.ahajournals.org/content/118/17/1768.longhttp://www.ncbi.nlm.nih.gov/pubmed/18824640?tool=bestpractice.com

心脏康复是一个长期的综合项目，包括锻炼、 [ ]What are the effects of exercise-based cardiac rehabilitation in people with coronary heart disease?http://cochraneclinicalanswers.com/doi/10.1002/cca.1187/full显示答案 饮食和生活方式干预、患者教育 [ ]What are the effects of patient education in the management of coronary heart disease?http://cochraneclinicalanswers.com/doi/10.1002/cca.278/full显示答案 和咨询。建议对合适的 NSTE-ACS 患者进行心脏康复，可能改善临床结局。[95]Wenger NK, Froelicher ES, Smith LK, et al. Cardiac rehabilitation as secondary prevention. Agency for Health Care Policy and Research and National Heart, Lung, and Blood Institute. Clin Pract Guidel Quick Ref Guide Clin. 1995;17:1-23.http://www.ncbi.nlm.nih.gov/pubmed/8595435?tool=bestpractice.com[96]DeBusk RF, Miller NH, Superko HR, et al. A case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med. 1994;120:721-729.http://www.ncbi.nlm.nih.gov/pubmed/8147544?tool=bestpractice.com[97]Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol. 2004;44:988-996.http://www.ncbi.nlm.nih.gov/pubmed/15337208?tool=bestpractice.com [ ]Do multiple risk factor interventions help to prevent cardiovascular disease in low- and middle-income countries?http://cochraneclinicalanswers.com/doi/10.1002/cca.1091/full显示答案