A 60-year-old male patient on aspirin, nitrates, and a beta blocker, being followed for chronic stable angina, presents to the ER with a history of two to three episodes of more severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. The best course of action of the following is to

This patient presents with unstable angina, a change from the previous chronic stable state in that chest pain has become more frequent and more severe. Intravenous heparin is indicated. Subcutaneous administration of low-molecular-weight heparin (such as enoxaparin) is an alternative. There is no role for digoxin, as this may increase myocardial oxygen consumption and exacerbate the situation. Thrombolytic therapy is reserved for the treatment, typically within 6 h, of ECG-documented myocardial infarction and does not reduce cardiac events in the setting of unstable angina. A more aggressive approach is early interventional cardiac catheterization with angioplasty and/or stent placement, possibly in conjunction with glycoprotein IIb/IIIa inhibitors.