{
  "schemaVersion": 2,
  "eyebrow": "Cardiovascular Medicine",
  "title": "Unstable Angina",
  "summary": "Evaluate suspected unstable angina as a troponin-negative ischemic syndrome: obtain prompt ECG and serial high-sensitivity troponin testing, exclude infarction, then use ischemic features and risk stratification to select invasive angiography or noninvasive coronary evaluation.",
  "seoDescription": "Physician guide to diagnosing and risk-stratifying unstable angina after serial troponin testing, with indications for angiography and noninvasive evaluation.",
  "clinicalQuestion": "How should clinicians confirm, risk-stratify, and investigate suspected unstable angina after myocardial infarction is excluded?",
  "specialty": "Cardiology and Emergency Medicine",
  "audience": "U.S. physicians and medical trainees",
  "tags": [
    "unstable angina",
    "NSTE-ACS",
    "high-sensitivity troponin",
    "acute chest pain",
    "coronary angiography",
    "GRACE score",
    "TIMI score"
  ],
  "keyTakeaways": [
    "Classify ischemic chest pain as NSTEMI, not unstable angina, when high-sensitivity troponin shows a rise or fall with at least one value above the 99th percentile plus evidence of ischemia. [23]",
    "Obtain a 12-lead ECG within 10 minutes of emergency-department arrival; new ST depression or transient ST elevation identifies a high-risk pathway even before a biomarker diagnosis is complete. [22]",
    "For troponin-negative patients without ischemic ECG changes, distinguish residual unstable angina from lower-risk chest pain using recurrent symptoms, objective ischemia, and structured risk assessment rather than symptom labels alone. [8][22][24]",
    "Coronary angiography is most defensible when the pretest probability of obstructive culprit coronary disease is high; many contemporary unstable-angina evaluations show normal or nonobstructive coronary arteries. [8][18]",
    "In selected patients with non-elevated or uncertain high-sensitivity troponin, no ECG changes, and no recurrent chest pain, CCTA or functional stress imaging can be used for further triage. [21]"
  ],
  "sections": [
    {
      "id": "confirm-or-reclassify",
      "eyebrow": "Diagnostic Branch Point",
      "heading": "Confirm unstable angina only after excluding myocardial infarction",
      "intro": "The critical first decision is whether the presentation meets criteria for acute myocardial infarction.",
      "paragraphs": [
        "Use serial high-sensitivity cardiac troponin testing together with ECG and ischemic assessment. NSTEMI requires a rise or fall in high-sensitivity troponin with at least one value above the 99th percentile and at least one ischemic correlate: ischemic symptoms, ischemic ECG changes, new Q waves, a new ischemic regional wall-motion abnormality, or intracoronary thrombus. A patient meeting these criteria should enter an NSTEMI pathway rather than retain the diagnosis of unstable angina. [23]",
        "Reserve unstable angina for a syndrome of clinically convincing ischemia without biomarker evidence of myocardial injury. High-sensitivity assays have reclassified a proportion of patients formerly labeled as unstable angina as MI, leaving a contemporary unstable-angina population with lower mortality and less frequent obstructive coronary disease. [8][11][14]",
        "Obtain the initial 12-lead ECG within 10 minutes of emergency-department arrival. New ST-segment depression, transient ST-segment elevation, or elevated troponin identifies high risk and supports an invasive NSTE-ACS approach; do not allow a later negative troponin result to negate dynamic ischemic ECG findings or ongoing ischemic symptoms. [22]"
      ],
      "bullets": [
        "Repeat or compare ECGs when symptoms recur; transient ischemic changes may be absent on a single tracing. [22][23]",
        "Use imaging evidence of a new regional wall-motion abnormality as an ischemic criterion when biomarker dynamics support MI and the ECG is nondiagnostic. [23]",
        "Do not use normal troponin alone to establish unstable angina; require a clinical ischemic syndrome and determine whether objective ischemia or coronary disease is demonstrable. [8][11]"
      ],
      "subsections": [],
      "table": {
        "caption": "Initial classification of suspected non-ST-elevation acute coronary syndrome. [22][23]",
        "columns": [
          "Finding",
          "Interpretation",
          "Immediate next step"
        ],
        "rows": [
          [
            "Rise/fall in hs-cTn, at least one value >99th percentile, plus ischemic symptom, ECG, imaging, Q-wave, or thrombus criterion",
            "NSTEMI, not unstable angina. [23]",
            "Use high-risk NSTE-ACS assessment and consider invasive management according to risk. [22][23]"
          ],
          [
            "New ST depression or transient ST elevation",
            "High-risk ischemic presentation even if initial biomarkers are not elevated. [22]",
            "Treat through a high-risk invasive pathway and reassess with serial ECG and troponin testing. [22]"
          ],
          [
            "Serial biomarkers without myocardial-injury pattern, no persistent ST elevation, clinically convincing ischemic symptoms",
            "Possible unstable angina after competing causes are assessed. [8][11]",
            "Estimate probability of obstructive CAD and select angiography or noninvasive testing. [8][21]"
          ]
        ]
      }
    },
    {
      "id": "risk-stratify",
      "eyebrow": "Disposition and Testing",
      "heading": "Risk-stratify troponin-negative ischemic presentations",
      "intro": "Risk scores complement, but do not replace, recurrent symptoms, ECG interpretation, and biomarker testing.",
      "paragraphs": [
        "Base early short-term risk assessment on symptom pattern, vital signs, physical examination, ECG findings, and high-sensitivity troponin results. Higher-risk NSTE-ACS patients derive the greatest benefit from revascularization, making correct risk assignment central to selecting invasive rather than conservative evaluation. [23][24]",
        "Use TIMI or GRACE as structured adjuncts. In an ACC/AHA-derived pathway, TIMI 0–1 was low risk, TIMI 2–3 intermediate risk, and TIMI at least 4 high risk when ECG and biomarker abnormalities were absent; patients with new ST depression, transient ST elevation, or elevated troponin were considered high risk independent of that score. [22]",
        "For patients considered to have unstable angina, a GRACE score of 109–140, relevant comorbidity, recurrent symptoms, or a positive ECG or stress test has been used to support coronary angiography within 72 hours. This is a selection framework, not proof of obstructive culprit disease. [8]"
      ],
      "bullets": [
        "Escalate from an initially conservative plan if angina recurs, an ECG becomes ischemic, a stress test is positive, or serial troponin testing reclassifies the patient as NSTEMI. [8][22][23]",
        "A typical angina history, Canadian Cardiovascular Society class 3 or 4 symptoms, absent fixed exertional threshold, prior PCI, positive stress testing, smoking, hypertension, age over 65 years, and male sex each increase the likelihood of obstructive CAD among patients referred with unstable angina. [8]",
        "Recognize that contemporary unstable angina has a low rate of obstructive CAD; avoid assuming that an angiographic culprit will be present solely because symptoms are severe. [8][18]"
      ],
      "subsections": [],
      "table": {
        "caption": "Features that change the evaluation path in suspected unstable angina. [8][22][24]",
        "columns": [
          "Clinical pattern",
          "Risk implication",
          "Testing or disposition consequence"
        ],
        "rows": [
          [
            "New ST depression, transient ST elevation, or elevated troponin",
            "High risk. [22]",
            "Invasive NSTE-ACS pathway rather than outpatient-style evaluation. [22]"
          ],
          [
            "TIMI 0–1 without ECG or biomarker changes",
            "Low risk in an ACC/AHA-derived pathway. [22]",
            "Use a lower-intensity, risk-matched diagnostic strategy after serial assessment. [22]"
          ],
          [
            "TIMI 2–3 without ECG or biomarker changes",
            "Intermediate risk in an ACC/AHA-derived pathway. [22]",
            "Select further testing based on symptom recurrence, objective ischemia, and CAD likelihood. [22][24]"
          ],
          [
            "GRACE 109–140, recurrent symptoms, relevant comorbidity, or positive ECG/stress test",
            "Supports invasive evaluation in unstable angina. [8]",
            "Consider coronary angiography within 72 hours. [8]"
          ]
        ]
      }
    },
    {
      "id": "choose-anatomic-or-functional-testing",
      "eyebrow": "Coronary Evaluation",
      "heading": "Choose angiography, CCTA, or stress imaging by residual risk",
      "intro": "The preferred test depends on whether the immediate question is culprit anatomy, coronary atherosclerosis, or inducible ischemia.",
      "paragraphs": [
        "Choose invasive coronary angiography when the pretest probability of significant obstructive coronary disease causing the symptoms is high, particularly with recurrent ischemia or objective evidence on ECG or stress testing. Angiography directly defines coronary anatomy and forms the basis for revascularization decisions, but may show normal arteries, nonobstructive CAD, or single- or multivessel obstructive disease in patients presenting with unstable angina. [8][18]",
        "For a clinically stable patient with non-elevated or uncertain high-sensitivity troponin, no ECG changes, and no recurrent chest pain, consider CCTA or noninvasive functional stress imaging as part of initial triage. CCTA is highly sensitive for coronary atherosclerosis but may not identify whether plaque explains symptoms when stenoses are nonobstructive; functional imaging better assesses ischemia from obstructive CAD but does not define atherosclerotic plaque burden. [21]",
        "Interpret a negative or nonobstructive anatomic evaluation as a diagnostic pivot rather than a false positive by default. In a CT angiography study of patients with initially negative ECG and troponin results, 9 of 40 had normal CCTA and 16 had no significant obstructive lesion; invasive angiography likewise has recognized limitations in characterizing ischemic syndromes when lesions are not clearly severe or arteries are not normal. [18][20]"
      ],
      "bullets": [
        "Use CCTA when identifying or excluding coronary atherosclerosis will guide disposition in the stable, ECG-negative, nonrecurrent-symptom subgroup. [21]",
        "Use functional stress imaging when demonstrating inducible ischemia from obstructive CAD is the central unresolved question. [21]",
        "Move to invasive angiography when symptoms recur or objective testing indicates ischemia, rather than relying on a single negative initial ECG or troponin result. [8][22]"
      ],
      "subsections": [],
      "table": {
        "caption": "Selection of coronary testing after MI has not been established. [8][18][21]",
        "columns": [
          "Clinical question",
          "Preferred evaluation",
          "Key limitation"
        ],
        "rows": [
          [
            "Is a high-probability obstructive culprit lesion present and is revascularization likely?",
            "Invasive coronary angiography. [18]",
            "May identify normal, nonobstructive, or obstructive disease; angiography has limitations for less obvious ischemic substrates. [18]"
          ],
          [
            "Is coronary atherosclerosis present in a stable patient with non-elevated/uncertain hs-cTn, no ECG changes, and no recurrent pain?",
            "CCTA. [21]",
            "High sensitivity for atherosclerosis does not establish that nonobstructive plaque causes the symptoms. [21]"
          ],
          [
            "Is there inducible ischemia attributable to obstructive CAD?",
            "Functional stress imaging. [21]",
            "Does not characterize coronary atherosclerotic burden. [21]"
          ]
        ]
      }
    },
    {
      "id": "manage-diagnostic-outcomes",
      "eyebrow": "Post-Test Decisions",
      "heading": "Act on the coronary phenotype rather than the unstable-angina label",
      "intro": "Subsequent management depends on whether testing shows obstructive disease, nonobstructive disease, or no coronary abnormality.",
      "paragraphs": [
        "When angiography identifies a severe stenotic lesion compatible with the ischemic presentation, use the angiographic result to make revascularization decisions. Angiography is particularly useful when it demonstrates either normal arteries or a severely stenotic lesion; intermediate or anatomically uncertain lesions require caution because the angiogram is a two-dimensional representation and may miss eccentric narrowing depending on imaging angle. [18]",
        "When CCTA or angiography shows nonobstructive CAD, do not equate the result with a definitive explanation for symptoms. CCTA identifies plaque effectively but may not provide a diagnosis because many patients lack obstructive disease; functional testing may clarify whether obstructive ischemia is present. [21]",
        "When the patient has persistent or recurrent ischemic symptoms despite an initially negative ECG and troponin profile, repeat the clinical assessment and reconsider an invasive strategy or objective ischemia testing. In the unstable-angina literature, recurrence of symptoms and positive ECG or stress testing are explicit triggers for coronary angiography. [8]"
      ],
      "bullets": [
        "Document the basis for the final diagnosis: biomarker-negative ischemic syndrome, objective ischemia result, and coronary anatomy if evaluated. [8][11][18]",
        "Reclassify the encounter if repeat high-sensitivity troponin testing develops a rise/fall pattern with a value above the 99th percentile and an ischemic correlate. [23]",
        "Do not use the term unstable angina to obscure a completed negative evaluation; its contemporary clinical value depends on credible ischemia without myocardial injury. [8][11]"
      ],
      "subsections": [],
      "table": {
        "caption": "Interpretation of downstream coronary testing in suspected unstable angina. [18][21]",
        "columns": [
          "Test result",
          "What it establishes",
          "Next decision"
        ],
        "rows": [
          [
            "Severely stenotic lesion on invasive angiography",
            "Anatomy that can support a coronary cause and revascularization decision. [18]",
            "Determine revascularization strategy using angiographic findings and clinical presentation. [18]"
          ],
          [
            "Nonobstructive plaque on CCTA",
            "Coronary atherosclerosis is present, but symptom causality may remain uncertain. [21]",
            "Consider functional imaging if obstructive ischemia remains the unresolved question. [21]"
          ],
          [
            "Normal coronary anatomy",
            "Obstructive epicardial CAD is not demonstrated. [18]",
            "Redirect the diagnostic assessment rather than pursue revascularization for an absent obstructive lesion. [18]"
          ]
        ]
      }
    }
  ],
  "faq": [
    {
      "question": "Can unstable angina be diagnosed after one normal high-sensitivity troponin result?",
      "answer": "No. A single normal value does not exclude evolving infarction; use serial high-sensitivity troponin testing, ECG reassessment, and ischemic clinical assessment. NSTEMI is diagnosed when troponin dynamics include at least one value above the 99th percentile plus an ischemic criterion. [22][23]"
    },
    {
      "question": "Which troponin-negative chest-pain patients are candidates for CCTA or stress imaging?",
      "answer": "Consider CCTA or functional stress imaging in patients with non-elevated or uncertain high-sensitivity troponin, no ECG changes, and no recurrence of chest pain. CCTA answers the atherosclerosis question; functional imaging addresses inducible ischemia from obstructive CAD. [21]"
    }
  ],
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      "snippet": "Methods: This article presents a critical review of the 2007 ACC/AHA UA/NSTEMI guidelines, highlighting some of the areas of controversy, with",
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      "number": 10,
      "title": "Treatment Strategies in Non‐ST‐Elevation Acute Coronary ...",
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      "url": "https://onlinelibrary.wiley.com/doi/10.1111/j.1540-8183.2008.00375.x",
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      "snippet": "Updated guidelines for the management of patients with unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI;",
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      "number": 11,
      "title": "Clinical implications of high‐sensitivity cardiac troponins",
      "detail": "onlinelibrary.wiley.com",
      "url": "https://onlinelibrary.wiley.com/doi/full/10.1111/joim.12779",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "The diagnosis of unstable angina is based on symptoms suggestive of progressive, severe unstable coronary artery disease, but without",
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    {
      "number": 12,
      "title": "Comparison of usual care and the HEART score for effectively and ...",
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      "url": "https://onlinelibrary.wiley.com/doi/full/10.1002/clc.23325",
      "authors": "onlinelibrary.wiley.com",
      "host": "onlinelibrary.wiley.com",
      "snippet": "The TIMI risk score for unstable angina ... Modified HEART score and high-sensitivity cardiac troponin in patients with suspected acute myocardial",
      "score": 0.5634506
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    {
      "number": 13,
      "title": "High-Sensitivity Troponin T Concentrations in Acute Chest Pain ...",
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      "url": "https://journals.lww.com/AMJM/00003017-201003160-00011.fulltext",
      "authors": "journals.lww.com",
      "host": "journals.lww.com",
      "snippet": "For the purposes of the present analysis, patients were categorized as having unstable angina with a cardiac troponin T (cTnT) value of",
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    {
      "number": 14,
      "title": "How to use high-sensitivity cardiac troponins in acute cardiac care",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/eurheartj/article/33/18/2252/425593",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "In patients with putative stable angina, with unstable angina may migrate. Such a group may comprise up to 14% of the patients diagnosed with AMI.41",
      "score": 0.51091194
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    {
      "number": 15,
      "title": "Early diagnosis of acute coronary syndrome | European Heart Journal",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/eurheartj/article/38/41/3049/4318805",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "E. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making . JAMA. 2000.",
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    {
      "number": 16,
      "title": "Acute Coronary Syndrome – Role of Computed... : Journal of Radiological Science",
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      "url": "https://journals.lww.com/jrs/fulltext/2025/01000/acute_coronary_syndrome___role_of_computed.7.aspx",
      "authors": "journals.lww.com",
      "host": "journals.lww.com",
      "snippet": "coronary artery disease, following plaque rupture or rapid thrombus occlusion. ACS is classified into ST-segment elevation MI (STEMI) or non-ST-segment elevation ACS (NSTE-ACS) which is further classified into non-STEMI (NSTEMI) or unstable angina. The diagnostic criteria include persistent ST eleva",
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      "title": "Computed tomography coronary angiography in non-ST-segment ...",
      "detail": "academic.oup.com",
      "url": "https://academic.oup.com/bjr/article/95/1140/20220346/7477412",
      "authors": "academic.oup.com",
      "host": "academic.oup.com",
      "snippet": "Computed tomography coronary angiography (CTCA) substantially altering the prevalence of the diagnoses of unstable angina and myocardial infarction.6,7",
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    {
      "number": 18,
      "title": "Coronary Angiography - an overview | ScienceDirect Topics",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/topics/nursing-and-health-professions/coronary-angiography",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Coronary angiography is a diagnostic procedure that involves the use of a catheter to visualize the coronary arteries with contrast injections, enabling precise diagnosis of coronary artery disease (CAD). Coronary angiography as part of the early invasive strategy should be considered in patients wi",
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    {
      "number": 19,
      "title": "Prevalence, predictors, and outcomes of patients with non–ST-segment elevation myocardial infarction and insignificant coronary artery disease: Results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CR...",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S0002870306002547",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "E) initiative\n# Prevalence, predictors, and outcomes of patients with non–ST-segment elevation myocardial infarction and insignificant coronary artery disease: Results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AH",
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    {
      "number": 20,
      "title": "Role of multi-slice CT coronary angiography in evaluating the different patterns of coronary artery disease in patients with unstable angina - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/pii/S0378603X15000789",
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      "host": "www.sciencedirect.com",
      "snippet": "Title: Role of multi-slice CT coronary angiography in evaluating the different patterns of coronary artery disease in patients with unstable angina - ScienceDirect\n## The Egyptian Journal of Radiology and Nuclear Medicine. Volume 46, Issue 3, September 2015, Pages 605-614. # Original article Role of",
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      "number": 21,
      "title": "Coronary computed tomography angiography versus functional stress imaging to triage chest pain in the emergency room? - ScienceDirect",
      "detail": "www.sciencedirect.com",
      "url": "https://www.sciencedirect.com/science/article/abs/pii/S1537189123001325",
      "authors": "www.sciencedirect.com",
      "host": "www.sciencedirect.com",
      "snippet": "Title: Coronary computed tomography angiography versus functional stress imaging to triage chest pain in the emergency room? - ScienceDirect\n# Coronary computed tomography angiography versus functional stress imaging to triage chest pain in the emergency room?☆. In patients with a suspected acute co",
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    {
      "number": 22,
      "title": "Management of patients with unstable angina/non-ST-elevation myocardial infarction: a critical review of the 2007 ACC/AHA guidelines - PMC",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2705816",
      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "The 2007 ACC/AHA guideline recommendations for early risk stratification (1) remain essentially unchanged since publication of the 2002 guidelines (2). They state that patients should be stratified into one of three groups: low-, moderate- and high-risk, according to their risk factors. These risk f",
      "score": 0.81979275
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    {
      "number": 23,
      "title": "Current Management of Non-ST-Segment Elevation Acute Coronary Syndrome",
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      "authors": "pmc.ncbi.nlm.nih.gov",
      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "### 3.2. Risk Stratification\n\nEarly risk stratification upon admission is essential for a tailored therapeutic strategy in patients with NSTE-ACS because those at a higher risk benefit the most from revascularization [2][40][41][42] (Figure 2). There is a consensus on basing the initial short-term risk",
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      "number": 24,
      "title": "The use of risk scores for stratification of non-ST elevation acute coronary syndrome patients",
      "detail": "pmc.ncbi.nlm.nih.gov",
      "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC2722456",
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      "host": "pmc.ncbi.nlm.nih.gov",
      "snippet": "## . The ability to assign relative risk to patients presenting with NSTE ACS assists the clinician in determining the appropriate strategy for an individual patient. The information required for this assessment is derived from the patient’s history and physical examination, electrocardiogram (ECG) ",
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  ],
  "publishedAt": "2026-09-15T23:05:51.740500+00:00",
  "updatedAt": "2026-09-15T23:05:51.740500+00:00",
  "readingMinutes": 5,
  "slug": "unstable-angina"
}