ACS - NSTEMI Flashcards
What is NSTEMI?
-partial occlusion of the coronary artery resulting in reduce blood flow and so myocardial infarction = increased troponin
Presentations of NSTEMI
men - chest pressure/discomfort lasting several minutes, sweating, dyspnoea, nausea, anxiety
women- middle/upper back pain, dyspnoea
Diagnosis of NSTEMI
ECG- ST depression, T-wave changes, transient ST elevation, normal
Risk factors for NSTEMI
- atherosclerosis
- diabetes
- smoking
- dyslipidaemia
- hypertension
- metabolic syndrome
- obesity
- age > 65
- smoking
- cocaine use
- physical inactivity
- Fx of CAD
- stent thrombosis or restenosis
- CKD
- surgical procedures
- sleep apnoea
- depression
Classification of NSTEMI
5 types:
1) spontaneous MI caused by pathological process in the wall of the coronary artery (plaque rupture)
2) MI secondary to increase in oxygen demand or decrease in supply
3) sudden cardiac death before cardiac biomarkers obtained
4a) MI associated with PCI
4b) MI associated with stent thrombosis
4c) MI associated with re-stenosis
4) MI associated with coronary bypass graft surgery
Classification of NSTEMI
5 types:
1) spontaneous MI caused by pathological process in the wall of the coronary artery (plaque rupture)
2) MI secondary to increase in oxygen demand or decrease in supply
3) sudden cardiac death before cardiac biomarkers obtained
4a) MI associated with PCI
4b) MI associated with stent thrombosis
4c) MI associated with re-stenosis
4) MI associated with coronary bypass graft surgery
Type 1:
- spontaneous and associated symptoms of ACS, more increase in troponin levels than T2 MI
- T2 MI- although coronary artery disease may be present on angiogram, there is absence of acute pathology
Case histories of NSTEMI
1) A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the accident and emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads.
- some don’t have chest pain
- also epigastric pain, indigestion feeling, isolated dyspnoea, syncope,
Investigations and diagnosis of NSTEMI:
- 12 lead ECG within 10 mins (no evidence of STEMI), high sensitivity troponin elevation, MI symptoms
- Urgent echocardiography
- chest x-ray
- FBC
- U, E, Creatinine
- LFTs
- blood glucose
- CRP
Consider:
- echocardiography
- invasive coronary angiography ICA
Differentials other than NSTEMI:
- STEMI
- UA
- Aortic dissection
- Pulmonary embolism
- Peptic ulcer disease
- Acute pericarditis
- Oesophageal spasm
- Costochondritis
- Panic attack
- Stable ischaemic heart disease
- Myocarditis
- Acute cholecystitis
- Boerhaave syndrome (oesophageal rupture)
- Brugada syndrome (tachycardia)
- Acute stress cardiomyopathy (often the clinical state is triggered by a severe extracardiac stressor (e.g., intracranial haemorrhage, phaeochromocytoma, exogenous catecholamine administration, severe emotional stress, takotsubo cardiomyopathy, apical ballooning syndrome)).
Risk score for NSTEMI
- GRACE score- predict 6-month mortality
- Thrombolysis in MI TMI risk
- KILIP classification - left ventricular failure?
- HEART score
Treatment Algorithm NSTEMI
clinically unstable:
- immediate refer invasive coronary angiography + revascularisation
- aspirin
- oxygen <90%
- glyceryl trinitrate translingual
- morphine sulfate
- anti-emetic- ondansetron, metoclopramide, cyclizine
- P2Y12 inhibitor- prasugrel, ticagrelor, clopidogrel
- heparin
Clinically stable -
Consider:
-beta blocker - bisoprolol, carvedilol
-ACEi or an
Treatment Algorithm NSTEMI
clinically unstable:
- immediate refer invasive coronary angiography + revascularisation
- aspirin
- oxygen <90%
- glyceryl trinitrate translingual
- morphine sulfate
- anti-emetic- ondansetron, metoclopramide, cyclizine
- P2Y12 inhibitor- prasugrel, ticagrelor, clopidogrel
- heparin
Clinically stable -
Consider:
-beta blocker - bisoprolol, carvedilol
-ACEi or angiotensin-II receptor antagonist- enalapril, ramipril, lisinopril, valsartan, losartan, candesartan
-refer invasive coronary angiography + revascularisation
-manage hyperglycaemia
Post stabilisation: -continue dual antiplatelet therapy- aspirin indefinitely) AND prasugrel/ticagrelor/clopidogrel -BB- bisoprolol, carvedilol -ACEi -statin- atorvastatin, rosuvastatin, Consider: -aldosterone antagonist: -eplerenone, spironolactone -cardiac rehab
Complications with NSTEMI:
- cardiac arrythmias
- acute heart failure
- cardiogenic shock
- ventricular rupture or aneurysm
- acute mitral regurgitation
- post-MI pericaditis (Dressler syndrome)
- VTE
- depression
- in-stent thrombosis
