Acute Coronary Syndrome (ACS) - NSTEMI

Question 1

Aetiology of an NSTEMI.

Answer 1

Partial Occlusion of a Coronary Artery.

Question 2

Investigations of an NSTEMI (2).

Answer 2

1. ECG (Check for ST Elevation) Changes.
2. Check Serial Troponin Levels (at baseline and 6/12 hours after onset of symptoms).

Question 3

Give 3 ECG changes that may indicate an NSTEMI.

Answer 3

1. ST Depression.
2. Deep T Wave Inversion.
3. Pathological Q Waves (suggesting a deep infarct - late sign).

Question 4

What are Troponin?

Answer 4

Proteins found in cardiac muscle - a rise is consistent with myocardial ischaemia as the proteins are released from the ischaemic muscle.

Question 5

Differential Diagnoses of Raised Troponin Levels (6).

Answer 5

1. CKD.
2. Sepsis.
3. Myocarditis, Pericarditis, Arrhythmias, Acute HF.
4. Aortic Dissection.
5. PE.
6. Prolonged Strenuous Exercise.

Question 6

Acute Management of an NSTEMI (6).

Answer 6

BATMAN :
1. B - B-Blockers (Unless Contraindicated).
2. A - Aspirin 300mg STAT.
3. T - Ticagrelor 180mg STAT (or Clopidogrel 300mg).
4. M - Morphine (Pain).
5. A - Anticoagulant - Fondaparinux (Unless High Bleeding Risk/Immediate Angiography/Creatinine >265 : Unfractionated Heparin).
6. N - Nitrates e.g. GTN to relieve coronary artery spasm.

Question 7

What scoring system is used in NSTEMI management?

Answer 7

GRACE Score - 6 month risk of death/repeat MI after NSTEMI :
1. <5% - Low Risk.
2. 5-10% - Medium Risk.
3. >10% - High Risk.
Medium/High Risk - Early PCI (within 4 days of admission).

Question 8

Give 3 indications for coronary angiography (with follow-on PCI if necessary) in NSTEMI.

Answer 8

1. Immediate : Clinically Unstable.
2. Within 72 Hours : GRACE > 3%.
3. Re-experiencing Ischaemia after Admission.

Question 9

What is GRACE based on? (6)

Answer 9

1. Age.
2. Heart Rate & BP.
3. Killip Class and Renal Function (Creatinine).
4. Cardiac Arrest?
5. ECG.
6. Troponin.