acute coronary syndrome without ST elevation

Question 1

clinical presentation for acute coronary heart syndrome without ST elevation.

Answer 1

unstable angina pectoris but different from chronic heart disease angina pectoris

it happens more frequent

more intense

requires more NG tablets

longer duration 15-30 min

it starts directly with maximal pain does not start gradulally and fall away gradually

provoked with small efforts and appearing at rest

nocturnal pain

Question 2

ECG READING in NSTEMMI and unstable angina ? and lab findings ?

Answer 2

PERSISTANT
st depression
negative t waves

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normal or evelvated
Tr-I
Tr-T - BEDSIDE TROPONIN

the degree of elevation over correlates to the size of the infracts

myoglobin - rise in 1 hr - but non specific not used

CK-MB (4-9hrs) - more specific to also cardiac tissue
BUT BEST TO KNOW REINFRACTION
12-24hr maximum

elevated BNP , CRP , AST , LDH

Question 3

different to acute coronary syndrome ECG reading that to chronic ?

Answer 3

ECG changes usually only vanish after couple of weeks unlike with chronic coronary artery disease

Question 4

in STEMI why is there an ST elevation and in NSTEMI there is not

Answer 4

STEMI it is a transmural infraction ,

NSTEMI it is infraction of the subendocardial tissue

Question 5

test for definitive diagnosis ?

Answer 5

coronary angiography - can identify the side and degree of vessel occlusion

Question 6

risk stratification do we do with NSTEMI and why do we do this ?

Answer 6

GRACE score 
1)age
hr
systolic bp
serum creatinin 
kilip class
cardiac arrest at admission 
elevated cardiac markers 
st segment elevation 

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kilip?
1) signs of heart failure 
2) rales
3) acute pulmonary edema
4) cardiogenic shock 

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grace score 
low < or equal to 108
intermediate 109-140
high - more than 140

of further treatment and prompt angiography

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The following
are associated with an increased risk:
• History of unstable angina.
• ST depression or widespread T-wave inversion.
• Raised troponin (except patients with ST elevation MI).
• Age >70 years.
• General comorbidity, previous MI, poor LV function or DM.

Question 7

what is the management of someone with NSTEMI ?

Answer 7

a-e

2 large bore iv canula

!!!! IF SAO2 <90% OR BREATHLESS, LOW-FL OW O2
2-4L/MIN !!!!!!

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Analgesia: Eg morphine 5–10mg IV + metoclopramide 10mg IV

Nitrates: 2 puffs of GTN spray or sublingual tablets as required

Aspirin: 300mg PO.
Consider need for second antiplatelet agent
eg clopidogrel (300mg PO then 75mg
OD PO) = for lw risk
Ticagrelor (180mg then 90mg/12h PO) is a prefered alternative, particularly in
higher risk groups

 ≥60yrs age
 •previous stroke, TIA, MI, or CABG 
•known coronary
artery stenosis  or carotid stenosis 
 •DM 
•peripheral
arterial disease 
•chronic kidney disease).

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risk assessment

GRACE score!!!!

occuranceof chest pain

Secondary criteria—diabetes, CKD,
LVEF <40%, early angina post MI, recent PCI, prior CABG

= and see management according to grace score

Question 8

what is the management in low risk

Answer 8

Conservative strategy (low-risk pt):
• No recurrence of chest pain
• No signs of heart failure
• Normal ECG
• —ve baseline (± repeat) troponin

May be discharged (check troponin
interval required with your laboratory
and retest after delay if necessary).
Arrange further outpatient investigation,
eg stress test.

Question 9

what is the managemnet in high risk patients for nstemi?

Answer 9

1) Fondaparinux: 2.5mg OD SC or LMWH 1mg/kg/12h SC

2) Second antiplatelet agent
ticagrelor 180mg PO

Prasugrel (60mg then 10mg/d PO) is an
alternative to clopidogrel for those undergoing PCI.

3) IV nitrate if pain continues
maintain systolic BP >100mmHg

4) Oral b-blocker, eg bisoprolol 2.5mg OD
CI: cardiogenic shock, heart failure, asthma/COPD or heart
block; consider rate-limiting calcium antagonist (eg
verapamil 80–120mg/8h PO, or diltiazem 60–120mg/8h PO)

5) Prompt cardiologist review for angiography
1 Urgent (<120min after presentation) if ongoing
angina and evolving ST changes, signs of cardiogenic
shock or life-threatening arrhythmias
2 Early (<24h) if GRACE score >140 and high-risk patient
3 Within 72h if lower-risk patient

Question 10

what are the further treatments for NSTEMI?

Answer 10

Wean off glyceryl trinitrate (GTN) infusion when stabilized on oral drugs.

• Continue fondaparinux (or LMWH or heparin) until discharge.
• Observe on cardiac monitor or telemetry in case of dysrhythmia. Check serial ECGS,

troponin T levedls >12h after pain.
or 6hr rule out according to trust

• Address modifiable risk factors: smoking, hypertension, hyperlipidaemia, diabetes.
• Gentle mobilization.
• Ensure patient on dual antiplatelet therapy, -blocker, ACE

ACE-i: Should be given to all patients unless there are CI (monitor renal function).

Lipid management: Start early, eg atorvastatin 80mg OD

Question 11

which type of drugs are not recommended in patients with unstable angina and NSTEMI ?

Answer 11

fibrinolytic treatment