Cardiac Emergencies: STEMI, NSTEMI

Question 1

Initial assessment of chest pain

Answer 1

Current pain?
-Vital signs - are they stable?

Cardiac?
Past CV Hx
-MI, CABG/PCI
-CV risk factors
-Past chest pain investigations

ACS?
-chest pain => neck, jaw lasting 15+mins
-N+V, sweathing, SOB?
-haemodynamic instability?
-new onset/angina at rest 
angina?

Question 2

Immediate management of suspected ACS

-where to refer

Answer 2

12ECG
300mg aspirin
GTN, IV morphine

A&E

• Current pain
• Pain in last 12hrs AND abnormal ECG/not available

Urgent day assessment

• Pain last 12hrs AND normal ECG
• Pain in last 12-72hrs

Question 3

Initial hospital management

-diagnosis of ACS

Answer 3

12ECG if not done already

Bloods

• TNT stat => HIGH
• FBC, U&E, LFT, CRP, glucose, Mg, PO4, lipids

Imaging
-CXR

ECG

• ST elevation/depression
• T inversion
• Q waves

Question 4

STEMI management

• immediate
• definitive

Answer 4

STAT if not given already

• 300mg aspirin
• IV morphine
• O2 if U94%
• GTN

U12hrs of onset
PCI possible in 2hrs
✅ - prasugrel + heparin
-if on AC => clopidogrel
-if high bleed risk => ticagrelor or clopidogrel

❌- fibrinolysis + antithrombin

• ticagrelor after fibrinolysis
• ECG to assess efficacy => PCI if not

12+hrs of onset => ticagrelor

Question 5

NSTEMI management

• immediate
• definitive

Answer 5

STAT if not given already
-300mg aspirin
-IV morphine
-O2 if U94%
-GTN
Fondaparinux unless PCI or high bleed risk

GRACE - predict 6month mortality, CV risk

Low - ticagrelor
-if high bleed risk => clopidogrel

Intermediate-high - angiography

• PCI - prasugrel + heparin
• if not on AC - ticagrelor
• if on AC - clopidogrel

Question 6

Secondary prevention

Answer 6

Cardiac rehab

• started before discharge
• education on physical activity, lifestyle advice, stress management, health

Lifestyle changes

• healthy eating - high fruit, veg, fish
• alcohol reduction
• 20-30mins physical activity
• smoking cessation
• weight control

Drug
ACEi/ARB
Bb 2.5mg
Statin 80mg
Dual AP in total
-PCI done - PO AC + clopidogrel (75mg OD)
-PCI not done - PO AC + aspirin (75mg OD)

GTN spray

Question 7

Differences between ACS and stable angina

Answer 7

Stable angina

• exertional pain, resolves on rest/GTN
• no ECG changes or TnT
• lasts U5mins

ACS (STEMI, NSTEMI, unstable angina)

• pain on rest/decreased activity, not relieved by GTN or rest
• ECG changes and high TnT
• lasts 5mins+

Question 8

Relative efficacies of aspirin, ticagrelor, clopidogrel and prasugrel

Answer 8

Most potent, highest bleed risk

Prasugrel
Ticagrelor
Clopidogrel

Least potent, lowest bleed risk

Question 9

Management of all patients in hospital

Answer 9

ACS specific LMWH 5 days (heparin if PCI planned) => VTE prophylactic LMWH

Cardiac monitoring - 48hrs
Admit - 4-7 days
-daily examination
-2-3 days TnT

Correct electrolyes
Start ACEi, Bb - reduce cardiac remodelling, demand

Question 10

Indications and contraindications for

• PCI
• Thrombolysis

Answer 10

PCI indications
-any ACS
PCI relative CI
-significant comorbidities

Thrombolysis indications
STEMI in 2 contiguous ECG leads
-1mm+ in limb leads
-2mm+ in chest leads
New LBBB
Thrombolysis CI
-active int bleeding
-bleeding disorder
-aortic dissection
-hemorrhagic stroke at any time
-U6months ischemic stroke
-U2wks trauma/surgery