Non-ST Elevation MI

Question 1

Aetiology of NSTEMI

Answer 1

-Age (increasing- 70+)
-Lifestyle factors: smoking, diet, exercise
-Family history (genetic- younger than 50 heart attack)
-Other risk factors: HTN, DM, High cholesterol, CKD

Question 2

Pathophysiology of NSTEMI

Answer 2

-Atherosclerosis
=Plaque erosion with overlying thrombosis
=Inflammation in plaque disruption
=Platelet aggregation and activation on exposed thrombogenic surface of rupture plaque
=Release mitogenic substances that disrupts endothelium
=Narrowing of lumen

Question 3

NSTEMI symptoms

Answer 3

-Pain= chest (80%), upper abdomen, back, jaw
-Nausea, vomiting
-Sweating
-Dyspnoea (heart failure)
-Palpitations

Question 4

Clinical signs of NSTEMI

Answer 4

-Levine’s sign (fist over chest- in pain, heavy central tightness)
-Rhythm disturbance- Tachycardia, bradycardia (inferior infarct AV node)
-Pulmonary oedema (usually STEMI)
-BP- hypertensive, hypotensive
-Diaphoresis (sweating)

Question 5

NSTEMI Investigations

Answer 5

-Basic observations (BP)
-ECG
-Bloods: troponin
-CXR
-ECHO
GRACE score

Question 6

Diagnostic criteria of NSTEMI

Answer 6

Cardiac biomarkers> 99th percentile ±
1- Symptoms relating to Ischaemia
2- ECG: new/ presumed new ECG changes
3- Q waves on ECG
4- Imaging: new RWMA abnormality

Question 7

NSTEMI treatment

Answer 7

-Analgesia
-Anti-platelets: Aspirin 300mg, Ticagrelor (conservative management), Clopidogrel, Prasugrel
-Anticoagulation (unfractionated Heparin) if immediate angiography planned or creatinine >265/ fondaparinux not high risk of bleeding and not having angiography immediately
-ACEi/ beta blockers/ statin
-Anti-anginal: calcium channel blockers, ISMN
-Oxygen (if sats<90%)
-PPI
-Percutaneous coronary intervention within 72 hours of presentation

Question 8

Prognosis of NSTEMI

Answer 8

DARTH VADER

-Death
-Arrhythmia
-Rupture
-Tamponade
-Heart Failure

-Valve disease
-Aneurysm of ventricle
-Dressler’s syndrome
-Embolism
-Recurrence

Question 9

Long-term care NSTEMI

Answer 9

-DAPT
-Secondary prevention: cholesterol, BP, BM
-Lifestyle advice: diet, weight, smoking
-Cardiac rehabilitation

Question 10

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?

Answer 10

-immediate: patient who are clinically unstable (e.g. hypotensive)
-within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
-coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Question 11

Percutaneous coronary intervention for patients with NSTEMI/unstable angina

Answer 11

-unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
-further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI
=if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
=if taking an oral anticoagulant: clopidogrel

Question 12

Conservative management for patients with NSTEMI/unstable angina

Answer 12

-further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug)
=if the patient is not at a high risk of bleeding: ticagrelor
=if the patient is at a high risk of bleeding: clopidogrel

Question 13

GRACE score

Answer 13

The Global Registry of Acute Coronary Events (GRACE) is the most widely used tool for risk assessment. It can be calculated using online tools and takes into account the following factors:
age
heart rate, blood pressure
cardiac (Killip class) and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels

Question 14

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-on PCI if necessary)?

Answer 14

immediate: patient who are clinically unstable (e.g. hypotensive)
within 72 hours: patients with a GRACE score > 3% i.e. those at intermediate, high or highest risk
coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Question 15

Drugs for PCI

Answer 15

Further drug therapy
unfractionated heparin should be given regardless of whether the patient has had fondaparinux or not
further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug) prior to PCI
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel

Question 16

Conservative management drugs

Answer 16

further antiplatelet (‘dual antiplatelet therapy’, i.e. aspirin + another drug)
if the patient is not at a high risk of bleeding: ticagrelor
if the patient is at a high risk of bleeding: clopidogrel