Non-ST elevation MI

Question 1

Pathology of NSTEMI:

Answer 1

1) various processes!
2) plaque rupture & non-occlusive thrombosis
3) dynamic obstruction
- epicardial coronary spasm
- local vasoconstriction-thromboxane from platelets
- coronary endothelial dysfunction- poor NO production
- adrenergic stimulation-cold exposure
4) severe coronary luminal narrowing
5) secondary supply/demand mismatch-severe anemia

Question 2

How is NSTEMI different from STEMI?

Answer 2

NSTEMI=

• non-transmural or subendocardial
• non-Q wave MI
• multivessel or diffuse CAD

Question 3

• women most commonly present with:

- men most commonly present with:

Answer 3

• unstable angina

- STEMI

Question 4

NSTEMI clinical presentation:

Answer 4

• like angina but WORSE -heavy chest, tight, squeezing….all that
• SOB, profound diaphoresis, nausea,vomit,palpitation,weakness
• clear lungs or congestion (rales)
• “Levines sign”

Question 5

NSTEMI - cardiac exam findings:

Answer 5

• S1 and S2 normal to muffled (bc reduced force of ventricular contractility)
• S4 very common at apex (due to stiff myocardium - cant relax well)
• S3 variable
• extremities have peripheral arterial disease

Question 6

ECG of NSTEMI:

Answer 6

• J point depression common
• horiz or downsloping ST segments
• SYMMETRIC T wave inversion = ischemia

Question 7

ASYMMETRIC T WAVE INVERSION=

Answer 7

repol abnormlity

Question 8

NSTEMI - lab tests:

Answer 8

1) serum markers:
- troponin (cTnI 5-10days or cTnT 10-14 days)
- creatine kinase MB isoform (CK-MB return to norm 2-3 days)
2) others
- DM
- dyslipidemia
- renal function

Question 9

What imaging identifies plaque rupture?

Answer 9

-intravascular ultrasound (IVUS)

Question 10

NSTEMI - management:

Answer 10

-NO THRYOMBOLYTIC THERAPY USUALLY
-GIve:
nitrates
beta blockers
aspirin
ADP antogonists (clopidogrel)
antigoagulants
statins
ACEI
-put them in the ICU
-O2 if needed

Question 11

Clopidogrel does what?

Answer 11

-bind ADP to platelet receptors irreversibly = inh platelet aggregation

Question 12

When to do coronary angiography or intervention?

Answer 12

• if ST segments change or evolve
• Troponins elevate
• recurrent ischemia after admission
• HF
• PCI within past 6mo
• previous CABGS

Question 13

Long term NSTEMI?

Answer 13

-modify risk factors!!
-continue meds:
ASA/clopidogrel
beta blockers
ACEI
statins