NSTEMI Flashcards
Coronary territories
Lateral = Circ
Septal = LAD
Inferior = RCA
Criteria for diagnosis of acute myocardial infarction suggestive of myocardial necrosis
A combination of
Troponin >99th percentile of upper reference range (0-14ng/L)
plus at least one of :
- Symptoms of myocardial Ischeamia
- New ECG changes
- Pathological Q waves
- Imaging of myocardial dysfunction consistent with ischaemic aetiology
- Intracoronary thrombus detected on angiogram or autopsy
Transthoracic echocardiogram
What can it identify?
- Can help identify alternative diagnosis e.g aortic dissection, pericardial effusion, aortic valve stenosis, mitral valve prolapse, right ventricular dilatation suggestive of pulmonary embolism
Other methods of non-invasive imaging e.g cMRI, SPECT, CTCA
Differential diagnosis
Cardiac: myopericarditis, cardiomyopathies, tachyarrhythmias, acute heart failure, hypertensive emergencies, aortic valve stenosis, takatsubo syndrome, cardiac trauma, coronary spasm
Pulmonary: Pulmonary embolism, pneumothorax, bronchitis/pneumonia, pleuritis
Vascular: aortic dissection, stroke
GI: Oesophagiutis, reflux spasm, peptic ulcer, gastritis, pancreatitis, cholecystitis
Orthopedic: MSK, chest trauma, costochondritis, cervical spinal pathologies
Anxiety
Anaemia
Clinical risk scores
GRACE risk score most commonly used – estimates early 6 month mortality for patients with acute coronary syndrome
Age
Heart rate
Systolic BP
Creatinine
Cardiac arrest at admission
ST segment deviation
Abnormal cardiac enzymes
Killip class : No CHF, pulmonary crackles/ JVD, pulmonary oedema, cardiogenic shock
Bleeding risk assessment
Major
DOAC
CKD eGFR <30ml/min
Hb <11g/dL
Spontaneous bleeding requiring transfusion
Thrombocytopenia <100 x10(9)/L
Chronic bleeding
Liver cirrhosis with portal hypertension
Active malignancy last 12 months
ICH
Moderate or severe ischaemic stroke within last 6 months
Recent major surgery in last 30days
Minor
age >75yrs
Moderate CKD 30-59mL/min
NSAIDS
Any ischaemic stroke
Initial management
Anti platelet or anticoag
Anti platelets
Immediate Loading:
Aspirin 300mg PO then 75mg OD (inhibition of thromboxane A2)
+ P2Y12 inhibitor
Ticagrelor 180mg STAT then 90mg BD
or
Clopidogrel 300-600mg STAT then 75mg OD (less potent and variable platelet inhibition)
Symptom control
GTN 400mcg s/L
+/- IV nitrates 1-10mg/min
IV morphine 10mg – immediate pain relief, reduce catecholamine response, mild vasodilator.
Beta blocker – reduce cardiac mortality, increase coronary perfusion by increasing ventricular filling in diastole, reduce myocardial demand – reduce ischaemia. Reduce risk of malignant arrhythmias
Pharmacological management
Lipid lowering therapy – statins, ezetimibe, nustedni, inclisiran, PCSK-9
ACE/ARBS - reduce all cause mortality (ISIS-4, GISSI-3)
Beta blockers - (ISIS1, Commit)
MRA EF<40% - reduction in death and hospitalisation (Ephesus)
+/- PPI –
Consider heart failure (LV impairment, primary prevention devices)
