Unstable angina and NSTEMI

Question 1

Describe the presentation of UA/NSTEMI

Answer 1

• Angina at rest
• New onset severe angina
• Worsening angina
  
  • Increased frequency
  • Prolonged duration
  • Lower threshold of attack

Question 2

Describe the ECG changes in UA/NSTEMI

Answer 2

• Normal ECG
• Non-specific changes
• ST depression
• T wave inversion

Question 3

Differentiate between the pathophysiology of UA and NSTEMI

Answer 3

• UA: Sub-total occlusive thrombus
• NSTEMI: Total occlusive thrombus → Cardiac markers

Question 4

Outline the initial management of UA/STEMI

Answer 4

• Diamorphine 2.5-10mg IV PRN + Metoclopramide 10mg
• Oxygen (if hypoxic)
• Nitroglycerine 2 puffs sublingual (unless hypotensive)
• Aspirin 300mg PO

Question 5

What is used to initially risk stratify UA/NSTEMI?

Answer 5

GRACE score

Question 6

Request two investigations for suspected UA/NSTEMI

Answer 6

• Serial ECG: silent ischaemia or arrhythmias are more prolonged in NSTEMI
• Serial biomarkers: CK, CK-MB, TnI

Question 7

How is UA/NSTEMI management determined?

Answer 7

• Early risk stratification (on presentation)
  
  • GRACE score
• Late risk stratification (once episodic pain settles)
  
  • Exercise ECG
  • Stress radionuclide myocardial perfusion imaging
  • LV imaging

Question 8

Outline the management of UA/NSTEMI in low GRACE score

Answer 8

All of the following:

• Monitored bed on step-down unit
• Dual antiplatelet: Aspirin + clopidogrel/ticagrelor (NSTEMI)
• LMWH: till 2-5d after last episode of pain and ECG changes
• Beta-blocker + GTN spray
• Late risk stratification (48-72h after admission)

Question 9

Outline the management of UA/NSTEMI in high GRACE score

Answer 9

All of the following:

• CCU and early invasive strategy
• Aspirin + Clopidogrel/ticagrelor (NSTEMI)
  
  • Consider GP IIb/IIIa receptor inhibitors
• LMWH (till 2-5d after last episode of pain and ECG changes)
• Beta-blocker + GTN spray
• Coronary angiography + Inpatient PCI within 96hr of admission
• Lifelong aspirin 75-300mg PO

Question 10

Name three indications for PCI in UA/NSTEMI?

Answer 10

• Initial high-risk on GRACE score
• High-risk on late risk stratification
• Continuous symptoms on monitored bed and optimal medical therapy
• Haemodynamically unstable
• Features of heart failure; Poor LV systolic function (EF <40%)
• Sustained VT
• PCI in previous 6 months or previous CABG

Question 11

Outline a discharge plan for UA/NSTEMI

Answer 11

Typically discharged after 3-7 days

• TTO
  
  • Dual antiplatelets: Aspirin + Clopidogrel (UA)/Ticagrelor (NSTEMI)
  • ACEi
  • Beta-blocker/CCB
  • Statin GTN
• Modifiable risk factors: Lipids; DM; BP; smoking; diet; weight
• 1-month off work
• Inform DVLA - no driving for 4 weeks, 1 week if successful angioplasty

Question 12

What is Wellen’s syndrome?

Answer 12

ECG pattern of deeply inverted pointed T waves in V2-3

Highly specific for a critical LAD stenosis.

High risk of extensive anterior wall MI within the next few days-weeks.