DIAGNOSIS & MANAGEMENT of

NON ST-ELEVATION MYOCARDIAL INFARCTION (NSTEMI)

ALAN NA, 5th Year, 2010

Kursk State Medical University, Russia

Scheme of Diagnosis

PRESENTATIONSymptoms

◦Chest pain/discomfort, usually retrosternal, central or in the left chest.

◦May radiate to the jaw or upper limb.◦Severity of pain is variable.◦Difficult to differentiate between symptoms of

STEMI and UA/NSTEMI.◦Aypical presentations include unexplained

fatigue, SOB, epigastric discomfort, nausea, vommiting.

Physical Examination◦Identify precipitating factors & consequences of

UA/STEMI. Uncontrolled HTN Anemia Thyrotoxicosis Severe aortic stenosis Hypertrophic Cardiomyopathy Other comorbid conditions, eg. Lung diseases.

◦ Evidence of LV Dysfunction ( Hypotension, respiratory crackles or S3 gallop) carries poor prognosis.

◦ Presence of carotid bruit or PVD identifies patient with higher likelihood of significant CAD.

PROVISIONAL DIAGNOSIS

ACUTE CORONARY SYNDROME

(ACS)

FURTHER WORKUP

1. ECG

2. Cardiac Biomarkers

3. Echocardiography

4. CXR, FBC, PT, PTT, LFT, Creatinine, BUSE, glucose and lipid profile.

* TRO conditions that presents as ACS e.g aortic dissection

ECGSupports the diagnosis and provides prognostic

information.A recording made during an episode of chest pain is

especially valuable.Diagnostic features of UA/ NSTEMI

1. ST- Depression > 5mV

2. T- wave inversion > marked 0.2mV symmetrical T wave inversion on chest leads.

Note: Other changes are BBB and arrythmias. Serial ECG should be done. Normal ECG DOES NOT exclude UA/NSTEMI.

Cardiac BiomarkersTroponin I (TnI), Troponin T (TnT),

Troponin C.CK-MB.Myoglobin

Final DiagnosisIf ischemia is severe enough to cause

myocardial damage, detectable quantities of TnI, TnT and CK-MB will be released.

• If no cardiac marker is detected, patient is said to have UA.

• If cardiac marker is elevated, patient has NSTEMI.

Risk Stratification

Treatment General MeasuresAntithrombotic therapyAnti-ischemic agentsStatinsRevascularization

General Measures1. Admit to CCU. Monitor cardiac rhythm for

24-48 hrs. Patient encouraged to report any recurrence of chest pain.

2. Bed rest, sedation, analgesic administered as in AMI. IV morphine + antiemetic e.g. IV Metoclopromide (Maxolon).

3. BP Monitoring4. IV lines for drug administration.5. Oxygen via nasal prongs.6. Serial ECGs7. Treat other coronary risk factors, e.g DM,

hypercholesterolemia.

Antithrombotic therapy1. Antiplatelet agents

◦ COX Inhibitors: Aspirin◦ Adenosine diphosphate receptor antagonists: Clopidogrel

(Plavix), Ticlodipine (Ticlid)

2. Anticoagulants◦ Unfractionated Heparin (UFH) ◦ Low Molecular Weight Heparin (LMWH): deltaparin,

nadroparin (Fraxiparine), enoxaparin (Clexane).

3. Platelet Glycoprotein IIB/IIIa receptor antagonists.

◦ E.g.Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggrastat).

Anti-ischemic Agents

1. Nitrates

2. Morphine

3. BB: Metoprolol, Propanolol,Atenolol

4. CCB: Diltiazem, Verapamil

* Bed rest, supplemental Oxygen should be given to all patients, maintained at >90%.

Nitrates

Morphine

Beta Blockers

Calcium Channel Blockers

Revascularization

2 management approaches:Early Conservative Strategy(EC)

◦Coronary Angiogram for patients with ischemia despite optimal therapy.

Early Invasive Strategy (EI)◦All patients, without any

contraindications are subjected to coronary angiogram and revascularisation. (If indicated)

Indications for EIHigh Risk in Risk Stratification

Not recommended in:Extensive co-morbiditiesLow Risk in Risk Stratification

Management