DIAGNOSIS & MANAGEMENT

of
NON ST-ELEVATION MYOCARDIAL
INFARCTION (NSTEMI)
ALAN NA, 5th Year, 2010
Kursk State Medical University, Russia
Scheme of Diagnosis
 PRESENTATION
Symptoms
◦ 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.
5.
* TRO conditions that presents as ACS e.g aortic

dissection
ECG
 Supports 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.

1.
2.
Cardiac Biomarkers
TroponinI (TnI), Troponin T (TnT),
Troponin C.
CK-MB.
Myoglobin
 Final Diagnosis
If 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 Measures
Antithrombotic therapy
Anti-ischemic agents
Statins
Revascularization
General Measures
1.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 Monitoring
4.IV lines for drug administration.
5.Oxygen via nasal prongs.
6.Serial ECGs
7.Treat other coronary risk factors, e.g
Antithrombotic therapy
1.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 EI
High Risk in Risk Stratification


N o t re co m m e n d e d in :
E xte n siveco -m o rb id itie s
Lo w R isk in R isk S tra tifica tio n
Management