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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
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:
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
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