NTSEMI and Unstableangina

• Non-ST-elevation MI (NSTEMI) applies to patients with suspected MI in the

absence of other plausible causes of troponin elevation (e.g. sepsis,
pulmonary embolus).
• On physical examination, patients with NSTEMI may have a ‘normal’ ECG
reading, or show minor changes (occurs in up to 50% of patients).
• All patients with NSTEMI should have their risk stratified to direct
management decisions.
• The management of patients with NSTEACS requires evolving risk
stratification:
Clinical assessment, assessment of Cardiac biomarkers and Time.
ECGChanges
NSTEMI:
• STdepressions (0.5 mm at least) or T wave inversions ( 1.0 mm at
least) without Q waves in 2 contiguous leads with prominent R
wave or R/Sratio >1.
• Isolated Twaveinversions:
• can correlate with increased risk forMI
• may represent Wellen’s syndrome:
• critical LADstenosis
• >2mm inversions in anterior precordial leads

Unstable Angina:
• May present with nonspecific or transient STsegment depressions
or elevations
Diagnosis
Evolving RiskStratification
• Provides prognostic information
• Determines treatment and level of
intervention
Low risk patients ---> early discharge,
High risk ---> admission to highcare
• Helps decongest the casualty and make
available medical resources to more
needy patients.
• Risk stratification should be ongoing – at
admission, 6-8 hrs, 24hrs, discharge
Evolving risk stratification…

Admit to coronary care unit or high

dependency unit:
• Estimate ischemic risk,
estimate bleeding risk, choose
augmented antithrombotic
therapy
→ refer for angiography to
determine surgery/PCI, or
medical therapy.
Evolving risk stratification…
Evolving risk stratification…
Intermediate-risk NSTEACS
Recurrent ischemia or elevated troponin?
YES
• admit to CCU or high dependency unit:
 estimate ischemic risk, estimate
bleeding risk, choose augmented
antithrombotic therapy
→refer for angiography to determine
surgery/PCI, or medical therapy.
NO
• undertake stress test (e.g. exercise ECG):
→positive – refer for angiography to determine
surgery/PCI, or medical therapy
→negative – proceed to discharge patient with
urgent cardiac follow-up (on upgraded medical
therapy) according to long-term management
after control of myocardial ischemia.
Evolving risk stratification…
YES
Stress test (e.g. exercise ECG)
using treadmill.
Appropriate period of
observation. Consider if
stress test (e.g. exercise
ECG) needed?
NO
Proceed to discharge patient with urgent
cardiac follow-up (on upgraded medical
therapy) according to long-term
management after control of myocardial
ischemia.
Variables Used in the TIMI Risk Score

• Age ≥ 65 years =1 point

• At least 3 risk factors for CAD =1 point

• Prior coronary stenosis of ≥ 50% =1 point

• ST-segment deviation on ECG presentation =1 point

• At least 2 anginal events in prior 24 hours =1 point

• Use of aspirin in prior 7 days =1 point

• Elevated serum cardiac biomarkers =1 point

TIMI RiskScore
GRACE Risk Score
Odds ratio

• Variable
1.7 per 10 y
2.0 per class
• Older age Killip
1.4 per 20 mm Hg ↑
class Systolic
2.4 BP
• ST-segment
4.3 deviation
2.per 1-mg/dL ↑
• Cardiac arrest during presentation
1.6
• Serum3.per
creatinine level
30-beat/min
↑
• Positive initial cardiac biomarkers
• Heart rate
 Management
• It Includes increasing myocardial oxygen demand delivery by improving
perfusion and decreasing myocardial oxygendemand.
• Reversing myocardial ischemia and confirming the diagnosis of ACS is
essential priority.
• Oxygen should be administered to patients with dyspnea, hypoxemia or
evidence of heart failure orshock.
• If precipitating reversible causes such as fever, anemia, hypoxemia,
infection, hypertension, anxiety, hyperthyroidism, arrhythmias or any drug
ingestion (eg cocaine, ephedrine) can be identified, they should be treated
aggressively.
• Further management includes relief of pain and anti- ischemic therepy,
therepy for platelet aggregation/thrombosis, ongoing risk stratification
and consideration of invasive reperfusionprocedures.
1. AntiIschemia
Therapy
2. Antiplatelettherapy
• The current guidelines recommend a loading dose of 300 to 600mg
of clopidogrel in patients of UA/NSTEMI, followed by 75 mg daily.
The duration of clopidogrel may depend upon whether or not the
patient has received stent.

3. Anti thrombin therapy

Recommendation
Low risk : Aspirin + Anticoagulant + either a glycoprotein IIb/IIIa inhibitor or a
thienopyridine
High Risk: Aspirin + Anticoagulant + a glycoprotein IIb/IIIa inhibitor +a
thienopyridine
 InterventionalManagement
• In patients with High Risk, following treatment with anti-ischemic and
antithrombotic agents, coronary arteriography is carried out within ~ 48 h of
admission, followed by coronary revascularization (PCI or coronary artery
bypass grafting), depending on the coronaryanatomy.
• In low-risk patients, the outcomes from
an invasive
which strategy
consists are similar to and
of anti-ischemic those
obtained from aconservative
antithrombotic strategy, by
therapy followed
“watchful waiting,” and in which coronary
arteriography is carried out only if rest pain
or ST-segment changes recur or there is
evidence of ischemia on a stresstest.
 UA/NSTEMI
treatmentAlgorithm
 Complications
• Ventricular dysfunction
• Cardiogenic shock
• Right Ventricular Infarction
• Pericarditis
• Thromboembolism
• Left ventricular aneurysm
• Sinus bradycardia
• AVBlock
• Ventricular tachycardia and fibrillation