NSTEMI

Question 1

Risk Factors

Answer 1

Non-Modifiable:
- Age
- Sex (Males)
- Family History
- Ethnicity
Modifiable:
- Smoking
- Poor nutrition
- Sedentary lifestyle
- Alcohol
- Stress
- HTN
- Obesity
- DM

Question 2

Pathophysiology

Answer 2

Complete occlusion of minor artery or partial exclusion of major artery resulting in subendothelial infarction (area far away from c.a occlusion dies)

Question 3

Signs and Symptoms

Answer 3

Central crushing pain radiating to jaw and shoulders
Diaphoresis
Dyspnoea
Lasts > 20 mins
Pain not relieved by GTN spray

Question 4

SILENT MI PATIENT

Answer 4

Older patient with poorly controlled diabetes - due to diabetic neuropathy

Question 5

Diagnosis

Answer 5

ECG - Non-ST elevation + T wave inversion
Cardiac enzymes - Myoglobin (1-4 hours), Troponin T+I = cardiac muscle injury (3-12 hours), Creatinine Kinase MB (3-12 hours) - determines re-infarction
Troponin has a shorter half-life than CK-MB therefore CK MB better biomarker after few days
CXR
CT angiography
Bloods

Question 6

Treatment

Answer 6

GRACE SCORE - 6 months risk of dead or repeat MI
< 5% low risk
5-10% medium risk
>10% high risk

BATMAN
Based decision on GRCE score
Aspirin 300mg
Ticagrelor 180mg stat dose (Clopidogrel 300mg if higher bleeding risk)
Morphine titrated to control pain
Anticoagulant: Fondaparux unless high bleeding risk
Nitrates (GTN)
Give O2 if sats below 94%

Question 7

Low risk management (<3%)

Answer 7

CONSERVATICE MANAGEMENT WITHOUT
ANGIOGRAPHY)
Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography immediately
- (Low bleed risk) Tricagrelor + Aspirin
- (High bleeding risk) Clopidogrel + Aspirin
Consider angio if ischaemia develops or shows on testing

Question 8

Which patients with NSTEMI/unstable angina should have coronary angiography (with follow-up PCI if necessary)?

Answer 8

• OFFER IMMEDIATE ANGIOGRAPHY IF CLINICAL
  CONDITION UNSTABLE (Otherwise offer within 72 hours)
• Consider angio (with follow-up PCI if indicated) within 72 hours if no other contraindications or active bleeding
• Coronary angiography should also be considered for patients if ischaemia is subsequently experienced after admission

Question 9

High risk management (>3%)

Answer 9

• Unfrationated heparin should be given regardless of whether patient has had Fondaprinux or not.
• Dual antiplatelet therapy: Aspirin +
  = If patient is not taking an oral anticoagulant: prasugrel or ticagrelor
  = If patient is taking an oral anticoagulant: clopidogrel
• Offer systemic unfractionated heparin in catheter laboratory if having PCI
  -Offer a drug-eluting stent if stenting indicated

Question 10

Grace Score

Answer 10

The Global Registry of Acute Coronary Events: 6 month mortality risk
- age
- heart rate, blood pressure
- cardiac (Killip class) and renal function (serum creatinine)
- cardiac arrest on presentation
- ECG findings
- troponin levels