NSTEMI

Question 1

Definition?

Answer 1

Acute ischaemic event resulting in necrosis, that can be detected by troponin

Question 2

Risk Factors?

Answer 2

• Atherosclerosis (angina, MI, stroke, TIA)
• Diabetes
• Smoking
• Dyslipidaemia
• Family history of CAD
• Age >65
• Hypertension
• Obesity and metabolic syndrome
• Physical inactivity
• Cocaine
• Depression
• Stent thrombosis
• Chronic kidney disease
• Surgery
• Sleep apnoea

Question 3

Differentials?

Answer 3

• Aortic dissection
• PE
• Peptic ulcer disease
• Acute pericarditis
• Oesophageal spasm
• Costochondritis
• Panic attack
• Stable IHD
• Myocarditis
• Boerhaave syndrome-oesophageal rupture and mediastinitis-N and V and hoarse voice
• Brugada syndrome-polymorphic ventricular tachycardia-STE in V1-3
• Acute stress cardiomyopathy

Question 4

Epidemiology?

Answer 4

Age: Elderly
Sex: Male
Ethnicity: N/A
Prevalence of NSTEMIs are increasing

Question 5

Aetiology?

Answer 5

• Transient or near-complete occlusion of a coronary artery or the myocardium of oxygen.
• Can also be caused by dynamic obstruction, severe AS, restenosis, recreational drug use, arterial inflammation or extrinsic factors.

Question 6

Clinical Presentation?

Answer 6

• Risk factors
• Chest pain
• Diaphoresis
• Physical exertion
• SOB
• Weakness
• Anxiety
• N and V
• Abdominal pain
• Hypertension

Question 7

Pathophysiology?

Answer 7

• Plaque formation in atherosclerosis and increased attraction of clotting factors forming a thrombus leads to partial occlusion of a coronary artery
• Leads to infarction distally /sub-endocardial as blood supply from ventricle and ischaemia medially

Question 8

Investigation pathway and findings?

Answer 8

• ECG-non-specific ST-T wave changes or ischaemic changes
• Trial of GTN-ongoing pain
• Cardiac troponins->99th percentile of normal
• CK->99th percentile of normal
• CK-MB->99th percentile of normal-useful in secondary increases
• FBC-normal, anaemia, thrombocytopenia
• Urea and serum creatinine-renal drug clearance
• Electrolytes-normal/deranged-arrhythmias
• Liver function tests-normal
• Blood glucose-normal or elevated
CXR-normal/pulmonary oedema

Question 9

Management?

Answer 9

• Antiplatelet therapy
• Oxygen
• GTN and morphine
• Beta-blocker
• CCB
• Assess for invasive procedure-PCI and anticoagulation

Question 10

Post-stabilisation?

Answer 10

• Cardiac rehab
• Antiplatelets
• Beta blockers
• Statin 
• Ezetimibe
PCSK-9 inhibitor(lipid lowering), ACEi and AngIIRA, and aldosterone ant and anticoagulation

Question 11

Complications?

Answer 11

• Cardiac arrhythmias
• CHF
• Cardiogenic shock
• Ventricular rupture/anuerysm
• Acute mitral regurgitation
• Dressler syndrome
• VTE
• Depression
• In-stent thrombosis

Question 12

Prognosis?

Answer 12

• High risk of morbidity and death from future sudden event
• Risks vary on patient characteristics and risk factors
• Risk of CVS related death in first yr after discharge is 10%