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2 Acute Coronary Syndrome: Non–ST-Segment Elevation Myocardial Infarction
31
Chest radiograph showing right upper/lower lung eld opacities and left lower lung
eld opacity consistent with pneumonia. [Tsigrelis C, Mohammad M, Fraimow HS,
Dellinger RP, Marchesani D, Reboli AC. Secondary bacterial pneumonia due to
Staphylococcus aureus complicating 2009 inuenza A (H1N1) viral infection.
Infection. 2010 Jun;38(3):237-9. https://doi.org/10.1007/s15010-010-0009-0,
2010-06-01] Caption adapted from original
• Findings of pneumothorax suggest consideration of that differential but do
not exclude NSTEMI.Evaluate oxygenation status.
Posteroanterior upright chest X-ray shows large pneumothorax of the right lung.
[Kim SH, Yoo WH. Recurrent pneumothorax associated with pulmonary nodules
after leunomide therapy in rheumatoid arthritis: a case report and review of the
literature. Rheumatol Int. 2011 Jul;31(7):919-22. https://doi.org/10.1007/s00296-
009-1240-9] Caption adapted from original
32
C. V. Pollack, Jr. and V. G. Riese
• Findings of hiatal hernia suggest consideration of that differential but do not
exclude NSTEMI.
Radiograph of large hiatal hernia. [Aurigemma G, Tighe D, Oh J, Espinoza
R.Pericardial disease and cardiac masses. In: Solomon S, editor. Atlas of echocardiography. Philadelphia: Current Medicine; 2008. ISBN: 1-57340-217-6] Caption
from original
Risk Scoring
• TIMI Risk Score may be helpful in establishing short-term prognosis, which
helps drive intensity of therapy.
2 Acute Coronary Syndrome: Non–ST-Segment Elevation Myocardial Infarction
33
TIMI risk score for unstable angina and NSTEMI. [Stillman AE, Oudkerk M,
Ackerman M, Becker CR, Buszman PE, Feyter PJ, Hoffmann U, Keadey MT,
Marano R, Lipton MJ, Raff GL, Reddy GP, Rees MR, Rubin GD, Schoepf UJ,
Tarulli G, Beek EJR, Wexler L, White CS.Use of multidetector computed tomography for the assessment of acute chest pain: a consensus statement of the North
American Society of Cardiac Imaging and the European Society of Cardiac
Radiology. Int J Cardiovasc Imaging. 2007 Aug;23(4):415-27. https://doi.
org/10.1007/s10554-007-9226-8] Caption from original
A summary of the TIMI risk score and modied TIMI risk scores as predictors of
30-day myocardial infarction/revascularization/death. [Jaffery Z, Hudson MP,
Jacobsen G, Nowak R, McCord J.Modied Thrombolysis in Myocardial Infarction
(TIMI) risk score to risk stratify patients in the emergency department with possible
acute coronary syndrome. J Thromb Thrombolysis. 2007 Oct;24(2):137-44. DOI:
https://doi.org/10.1007/s11239-007-0013-0] Caption from original
34
C. V. Pollack, Jr. and V. G. Riese
Special Populations
Age
• Risk for NSTEMI increases with age, starting at age 40in men and at meno-
pause in women.
• Age is a risk factor for mortality from NSTEMI.
• Likelihood of atypical presentation with NSTEMI increases with age.
Co-morbidities
• Hypertension, diabetes, and renal failure are important co-morbidities in
NSTEMI risk and prognosis.
• Obesity is a weaker predictor of NSTEMI risk.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• ECG must be performed as soon as the diagnosis of ACS is even considered.
Mimics
• All differential considerations listed under Primary Differential Considerations.
• Of these, only aortic dissection and pulmonary embolism are also
life-threatening.
Time-Dependent Interventions
• Stabilization of the NSTEMI patient is time sensitive; unlike in STEMI, restoration of perfusion is not extremely time sensitive.
• Current guidelines call for diagnostic angiography in 24–48 hours to estab-
lish preferred course of management.
2 Acute Coronary Syndrome: Non–ST-Segment Elevation Myocardial Infarction
• Unless contraindicated (allergy, active bleeding), 324–325 mg aspirin
should be administered immediately upon suspicion of an acute coronary
syndrome.
• Anticoagulation therapy should be initiated upon conrmation of ACS
diagnosis or with high suspicion in high-risk patients.
• Extremes of blood pressure should be promptly treated to avert shock
(hypotension) or undue myocardial oxygen demand (hypertension).
• Airway and oxygenation should be monitored and supported as
necessary.
• Patients with NSTEMI should be on continuous cardiac monitoring to
evaluate for dangerous arrhythmias.
• Consider early initiation of dual antiplatelet therapy (aspirin plus an ADP
receptor antagonist—ticagrelor or clopidogrel).
Overall Principles ofTreatment
• Immediate stabilization of the patient with control of blood pressure, pulse
rate, and pain is critical. The patient may require resuscitation, intubation, and
intensive support.
• Medical management with anticoagulation and antiplatelet therapy is
important.
35
• Bleeding risk should also be assessed so that the risk of treatment-related
hemorrhage can be minimized
• The higher the patient’s risk, the more disproportionately s/he benets from
aggressive therapy.
36
C. V. Pollack, Jr. and V. G. Riese
Algorithm for the initial management of patients with UA/NSTEMI with an invasive or conservative treatment strategy [1] Abbreviations: ASA, aspirin; CABG,
coronary artery-bypass grafting; EF, ejection fraction; GP, glycoprotein; IV, intravenous; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; UA/NSTEMI, unstable angina/non-ST-elevation myocardial infarction; UFH,
unfractionated heparin. [Cohen M. High-risk acute coronary syndrome patients
with non-ST-elevation myocardial infarction: denition and treatment. Cardiovasc
Drugs Ther. 2008 Oct;22(5):407-18. https://doi.org/10.1007/s10557-008-6120-0]
Caption from original
2 Acute Coronary Syndrome: Non–ST-Segment Elevation Myocardial Infarction
37
Disease Course
• NSTEMI mortality is 6–10 %, depending on the population studied, over 6
months.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr,
Chavey WE 2nd, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson
ED, Theroux P, Wenger NK, Wright RS, Jneid H, Ettinger SM, Ganiats TG,
Lincoff AM, Philippides GJ, Zidar JP; American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation
myocardial infarction: a report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines.
Circulation. 2013 Jun 11;127(23):e663-828. https://doi.org/10.1161/
CIR.0b013e31828478ac. Erratum in: Circulation. 2013 Jun 18;127(24):e863-4.
PMID: 23630129. http://www.ncbi.nlm.nih.gov/pubmed/23630129 **
2012 Writing Committee Members, Jneid H, Anderson JL, Wright RS, Adams CD,
Bridges CR, Casey DE Jr, Ettinger SM, Fesmire FM, Ganiats TG, Lincoff AM,
Peterson ED, Philippides GJ, Theroux P, Wenger NK, Zidar JP, Anderson JL;
American College of Cardiology Foundation; American Heart Association Task
Force on Practice Guidelines. 2012 ACCF/AHA focused update of the guideline
for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused
update): a report of the American College of Cardiology Foundation/American
Heart Association Task Force on practice guidelines. Circulation. 2012 Aug
14;126(7):875- 910.
22800849. http://www.ncbi.nlm.nih.gov/pubmed/22800849
Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute
Coronary Syndromes of European Society of Cardiology, Bassand JP, Hamm
CW, Ardissino D, Boersma E, Budaj A, Fernández-Avilés F, Fox KA, Hasdai D,
Ohman EM, Wallentin L, Wijns W.Guidelines for the diagnosis and treatment of
non-ST- segment elevation acute coronary syndromes. Eur Heart J. 2007
Jul;28(13):1598- 660. PMID: 17569677. http://www.ncbi.nlm.nih.gov/
pubmed/17569677 **
https://doi.org/10.1161/CIR.0b013e318256f1e0. PMID:
38
C. V. Pollack, Jr. and V. G. Riese
Review
Tricoci P, Leonardi S, White J, White HD, Armstrong PW, Montalescot G, Giugliano
RP, Gibson CM, Van de Werf F, Califf RM, Harrington RA, Braunwald E,
Mahaffey KW, Newby LK.Cardiac troponin after percutaneous coronary intervention and 1-year mortality in non-ST-segment elevation acute coronary syndrome using systematic evaluation of biomarker trends. J Am Coll Cardiol. 2013
Jul 16;62(3):242- 51. https://doi.org/10.1016/j.jacc.2013.04.043. PMID:
23684676. http://www.ncbi.nlm.nih.gov/pubmed/23684676
Lippi G, Franchini M, Cervellin G.Diagnosis and management of ischemic heart
disease. Semin Thromb Hemost. 2013 Mar;39(2):202-13. https://doi.
org/10.1055/s-0032-1333543. PMID: 23378254. http://www.ncbi.nlm.nih.gov/
pubmed/23378254 **
Giugliano RP, Braunwald E.The year in non-ST-segment elevation acute coronary
syndrome. J Am Coll Cardiol. 2012 Nov 20;60(21):2127-39. https://doi.
org/10.1016/j.jacc.2012.08.972. PMID: 23103037. http://www.ncbi.nlm.nih.
gov/pubmed/23103037 **
Trost JC, Lange RA. Treatment of acute coronary syndrome: Part 1: Non-ST-
segment acute coronary syndrome. Crit Care Med. 2011 Oct;39(10):2346-53.
https://doi.org/10.1097/CCM.0b013e31821e855f. PMID: 21602671. http://
www.ncbi.nlm.nih.gov/pubmed/21602671 **
Sami S, Willerson JT. Contemporary treatment of unstable angina and non-ST-
segment-elevation myocardial infarction (part 1). Tex Heart Inst J.
2010;37(2):141- 8. PMID: 20401284. http://www.ncbi.nlm.nih.gov/
pubmed/20401284
Sami S, Willerson JT. Contemporary treatment of unstable angina and non-ST-
segment-elevation myocardial infarction (part 2). Tex Heart Inst J. 2010;37(3):262-
75. PMID: 20548800. http://www.ncbi.nlm.nih.gov/pubmed/20548800
Thomas D, Giugliano RP. Day 1 care in patients with non-ST-segment elevation
myocardial infarction. Cardiovasc Revasc Med. 2010 Jan-Mar;11(1):41-51.
https://doi.org/10.1016/j.carrev.2009.07.005. PMID: 20129360. http://www.
ncbi.nlm.nih.gov/pubmed/20129360
Kalra S, Duggal S, Valdez G, Smalligan RD.Review of acute coronary syndrome
diagnosis and management. Postgrad Med. 2008 Apr;120(1):18-27. https://doi.
org/10.3810/pgm.2008.04.1756. PMID: 18467805. http://www.ncbi.nlm.nih.
gov/pubmed/18467805
Mauric AT, Oreto G.STEMI or NSTEMI, i.e. ST-evaluation or non-ST- evaluation
myocardial infarction? J Cardiovasc Med (Hagerstown). 2008 Jan;9(1):81-2.
https://doi.org/10.2459/JCM.0b013e328013d630. PMID: 18268425 http://www.
ncbi.nlm.nih.gov/pubmed/18268425
2 Acute Coronary Syndrome: Non–ST-Segment Elevation Myocardial Infarction
39
Clinical Trial
Berry C, Layland J, Sood A, Curzen NP, Balachandran KP, Das R, Junejo S,
Henderson RA, Briggs AH, Ford I, Oldroyd KG.Fractional ow reserve versus
angiography in guiding management to optimize outcomes in non-ST-elevation
myocardial infarction (FAMOUS-NSTEMI): rationale and design of a randomized controlled clinical trial. Am Heart J. 2013 Oct;166(4):662-668.e3. https://
doi.org/10.1016/j.ahj.2013.07.011. PMID: 24093845. http://www.ncbi.nlm.nih.
gov/pubmed/24093845
Chenevier-Gobeaux C, Meune C, Freund Y, Wahbi K, Claessens YE, Doumenc B,
Zuily S, Riou B, Ray P.Inuence of age and renal function on high-sensitivity
cardiac troponin T diagnostic accuracy for the diagnosis of acute myocardial
infarction. Am J Cardiol. 2013 Jun 15;111(12):1701-7. https://doi.org/10.1016/j.
amjcard.2013.02.024. PMID: 23540652. http://www.ncbi.nlm.nih.gov/
pubmed/23540652
Di Stefano R, Di Bello V, Barsotti MC, Grigoratos C, Armani C, Dell'Omodarme M,
Carpi A, Balbarini A.Inammatory markers and cardiac function in acute coronary syndrome: difference in ST-segment elevation myocardial infarction
(STEMI) and in non-STEMI models. Biomed Pharmacother. 2009
Dec;63(10):773-80. https://doi.org/10.1016/j.biopha.2009.06.004. PMID:
19906505. http://www.ncbi.nlm.nih.gov/pubmed/19906505
Cohort Study
Khan NA, Daskalopoulou SS, Karp I, Eisenberg MJ, Pelletier R, Tsadok MA,
Dasgupta K, Norris CM, Pilote L; GENESIS PRAXY Team. Sex differences in
acute coronary syndrome symptom presentation in young patients. JAMA Intern
Med. 2013 Nov 11;173(20):1863-71. https://doi.org/10.1001/jamain-
ternmed.2013.10149. PMID: 24043208. http://www.ncbi.nlm.nih.gov/
pubmed/24043208
Acharjee S, Roe MT, Amsterdam EA, Holmes DN, Boden WE.Relation of admis-
sion high-density lipoprotein cholesterol level and in-hospital mortality in
patients with acute non-ST segment elevation myocardial infarction (from the
National Cardiovascular Data Registry). Am J Cardiol. 2013 Oct 15;112(8):1057-
https://doi.org/10.1016/j.amjcard.2013.05.050. PMID: 23891245. http://
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www.ncbi.nlm.nih.gov/pubmed/23891245
Ferrara LA, Russo BF, Gente R, Esposito G, Rapacciuolo A, de Simone G.STEMI
and NSTEMI: a mono versus a multivessel disease? Int J Cardiol. 2013 Oct
3;168(3):2905-6. https://doi.org/10.1016/j.ijcard.2013.03.154. PMID: 23643429.
http://www.ncbi.nlm.nih.gov/pubmed/23643429
40
C. V. Pollack, Jr. and V. G. Riese
Patel JH, Gupta R, Roe MT, Peng SA, Wiviott SD, Saucedo JF. Inuence of
Presenting Electrocardiographic Findings on the Treatment and Outcomes of
Patients With Non-ST-Segment Elevation Myocardial Infarction. Am J Cardiol.
2013 Oct 2. doi:pii: S0002-9149(13)01926-7.
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24290492
Bahrmann P, Christ M, Bahrmann A, Rittger H, Heppner HJ, Achenbach S, Bertsch
T, Sieber CC. A 3-hour diagnostic algorithm for non-ST-elevation myocardial
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Antonsen L, Jensen LO, Thayssen P, Christiansen EH, Junker A, Tilsted HH,
Terkelsen CJ, Kaltoft A, Maeng M, Hansen KN, Ravkilde J, Lassen JF, Madsen
M, Sørensen HT, Thuesen L.Comparison of outcomes of patients ≥ 80 years of
age having percutaneous coronary intervention according to presentation (stable
vs unstable angina pectoris/non-ST-segment elevation myocardial infarction vs
ST-segment elevation myocardial infarction). Am J Cardiol. 2011 Nov
15;108(10):1395-400.
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21890087. http://www.ncbi.nlm.nih.gov/pubmed/21890087
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ST-segment elevation myocardial infarction (NSTEMI) in the United States
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org/10.1002/clc.20968. PMID: 22095658. http://www.ncbi.nlm.nih.gov/
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García-García C, Subirana I, Sala J, Bruguera J, Sanz G, Valle V, Arós F, Fiol M,
Molina L, Serra J, Marrugat J, Elosua R.Long-term prognosis of rst myocardial
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15;108(8):1061- 7.
https://doi.org/10.1016/j.amjcard.2011.06.003. PMID:
21791326. http://www.ncbi.nlm.nih.gov/pubmed/21791326
Case Study
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trends in the incidence, treatment, and outcomes of patients with STEMI and
NSTEMI. Am J Med. 2011 Jan;124(1):40-7. https://doi.org/10.1016/j.
amjmed.2010.07.023. PMID: 21187184. http://www.ncbi.nlm.nih.gov/
pubmed/21187184 **
Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Go AS.Population trends in the
incidence and outcomes of acute myocardial infarction. N Engl J Med. 2010 Jun