Non ST elevation myocardial infarction

Emergency Medicine

Clinicals - History

Fact Explanation
Chest pain This is the most common mode of presentation. Acute onset retro-sternal chest pain is described as pressure or heaviness over the area or sometimes as a non-specific discomfort. Patients often complain of radiation of the pain to the left arm, or the left side of the neck, or jaw. Pain is usually intermittent or persistent and last more than 20 minutes. Patients with cardiac autonomic neuropathy may not feel the chest pain.
The chest pain may be accompanied by excessive sweating, nausea, abdominal pain, dyspnoea, and syncope.
Chest pain
This is the most common mode of presentation. Acute onset retro-sternal chest pain is described as pressure or heaviness over the area or sometimes as a non-specific discomfort. Patients often complain of radiation of the pain to the left arm, or the left side of the neck, or jaw. Pain is usually intermittent or persistent and last more than 20 minutes. Patients with cardiac autonomic neuropathy may not feel the chest pain.
The chest pain may be accompanied by excessive sweating, nausea, abdominal pain, dyspnoea, and syncope.
Recent worsening of existing stable angina Acute plaque rupture causes sudden reduction of the coronary perfusion. This causes worsening symptoms of stable angina. Recent worsening of existing stable angina
Acute plaque rupture causes sudden reduction of the coronary perfusion. This causes worsening symptoms of stable angina.
Acute onset shortness of breath This is due to left heart failure and pulmonary edema. Acute onset shortness of breath
This is due to left heart failure and pulmonary edema.
Non-specific symptoms Some patients present with non-specific symptoms like epigastric pain, indigestion, or increasing dyspnoea. Non-specific symptoms
Some patients present with non-specific symptoms like epigastric pain, indigestion, or increasing dyspnoea.

Clinicals - Examination

Fact Explanation
Blood pressure Increased blood pressure increases the afterload and increases the workload of the heart. Patients with hypertension are more susceptible for the development of myocardial ischemia.
Hypotension may result as a complication of NSTEMI.
Blood pressure
Increased blood pressure increases the afterload and increases the workload of the heart. Patients with hypertension are more susceptible for the development of myocardial ischemia.
Hypotension may result as a complication of NSTEMI.
Features of heart failure Left heart failure results in pulmonary edema. Prompt diagnosis and management of heart failure is necessary.
The examination findings that suggest right heart failure are distended jugular veins, tender hepatomegaly and peripheral edema. Pulmonary crepitations are suggestive of left heart failure. Tachycardia and gallop rhythm can also be detected.
Features of heart failure
Left heart failure results in pulmonary edema. Prompt diagnosis and management of heart failure is necessary.
The examination findings that suggest right heart failure are distended jugular veins, tender hepatomegaly and peripheral edema. Pulmonary crepitations are suggestive of left heart failure. Tachycardia and gallop rhythm can also be detected.
Tachycardia Due to autonomic disturbances. Tachycardia
Due to autonomic disturbances.
Fever Fever is a known precipitant of myocardial ischemia in susceptible individuals. Fever
Fever is a known precipitant of myocardial ischemia in susceptible individuals.
Pulse Presence of tachycardia or bradycardia indicates increased risk of death or fatal myocardial infarction. Presence of arrhythmia like atrial fibrillation, ventricular tachycardia can also be detected. These indicates poor prognosis. Pulse
Presence of tachycardia or bradycardia indicates increased risk of death or fatal myocardial infarction. Presence of arrhythmia like atrial fibrillation, ventricular tachycardia can also be detected. These indicates poor prognosis.
None Physical examination can be completely normal in some patients. None
Physical examination can be completely normal in some patients.

Investigations - Diagnosis

Fact Explanation
Electrocardiogram (ECG) This is the first line investigation. Usually there is ST segment depression either persistent or transient. It may be accompanied by the T-wave changes, like inversion, flattening, or pseudo-normalization of T-waves. There may be no ECG changes at presentation. Electrocardiogram (ECG)
This is the first line investigation. Usually there is ST segment depression either persistent or transient. It may be accompanied by the T-wave changes, like inversion, flattening, or pseudo-normalization of T-waves. There may be no ECG changes at presentation.
Troponin (I or T) The differentiation of NSTEMI (Non-ST Elevation Myocardial Infarction) from unstable angina is based on the assessment of cardiac bio markers. Troponin levels peak 6 to 9 hours after the onset of clinical symptoms and remain elevated for 7 to 14dasys.These enzymes are more cardio specific than CK-MB and have high specificity. Troponin is the best predictor of short term prognosis. Troponin (I or T)
The differentiation of NSTEMI (Non-ST Elevation Myocardial Infarction) from unstable angina is based on the assessment of cardiac bio markers. Troponin levels peak 6 to 9 hours after the onset of clinical symptoms and remain elevated for 7 to 14dasys.These enzymes are more cardio specific than CK-MB and have high specificity. Troponin is the best predictor of short term prognosis.
Coronary angiography Detects the site of the lesion. Coronary angiography
Detects the site of the lesion.
2D Echocardiogram This investigation helps to estimate the left ventricular ejection fraction. Also useful in excluding the possible differential diagnoses like aortic stenosis, aortic dissection, pulmonary embolism, and hypertrophic cardiomyopathy. 2D Echocardiogram
This investigation helps to estimate the left ventricular ejection fraction. Also useful in excluding the possible differential diagnoses like aortic stenosis, aortic dissection, pulmonary embolism, and hypertrophic cardiomyopathy.
Heart-type fatty acid-binding protein (H-FABP) This is a newer cardiac biomarker with early diagnostic and prognostic value and can be used with in the first 6 hours of onset of symptoms. Heart-type fatty acid-binding protein (H-FABP)
This is a newer cardiac biomarker with early diagnostic and prognostic value and can be used with in the first 6 hours of onset of symptoms.
Creatinine Kinase MB (CK-MB) This is less cardio specific when compared to troponin and it has very limited value in diagnosing the NSTEMI. Creatinine Kinase MB (CK-MB)
This is less cardio specific when compared to troponin and it has very limited value in diagnosing the NSTEMI.

Investigations - Management

Fact Explanation
Pulse oxymetry Measures oxygen saturation. Pulse oxymetry
Measures oxygen saturation.
ECG Patient should be subjected to serial ECG monitoring. There can be transient episodes of ST-segment changes in ECG. ECG
Patient should be subjected to serial ECG monitoring. There can be transient episodes of ST-segment changes in ECG.
Stress ECG Only the patients who are asymptomatic should undergo stress ECG testing. Stress ECG provides prognostic information. Stress ECG
Only the patients who are asymptomatic should undergo stress ECG testing. Stress ECG provides prognostic information.
2D Echocardiogram Myocardial remodeling can be assessed. Presence of mural thrombi or complications like valve lesions and aneurysm formation can be detected. 2D Echocardiogram
Myocardial remodeling can be assessed. Presence of mural thrombi or complications like valve lesions and aneurysm formation can be detected.
Chest X-ray (CXR) CXR aids in diagnosing heart failure. Chest X-ray (CXR)
CXR aids in diagnosing heart failure.
MRI Helps in detecting the myocardial viability. MRI
Helps in detecting the myocardial viability.
Lipid profile Total cholesterol, LDL and HDL cholesterol levels and fasting triglyceride levels should be measured. Lipid profile
Total cholesterol, LDL and HDL cholesterol levels and fasting triglyceride levels should be measured.
Serum electrolytes Electronic disturbances occur due to autonomic disturbance If not corrected persistent electrolyte imbalance might lead to the development of arrhythmias. Serum electrolytes
Electronic disturbances occur due to autonomic disturbance If not corrected persistent electrolyte imbalance might lead to the development of arrhythmias.

Management - Supportive

Fact Explanation
Basic life support In an unconscious patient management of airway, breathing and circulation (ABC) should be given the priority. Basic life support
In an unconscious patient management of airway, breathing and circulation (ABC) should be given the priority.
Analgesics Narcotic analgesics are the drug of choice. Analgesics
Narcotic analgesics are the drug of choice.
Oxygen Given in a rate of 2–4l/min. The effectiveness of the reperfusion therapy depends on the arterial oxygen concentration as well. Oxygen
Given in a rate of 2–4l/min. The effectiveness of the reperfusion therapy depends on the arterial oxygen concentration as well.
Pharmacological management of heart failure Mild heart failure can be treated with slow intravenous infusion of furosemide 20–40mg and repeated 1 to 4 hourly. However severe heart failure may need higher doses. Titrating doses of intravenous nitroglycerine (0.25μg/kg/min titrate the dose every 5minutes) or oral nitrates can be administered if there is no response to diuretics. Pharmacological management of heart failure
Mild heart failure can be treated with slow intravenous infusion of furosemide 20–40mg and repeated 1 to 4 hourly. However severe heart failure may need higher doses. Titrating doses of intravenous nitroglycerine (0.25μg/kg/min titrate the dose every 5minutes) or oral nitrates can be administered if there is no response to diuretics.
Life style modifications Quit smoking. Nicotine replacement therapy if necessary. Smoking is a well-recognized cardiovascular risk factor and it is responsible for the development of thrombotic complications. Life style modifications
Quit smoking. Nicotine replacement therapy if necessary. Smoking is a well-recognized cardiovascular risk factor and it is responsible for the development of thrombotic complications.

Management - Specific

Fact Explanation
Aspirin Aspirin is an antiplatelet drug. It is proven that thrombosis is the critical component of the obstruction of the coronary arteries in NSTEMI. Aspirin inhibits the platelet activity and prevent thrombosis. Aspirin
Aspirin is an antiplatelet drug. It is proven that thrombosis is the critical component of the obstruction of the coronary arteries in NSTEMI. Aspirin inhibits the platelet activity and prevent thrombosis.
Clopidogrel This is a glycoprotein IIb/IIIa inhibitor and belongs to antiplatelet group. It reduces the risk of myocardial infarction. Clopidogrel
This is a glycoprotein IIb/IIIa inhibitor and belongs to antiplatelet group. It reduces the risk of myocardial infarction.
Lipid-lowering agents Controlled serum lipid levels significantly reduce the risk of re-infarction. Lipid-lowering agents
Controlled serum lipid levels significantly reduce the risk of re-infarction.
Beta blockers Beta blockers reduces the blood pressure and heart rate. They also have anti-arrhythmic properties. Beta blockers
Beta blockers reduces the blood pressure and heart rate. They also have anti-arrhythmic properties.
Intravenous or oral nitrates Nitrates have vasodilation properties. Intravenous or oral nitrates
Nitrates have vasodilation properties.
Calcium channel blockes Reduces the vasospasm. Also it reduces the conduction of electricle impulse from the sino-atrial node to atrio-ventricular node and reduces the heart rate. The use of CCB in the management of MI remains contravertial. Calcium channel blockes
Reduces the vasospasm. Also it reduces the conduction of electricle impulse from the sino-atrial node to atrio-ventricular node and reduces the heart rate. The use of CCB in the management of MI remains contravertial.
Angiotensin converting enzyme inhibitors (ACEIs) Patient should be prescribed an ACEI within the first 24 hours, unless there is any contraindication or hypotension. Angiotensin converting enzyme inhibitors (ACEIs)
Patient should be prescribed an ACEI within the first 24 hours, unless there is any contraindication or hypotension.
Percutaneous coronary interventions (PCI) Re-establish the patency of the coronary vessels. Percutaneous coronary interventions (PCI)
Re-establish the patency of the coronary vessels.
Coronary artery bypass graft This re-establish the vessel patency. This method of treatment is preferred if more than one vessel is affected. Coronary artery bypass graft
This re-establish the vessel patency. This method of treatment is preferred if more than one vessel is affected.
Sub cutaneous low molecular weight heparin (LMWH) Although there is relative increased risk of bleeding LMWH is proven to reduce the mortality. Sub cutaneous low molecular weight heparin (LMWH)
Although there is relative increased risk of bleeding LMWH is proven to reduce the mortality.
Vitamin K antagonists Although there is a considerable increase in the risk of bleeding combination of the aspirin and warfarin is proven to reduce the risk of reinfarction. Vitamin K antagonists
Although there is a considerable increase in the risk of bleeding combination of the aspirin and warfarin is proven to reduce the risk of reinfarction.

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