diagnosis & management of nstemi
TRANSCRIPT
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DIAGNOSIS & MANAGEMENT of
NON ST-ELEVATION MYOCARDIAL INFARCTION (NSTEMI)
ALAN NA, 5th Year, 2010
Kursk State Medical University, Russia
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Scheme of Diagnosis
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PRESENTATIONSymptoms
◦Chest pain/discomfort, usually retrosternal, central or in the left chest.
◦May radiate to the jaw or upper limb.◦Severity of pain is variable.◦Difficult to differentiate between symptoms of
STEMI and UA/NSTEMI.◦Aypical presentations include unexplained
fatigue, SOB, epigastric discomfort, nausea, vommiting.
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Physical Examination◦Identify precipitating factors & consequences of
UA/STEMI. Uncontrolled HTN Anemia Thyrotoxicosis Severe aortic stenosis Hypertrophic Cardiomyopathy Other comorbid conditions, eg. Lung diseases.
◦ Evidence of LV Dysfunction ( Hypotension, respiratory crackles or S3 gallop) carries poor prognosis.
◦ Presence of carotid bruit or PVD identifies patient with higher likelihood of significant CAD.
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PROVISIONAL DIAGNOSIS
ACUTE CORONARY SYNDROME
(ACS)
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FURTHER WORKUP
1. ECG
2. Cardiac Biomarkers
3. Echocardiography
4. CXR, FBC, PT, PTT, LFT, Creatinine, BUSE, glucose and lipid profile.
* TRO conditions that presents as ACS e.g aortic dissection
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ECGSupports the diagnosis and provides prognostic
information.A recording made during an episode of chest pain is
especially valuable.Diagnostic features of UA/ NSTEMI
1. ST- Depression > 5mV
2. T- wave inversion > marked 0.2mV symmetrical T wave inversion on chest leads.
Note: Other changes are BBB and arrythmias. Serial ECG should be done. Normal ECG DOES NOT exclude UA/NSTEMI.
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Cardiac BiomarkersTroponin I (TnI), Troponin T (TnT),
Troponin C.CK-MB.Myoglobin
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Final DiagnosisIf ischemia is severe enough to cause
myocardial damage, detectable quantities of TnI, TnT and CK-MB will be released.
• If no cardiac marker is detected, patient is said to have UA.
• If cardiac marker is elevated, patient has NSTEMI.
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Risk Stratification
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Treatment General MeasuresAntithrombotic therapyAnti-ischemic agentsStatinsRevascularization
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General Measures1. Admit to CCU. Monitor cardiac rhythm for
24-48 hrs. Patient encouraged to report any recurrence of chest pain.
2. Bed rest, sedation, analgesic administered as in AMI. IV morphine + antiemetic e.g. IV Metoclopromide (Maxolon).
3. BP Monitoring4. IV lines for drug administration.5. Oxygen via nasal prongs.6. Serial ECGs7. Treat other coronary risk factors, e.g DM,
hypercholesterolemia.
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Antithrombotic therapy1. Antiplatelet agents
◦ COX Inhibitors: Aspirin◦ Adenosine diphosphate receptor antagonists: Clopidogrel
(Plavix), Ticlodipine (Ticlid)
2. Anticoagulants◦ Unfractionated Heparin (UFH) ◦ Low Molecular Weight Heparin (LMWH): deltaparin,
nadroparin (Fraxiparine), enoxaparin (Clexane).
3. Platelet Glycoprotein IIB/IIIa receptor antagonists.
◦ E.g.Abciximab (Reopro), Eptifibatide (Integrilin), Tirofiban (Aggrastat).
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Anti-ischemic Agents
1. Nitrates
2. Morphine
3. BB: Metoprolol, Propanolol,Atenolol
4. CCB: Diltiazem, Verapamil
* Bed rest, supplemental Oxygen should be given to all patients, maintained at >90%.
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Nitrates
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Morphine
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Beta Blockers
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Calcium Channel Blockers
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Revascularization
2 management approaches:Early Conservative Strategy(EC)
◦Coronary Angiogram for patients with ischemia despite optimal therapy.
Early Invasive Strategy (EI)◦All patients, without any
contraindications are subjected to coronary angiogram and revascularisation. (If indicated)
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Indications for EIHigh Risk in Risk Stratification
Not recommended in:Extensive co-morbiditiesLow Risk in Risk Stratification
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Management