NSTEMI

Exam Cram

• NSTEMI: Non ST Elevation Myocardial Infarction

• Aetiology: coronary artery clot causing partial wall infarction

• Diagnosis: ECG- ST depression, T wave inversion; nil ST elevation

• Management: medical anticoagulation & cardio consult

Outline

Background

The lung's only pain fibres on in the pleura, hence lung disease presents with pleuritic chest pain, worse with breathing. 

Assessment

History

Examination

Investigations

> cardiac chest pain history: central dull ache radiating down left arm or left jaw with autonomic nausea, sweaty, lightheadedness & palpitations. 

> normal exam and observations +/- tachycardia

> ECG shows ST depression or new t wave inversions

> troponin rise and fall on repeat

> management: antiplatelet therapy and admit cardiology with telemetry. Usually antiplatelet therapy involves loading aspirin and clopidogrel and a anticoagulant fondaparinux 2.5mg 3d but there are variations depending upon local provision of PCI and preference so check local guidelines. If already on a antiplatelet top up from maintenance dose. If already on an anticoagulant (DOAC or warfarin), still give antiplatelets but no fondaparinux. Cardiology will arrange a coronary angiogram +/- PCI. 

If ongoing pain may require admission to HDU for GTN infusion. Ongoing pain is a concerning feature even if mild an not concerning for the patient because it reflects ongoing cardio-myocyte damage. 

Diagnosis & Classification

Diagnostic Criteria: chest pain, ischaemic ECG signs & raised troponin

Differential Diagnoses: unstable angina, STEMI, pericarditis

Classification: 

• GRACE Score predicts 6 month mortality

• HEART Score predicts major adverse cardiac events in 6 weeks

Management

Acute

1. Anticoagulation: Fondaparinux 2.5mg SC 3d or Enoxaparin 1mg/kg 

2. Aspirin 300mg + clopidogrel 300mg 

3. Investigations: ECHO, repeat ECG/ troponin till static

4. Housekeeping: analgesia- GTN, paracetamol & opioids (nil nsaids), escalation status, nil VTEp, 

5. Cardiology admission & Telemetry

Long Term

1. Aspirin 75mg OD 

2. Atorvastatin 80mg

3. Low dose beta-blocker & ace inhibitor

4. Cardiac rehab, smoking cessation, diet/ exercise & blood pressure monitor

5. Coronary imaging: angiogram vs CTCA- GRACE score can stratify

References & Resources

Written in 2025