Nota
NSTEMI / UNSTABLE ANGINA (UPDATED ESC & ACC/AHA GUIDELINES)
WHAT IS THE DIAGNOSIS?
Diagnosis is Non-ST Elevation Acute Coronary Syndrome (NSTE-ACS).
NSTE-ACS includes:
- NSTEMI
- Unstable Angina
NSTEMI is diagnosed when there is:
- Ischemic chest pain
- Elevated cardiac troponin
- No persistent ST elevation on ECG
Unstable angina is diagnosed when there is:
- Ischemic chest pain
- No troponin elevation
- Dynamic ECG changes may be present
WHY IS THIS NSTEMI?
Clinical Features:
- Typical ischemic chest pain
- Retrosternal discomfort
- Radiation to arm/jaw
- Associated sweating, nausea
ECG Findings:
- ST depression
- T-wave inversion
- Dynamic ischemic changes
Biomarkers:
- Elevated high-sensitivity Troponin I/T
RISK STRATIFICATION IN ER
1. GRACE SCORE (Preferred by ESC)
Variables:
- Age
- Heart rate
- Systolic blood pressure
- Serum creatinine
- Killip class
- Cardiac arrest
- ST deviation
- Positive troponin
Risk Categories:
Very High Risk:
- Shock
- Refractory chest pain
- Cardiac arrest
- Acute HF
- Life threatening arrhythmias
Management:
Immediate angiography (<2 hours)
High Risk:
- Positive troponin
- Dynamic ST changes
- GRACE >140
Management:
Angiography within 24 hours
Intermediate Risk:
Angiography within 72 hours
2. TIMI RISK SCORE
One point each:
- Age ≥65 years
- ≥3 CAD risk factors
- Known CAD >50%
- Aspirin use in previous 7 days
- Severe angina episodes
- ST deviation
- Positive biomarkers
Score:
0-2 Low Risk
3-4 Intermediate Risk
5-7 High Risk
MANAGEMENT OF NSTEMI
Initial Management
Aspirin
Loading:
300 mg oral
Maintenance:
75-100 mg daily lifelong
Mechanism:
Irreversible COX-1 inhibition
Effect:
Decreases thromboxane A2 production
Side Effects:
- GI bleeding
- Dyspepsia
- Hemorrhagic stroke
Evidence:
ISIS-2
Antithrombotic Trialists Collaboration
P2Y12 INHIBITOR
Ticagrelor
Loading:
180 mg
Maintenance:
90 mg twice daily
Mechanism:
Reversible P2Y12 receptor blockade
Advantages:
- Faster onset
- More potent than clopidogrel
Side Effects:
- Dyspnea
- Bleeding
- Bradycardia
Trial:
PLATO
Results:
16% reduction in CV death/MI/stroke
PRASUGREL
Loading:
60 mg
Maintenance:
10 mg daily
5 mg if age >75 or weight <60 kg
Mechanism:
Irreversible P2Y12 inhibition
Advantages:
More potent than clopidogrel
Contraindications:
- Previous stroke
- Previous TIA
Trial:
TRITON TIMI-38
Results:
Reduced ischemic events but increased bleeding
CLOPIDOGREL
Loading:
300-600 mg
Maintenance:
75 mg daily
Mechanism:
Irreversible P2Y12 blockade
Trial:
CURE Trial
Results:
20% relative risk reduction when added to aspirin
ANTICOAGULATION
Enoxaparin
Dose:
1 mg/kg SC twice daily
Mechanism:
Factor Xa inhibition
Advantages:
Predictable effect
Side Effects:
- Bleeding
- HIT (rare)
Evidence:
ESSENCE Trial
TIMI 11B Trial
Unfractionated Heparin
Dose:
60-70 U/kg bolus
Mechanism:
Antithrombin activation
Monitoring:
aPTT
Side Effects:
- HIT
- Bleeding
HIGH INTENSITY STATINS
Atorvastatin
40-80 mg daily
Rosuvastatin
20-40 mg daily
Mechanism:
HMG-CoA reductase inhibition
Effects:
- LDL reduction
- Plaque stabilization
- Anti-inflammatory effects
Side Effects:
- Myalgia
- Hepatitis
- Rare rhabdomyolysis
Trials:
MIRACL
PROVE-IT TIMI 22
JUPITER
CARDIOGENIC SHOCK IN PCI NON-CAPABLE HOSPITAL
Immediate Management
ABC stabilization
Oxygen if saturation <90%
Vasopressor:
Norepinephrine
First line
Inotrope:
Dobutamine
Mechanical ventilation if required
Urgent transfer to PCI center
Evidence:
SHOCK Trial
Conclusion:
Early revascularization improves survival
REFRACTORY ANGINA DESPITE GDMT
Definition:
Persistent ischemia despite optimal therapy
Management:
- Nitroglycerin infusion
- Beta blocker
- Anticoagulation
- DAPT
Immediate transfer to PCI-capable center
ESC:
Very-high-risk NSTE-ACS
Angiography within 2 hours
NEWER ANTIANGINAL DRUGS
Ranolazine
Mechanism:
Late sodium current inhibitor
Benefits:
No significant HR or BP reduction
Dose:
500 mg BID
Increase to 1000 mg BID
Side Effects:
- QT prolongation
- Dizziness
- Constipation
Trials:
CARISA
ERICA
MERLIN TIMI-36
Nicorandil
Mechanism:
- Nitrate donor
- Potassium channel opener
Dose:
10-20 mg BID
Side Effects:
- Headache
- Hypotension
- Oral ulceration
Trial:
IONA
Results:
Reduced coronary events
Ivabradine
Mechanism:
If channel inhibition in SA node
Dose:
5-7.5 mg BID
Indication:
Sinus rhythm with HR >70 bpm
Side Effects:
- Bradycardia
- Visual brightness phenomena
Trial:
BEAUTIFUL
Trimetazidine
Mechanism:
Metabolic modulator
Shifts metabolism from fatty acids to glucose
Dose:
35 mg BID
Side Effects:
- Parkinsonian symptoms (rare)
Trial:
ATPCI
SHOCK TRIAL
Full Name:
Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock
Findings:
Early PCI/CABG improves survival
Impact:
Class I recommendation for urgent revascularization
LANDMARK TRIAL FOR ROSUVASTATIN
JUPITER Trial
Population:
Normal LDL
Elevated hsCRP
Intervention:
Rosuvastatin 20 mg
Results:
44% reduction in major cardiovascular events
POST PCI MEDICAL THERAPY
- Aspirin lifelong
- Ticagrelor or Prasugrel for 12 months
- High intensity statin
- Beta blocker
- ACE inhibitor/ARB
- MRA if EF ≤40%
- SGLT2 inhibitor if diabetic/HF
NEWER LIPID LOWERING THERAPIES
PCSK9 Inhibitors
Evolocumab
Mechanism:
Prevents LDL receptor degradation
Trial:
FOURIER
Result:
15% reduction in major CV events
Alirocumab
Trial:
ODYSSEY OUTCOMES
Result:
Reduced mortality after ACS
Inclisiran
Mechanism:
siRNA against PCSK9 synthesis
Dosing:
Day 0
3 months
Then every 6 months
Trial:
ORION Program
COMPLETE REVASCULARIZATION IN STEMI
Current Recommendation:
Yes, complete revascularization is recommended in stable STEMI patients.
Evidence:
PRAMI
CvLPRIT
DANAMI-3 PRIMULTI
COMPLETE
COMPLETE Trial:
Reduced CV death and MI
Exception:
Cardiogenic shock
CULPRIT-SHOCK Trial:
Initial culprit-only PCI preferred.
CABG COUNSELLING
Benefits:
- Better survival in LM disease
- Better survival in diabetic multivessel CAD
- Fewer repeat procedures
- Better long-term freedom from angina
Risks:
- Stroke
- Bleeding
- Infection
- Mortality 1-3% in elective surgery
Recovery:
- ICU 24-48 hrs
- Hospital stay 5-7 days
- Full recovery 6-12 weeks
Evidence:
SYNTAX
FREEDOM
EXCEL
NOBLE
STICH
DrMKZ 
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