Unstable angina and NSTEMI Flashcards Preview

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Flashcards in Unstable angina and NSTEMI Deck (12)
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Describe the presentation of UA/NSTEMI

  • Angina at rest
  • New onset severe angina
  • Worsening angina
    • Increased frequency
    • Prolonged duration
    • Lower threshold of attack


Describe the ECG changes in UA/NSTEMI

  • Normal ECG
  • Non-specific changes
  • ST depression
  • T wave inversion


Differentiate between the pathophysiology of UA and NSTEMI

  • UA: Sub-total occlusive thrombus
  • NSTEMI: Total occlusive thrombus → Cardiac markers


Outline the initial management of UA/STEMI

  • Diamorphine 2.5-10mg IV PRN + Metoclopramide 10mg
  • Oxygen (if hypoxic)
  • Nitroglycerine 2 puffs sublingual (unless hypotensive)
  • Aspirin 300mg PO


What is used to initially risk stratify UA/NSTEMI?

GRACE score


Request two investigations for suspected UA/NSTEMI

  • Serial ECG: silent ischaemia or arrhythmias are more prolonged in NSTEMI
  • Serial biomarkers: CK, CK-MB, TnI


How is UA/NSTEMI management determined?

  • Early risk stratification (on presentation)
    • GRACE score
  • Late risk stratification (once episodic pain settles)
    • Exercise ECG
    • Stress radionuclide myocardial perfusion imaging
    • LV imaging


Outline the management of UA/NSTEMI in low GRACE score

All of the following:

  • Monitored bed on step-down unit
  • Dual antiplatelet: Aspirin + clopidogrel/ticagrelor (NSTEMI)
  • LMWH: till 2-5d after last episode of pain and ECG changes
  • Beta-blocker + GTN spray
  • Late risk stratification (48-72h after admission)


Outline the management of UA/NSTEMI in high GRACE score

All of the following:

  • CCU and early invasive strategy
  • Aspirin + Clopidogrel/ticagrelor (NSTEMI)
    • Consider GP IIb/IIIa receptor inhibitors
  • LMWH (till 2-5d after last episode of pain and ECG changes)
  • Beta-blocker + GTN spray
  • Coronary angiography + Inpatient PCI within 96hr of admission
  • Lifelong aspirin 75-300mg PO


Name three indications for PCI in UA/NSTEMI?

  • Initial high-risk on GRACE score
  • High-risk on late risk stratification
  • Continuous symptoms on monitored bed and optimal medical therapy
  • Haemodynamically unstable
  • Features of heart failure; Poor LV systolic function (EF <40%)
  • Sustained VT
  • PCI in previous 6 months or previous CABG


Outline a discharge plan for UA/NSTEMI

Typically discharged after 3-7 days

  • TTO
    • Dual antiplatelets: Aspirin + Clopidogrel (UA)/Ticagrelor (NSTEMI)
    • ACEi
    • Beta-blocker/CCB
    • Statin GTN
  • Modifiable risk factors: Lipids; DM; BP; smoking; diet; weight
  • 1-month off work
  • Inform DVLA - no driving for 4 weeks, 1 week if successful angioplasty


What is Wellen's syndrome?

ECG pattern of deeply inverted pointed T waves in V2-3

Highly specific for a critical LAD stenosis.

High risk of extensive anterior wall MI within the next few days-weeks.