CPG Management of Non-ST Elevation Myocardial Infaction (NSTE-ACS) (Third Edition) 20220627

An ECG.

Rise or fall in cardiac troponin, dynamic ST- or T-wave changes, GRACE score >140, TIMI risk score >4.

About 47%.

Haemodynamic instability, recurrent chest pain, dynamic ST-T wave changes, life-threatening arrhythmias, acute heart failure, mechanical complications of MI.

No, it may be present in 1% of a healthy reference population.

They are cost-effective, reduce ED-length of stay, and are safe.

An imbalance between myocardial oxygen demand and supply unrelated to acute coronary athero-thrombosis.

Unstable angina (UA) and Non-ST elevation myocardial infarction (NSTEMI).

Patient's chest pain features, past medical history, and ECG.

Atherosclerotic plaque rupture, fissure or ulceration with superimposed thrombosis, and coronary vasospasm.

To rule out ACS using the HEART score and cTn levels.

Spontaneous MI due to coronary athero-thrombosis, related to atherosclerotic plaque rupture, leading to decreased myocardial blood flow.

Type 1 MI (related to atherosclerotic plaque rupture) and Type 2 MI (due to an imbalance between myocardial oxygen supply and/or demand).

The assays used, and some have sex-specific cut-off points.

Elevation of cardiac troponin values 5 times > 99th percentile URL in patients with normal baseline values, along with symptoms or new ischemic ECG changes.

Detected by coronary angiography or autopsy in the setting of myocardial ischemia with a rise and/or fall of cardiac biomarker values.

1. New onset of severe angina or accelerated angina; no rest pain, 2. Angina at rest, subacute, 3. Angina at rest, acute.

It assists in rapid diagnosis and management, detecting LV systolic function and complications of MI.

A rise and/or fall of troponins above the 99th percentile URL along with evidence of ischemia.

cTn (subtypes T or I) testing, preferably hs-cTn.

They had little clinical impact on the diagnosis of MI; the uniform 99th percentile should remain the standard of care.

It should be treated as STEMI.

70%.

NSTEMI shows detectable cardiac biomarkers due to sufficient myocardial injury, while UA does not.

Within 10 minutes of FMC.

hs-cTn.

12-lead ECG-capable devices with computer-generated interpretations.

cTn should always be interpreted in the clinical setting; elevations without a rise and fall are often myocardial injuries, not MI.

Pre-existing coronary artery disease (CAD), impaired renal function, and being older than 75 years.

Approximately 2% for ED patients presenting with suspected cardiac chest pain.

Ischemic Heart Disease (IHD).

8%.

In nanograms per litre.

Myocardial injury is absent and cardiac biomarkers (cTn) are normal.

It is important for clinicians to be familiar with it for accurate interpretation of cTn results.

The ECG may be normal or show non-specific changes without typical ischemia/infarction features.

75-150 mg daily.

66%-78%.

Chest pain.

90 mg twice daily, to be given as part of DAPT for at least 1 year.

They detect cTn release at an earlier time point, improving early sensitivity for a diagnosis of MI.

MI, revascularization by PCI or CABG, death, and a combined endpoint of AMI, PCI, CABG, and death.

90%.

This re-classification increased the diagnosis of MI by 47% and is prognostically important as these patients will be treated more aggressively.

Indicated for residual/recurrent ischemia.

Admit the patient for further evaluation.

Cardiac death with symptoms suggestive of myocardial ischemia when biomarker values are unavailable.

Ischemia, which can lead to cell death and raised cardiac biomarkers.

8.0%.

A patient with a < 1% risk of MACE or death at ≥ 30-days follow-up.

Into 5 types based on pathology, clinical features, prognosis, and treatment strategies.

Pain radiating to both arms, similar pain to prior ischemic episodes, change in pain pattern over 24 hours, and associations with sweating and exertion.

They should be correlated with the clinical condition of the patient and the ECG.

They should be performed as changes may evolve.

They need proper evaluation and appropriate treatment while avoiding unnecessary admissions or invasive procedures.

On the first day and continued long-term (>1 year).

Dietary changes, regular exercise, and smoking cessation.

To evaluate patients with normal or non-diagnostic ECGs for possible or suspected NSTE-ACS.

Primarily cardiac disorders as well as non-cardiac disorders with cardiac involvement.

Chest pain at rest.

Access to cTn, preferably hs-cTn (subtypes T or I) testing.

It is crucial for diagnosing myocardial infarction (MI) through angiography or autopsy.

Repeat the test after 6 hours.

It is associated with a 10.5% incidence of death or reinfarction.

Shoulder pain, sweating, and a higher symptom distress score.

Hypotension, heart failure, and arrhythmias.

Their local cTn assays, whether point-of-care (POC) kits or lab-based.

66%-78%.

They can be quickly triaged to the monitored area.

Ischemic type chest pain lasting >30 mins, ECG changes of new ischemia, development of pathologic Q-waves, or imaging evidence of new loss of viable myocardium.

They are not specific and need to be interpreted in the clinical context.

LDL-C <1.8 mmol/L; the lower the better.

90%.

Started on the first day and continued long-term (> 1 year) for patients with LVEF ≤40%, anterior infarcts, and diabetes.

Very low likelihood of NSTE-ACS, definite NSTE-ACS or STEMI, or possible/suspected NSTE-ACS.

They have lower analytical sensitivity and too wide CoV to detect cTn at the 99th percentile URL.

Any characteristics not mentioned in higher risk categories.

By showing a significant rise and/or fall of cTn with at least one value greater than the 99th percentile URL in combination with other clinical criteria.

Women, those presenting with dyspnea, those with a normal ECG, and those with comorbidities.

High sensitivity, negative predictive value, and negative likelihood ratio for predicting short-term MACE.

20.3% risk of a major adverse event.

Low risk - 2.5% risk of a major adverse event.

Myocardial injury may be due to ischemia or non-ischemic causes, while MI is myocardial injury specifically due to ischemia, defined as myocardial cell death from prolonged ischemia.

Repeating ECG, echocardiography/POCUS, functional stress testing, and coronary angiography.

Patients with ongoing/recurrent chest symptoms without significant ECG or cTn elevations.

A clinical spectrum of Ischemic Heart Disease (IHD) that develops due to an imbalance between myocardial oxygen demand and supply.

In-hospital, 30-day, and 1-year mortality rates are still high, though lower than in previous years.

Women, diabetics, and the elderly.

NSTEMI or even STEMI.

The exact value should be stated, not just as positive or negative.

The need for further investigations.

Elevation of cardiac biomarker values 10 times > 99th percentile URL in patients with normal baseline values, along with new pathological Q waves or new LBBB.

They have lower sensitivity and specificity compared to cardiac troponins.

To identify possible etiologies such as aortic stenosis and signs of hypercholesterolemia.

ST/T changes may be present, whereas in UA they are usually absent or transient.

Assays should have a CoV of < 10% at the 99th percentile URL for accurate diagnosis.

Typically seen in elderly patients with pre-existing CAD and high long-term mortality.

The HEART score outperformed the TIMI and GRACE scores in predicting 30-day MACE.

In-hospital mortality and morbidity, readmission rates for cardiac-related events.

Unstable angina (UA) and Non-ST elevation myocardial infarction (NSTEMI).

Acute Coronary Syndrome (ACS).

They must be familiar with point of care (POC) kits or laboratory-based assays, the 99th percentile URL, and the lower limit of detection (LoD).

Analytical issues, including cross-reaction from other immuno-reactive proteins and some neuromuscular diseases.

Consideration of other causes of chest pain and early outpatient assessment for possible stable CAD.

Global hypoxia, hypoperfusion, heart failure, myocarditis, pericarditis, viral myocarditis, stress cardiomyopathy, sepsis, renal failure, and toxicity.

75 mg daily, to be given as part of DAPT for at least 1 year.

At 6 hours.

It carries a worse prognosis.

12.5%.

They may be admitted, observed in the ED, or referred for an early outpatient consult.

A rise and/or fall in cTn levels indicates acute injury, while persistently elevated levels indicate chronic injury.

Diabetes mellitus, LVEF <40%, early post-infarction angina, prior revascularization, GRACE score >109 and <140, TIMI risk score 3 & 4.

A change in concentrations of >20% from baseline.

Uncontrolled hypertension, anemia, thyrotoxicosis, and infection.

By a significant rise and/or fall in cTn, with at least one value above the 99th percentile URL, and at least one clinical indicator such as chest pain, ECG changes, imaging evidence, or identification of an intracoronary thrombus.

It is an important cause of acute coronary syndrome (ACS) in older individuals.

50%.

HEART Score.

Pericardial rub for pericarditis, tracheal shift for pneumothorax, low oxygen saturation for pulmonary embolism.

They are very sensitive and can detect myocardial injury earlier than older assays.

To help rule out ACS when initial history, physical examination, and ECG are not reliable.

Cardiac troponins (cTn), preferably high-sensitivity (hs-cTn).

Consider long-term therapy (> 1 year).

It stratifies them to a near zero short-term risk of ACS.

They should be admitted and managed accordingly.

Baseline hs-cTn at presentation < 99th percentile and specific conditions based on symptom onset.

Baseline and absolute changes in hs-cTn levels within the first hour.

A combination of ST elevation (at least 0.5 mm in at least 2 contiguous leads) and ST depression (at least 0.5 mm in 2 contiguous leads) - (12.4%).

Dyspnea, unexplained sweating, nausea and vomiting, syncope, fatigue, and epigastric discomfort.

A change of 50-60% from baseline is suggested to overcome biological and analytical variations.

2.2%.

In UA, myocardial injury is absent and cardiac biomarkers (troponins-cTn) are normal.

High risk - 72.7% risk of a major adverse event.

It supports diagnosis and provides prognostic information.

90%.

It may be insufficient to reliably rule in or rule out NSTE-ACS.

50%.

MI is diagnosed with a significant rise and/or fall in cTn, at least one value above the 99th percentile URL, and at least one clinical indicator such as chest pain, ECG changes, or imaging evidence.

They can indicate Acute Coronary Syndrome (ACS), including STEMI and NSTE-ACS, or non-ACS conditions.

HEART Score, TIMI risk score, ADAPT-ADP, ASPECT, HFA/CSANZ rule.

Cardiac troponins (cTn) T and I.

23.9%.

The decision should be individualized based on the patient's condition.

50%.

A variation of ≤20% in troponin values in the appropriate clinical context.

Assay-based errors and sample-based errors, such as using hemolysed specimens.

It was not designed for application to undifferentiated patients presenting with chest pain and suspected ACS.

They have a wide variation in false-positive and false-negative results and should not be the sole means to diagnose ACS.

They have high sensitivity and Negative Predictive Value (NPV), reducing the need for further testing.

1%.

Lung disease, peripheral vascular disease, and left ventricular failure.

ST elevation of ≥ 1 mm in 2 contiguous leads or a new onset LBBB in the resting ECG.

Cardiac troponins (cTn), preferably hs-cTn, both T and I.

10 mg daily, to be given as part of DAPT for at least 1 year.

No, it is not specific for angina pain.

UFH, LMWH, or Fondaparinux for 2-8 days or until hospital discharge.

About 2.1-3.3%.

CTCA is appropriate in all settings of acute chest pain suspicious of ACS if available.

Secondary, Primary, and Post-infarct.

In NSTE-ACS, the thrombus may be non-occlusive or there may be complete thrombosis of a vessel that is well collateralized.

Variation with respiration or position, localization to a point, pain reproduced on palpation, and sharp or stabbing pain.

It may indicate acute myocardial injury or chronic myocardial injury depending on the clinical context.

A level above the 99th percentile Upper Reference Limit (URL) is abnormal and indicative of myocardial injury.

Re-evaluate the patient.

Antiplatelet agents, high-intensity statins, and appropriate anti-ischemic therapy.