From the Guidelines
NSTEMI diagnosis is primarily based on elevated high-sensitivity troponin assays, which provide higher diagnostic accuracy, along with either ischemic symptoms or ECG changes such as ST-segment depression or T-wave inversions 1. The diagnosis of NSTEMI requires a combination of clinical evaluation, ECG findings, and elevated cardiac biomarkers.
- Key diagnostic criteria include:
- Chest discomfort without persistent ST-segment elevation
- Elevated high-sensitivity troponin assays
- Ischemic symptoms or ECG changes such as ST-segment depression or T-wave inversions
- Assessment of the probability of CAD based on chest pain characteristics, age, gender, CV risk factors, known CAD, and non-cardiac manifestations of atherosclerosis Initial management includes:
- Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor like ticagrelor or clopidogrel
- Anticoagulation with heparin, enoxaparin, or bivalirudin
- Beta-blockers, high-intensity statins, and ACE inhibitors for patients with reduced ejection fraction or diabetes The use of high-sensitivity troponin assays allows for rapid "rule-in" and "rule-out" algorithms, with a recommended 0 h/1 h or 0 h/2 h algorithm for blood draw 1. Early risk stratification is crucial to determine the timing of coronary angiography, with high-risk patients requiring intervention within 24 hours.
- The GRACE risk score, which includes initial cTn levels, serum creatinine, and eGFR, is superior to subjective physician assessment for predicting death or MI 1.
- The ARC-HBR and PRECISE-DAPT scores may be used to guide decision making on DAPT duration and bleeding risk 1.
From the Research
NSTEMI Diagnosis and Treatment
- NSTEMI is a type of acute coronary syndrome (ACS) that occurs when the blood flow to the heart is blocked, but not completely 2.
- The diagnosis of NSTEMI is based on clinical presentation, electrocardiogram (ECG) findings, and biomarker levels, such as troponin 3.
- The treatment of NSTEMI involves a combination of medical therapies, including antiplatelet agents, anticoagulants, and other medications to reduce the risk of ischemic events and improve outcomes 4, 5.
Medical Therapies for NSTEMI
- Antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor, is recommended for all patients with NSTEMI 3, 6.
- Anticoagulation with unfractionated heparin, low-molecular-weight heparin, or fondaparinux is also recommended for patients with NSTEMI 3, 4.
- Other medical therapies, such as statins, angiotensin-converting enzyme inhibitors, beta blockers, and nitroglycerin, may also be used to reduce the risk of ischemic events and improve outcomes 3.
Invasive vs. Conservative Strategy
- An early-invasive strategy, which involves coronary angiography and percutaneous coronary intervention (PCI), is recommended for high-risk patients with NSTEMI 2, 3.
- A conservative strategy, which involves medical therapy alone, may be recommended for low-risk patients with NSTEMI 2, 3.
Anticoagulation Strategies
- Anticoagulation is an important part of the treatment of NSTEMI, and may be used in combination with antiplatelet therapy to reduce the risk of ischemic events 4, 5.
- The choice of anticoagulant depends on the individual patient's risk factors and clinical circumstances, and may include unfractionated heparin, low-molecular-weight heparin, or fondaparinux 3, 4.