Non–ST-segment elevation myocardial infarction (NSTEMI)

  • NSTEMI type I (due to atherosclerotic plaque rupture and partially obstruction) vs type 2 (oxygen supply-demand mismatch)

  • Duration: ___ days

  • CC: chest discomfort

  • Onset: sudden

  • Course: constant

  • Progression: worsening

  • Assoc sx: pressure-like central chest pain radiating to left shoulder/neck, not relieved by rest; dyspnea, epigastric/jaw/arm pain, nausea, diaphoresis, fatigue, lightheadedness, palpitations, ± confusion (elderly), ± silent if diabetic

  • Neg: no pleuritic pain, no acute dyspnea/tachycardia/tachypnea/hypoxia (PE), no tearing/ripping pain to back (aortic dissection)

  • pertinent exam: JVP, carotid bruit, RRR ± S4/murmur, lungs (clear vs crackles), pulses intact/symmetric, extremities warm/cool, edema

  • pertinent Data: troponin, EKG (ST↓/T-wave inversion), CBC/CMP/Mg/coags, INR/DOAC last dose, CXR/CT, echo (RWMA/EF), prior cardiac testing, lipid panel, HbA1c, type and screen if high-risk/PCI likely, BNP if HF suspected

  • pertinent Hx: +/− HTN, DM, HLD, obesity, smoking; FH CAD <60

  • pertinent home meds: ___

  • DDx: NSTEMI, unstable angina, PE (less likely), aortic dissection (less likely), GERD, MSK

  • TIMI scores: (who needs early invasive strategy) ≥5 = high risk → early cath (≤24 hr), 3–4 = intermediate, 0–2 = low risk.

  • Hospital course to date: ___

Plan

  • Consult cardiology for risk stratification to determine cath vs noninvasive stress testing.

  • Ensure IV access (preferably two lines)

  • Telemetry, serial ECG/troponin until down trending.

  • check lipid panel, HbA1c, type and screen if high-risk/PCI likely, BNP if HF suspected

  • Sublingual nitroglycerin 0.4mg q5min up x3 doses if SBP ≥90 → gtt 5-10mcg/min titrated to pain (avoid in inferior MI, RV dsfx, PDEi use)

  • Morphine if symptoms persist and refractory to nitroglycerin, 2–4 mg IV slow push then 2 mg IV q5–15 min PRN Titrate carefully to pain with lowest effective dose

  • DAPT: 325mg load, then 81mg daily. P2y12 inhibitors (holding per Cards for possible catheterization/CABG)- clopidogrel 600mg then 75mg daily < ticagrelor 180mg load then 90mg BID (causes dyspnea) < prasugrel (if <75 and no h/o CVA)

  • Anticoagulation: UFH bolus (60 IU/kg (maximum 4,000 IU))and gtt (12 IU/kg per hour (maximum 1,000 IU/h) )for 48 hours or until PCI, goal PTT 60-80 checked q6; if no cath, enoxaparin until discharge (max 8 days) no need after DC. pharmacy adjusted heparin per PTT

  • Metoprolol titrate 25-50 q6hr for 48 hours, then increase to maintenance dose of up to 100 mg BID unless decompensated HF, HR <60, heart block, cocaine)

  • atorvastatin 80mg daily; consider adding ezetimibe if LDL ≥70; f/u lipid screen

  • For BP control: consider ACEi (captopril TID → lisinopril daily) or ARB (losartan, valsartan) if needed and renal function allows

  • ECG if symptomatic

Discharge care

  • continue DAPT for 12 months, BB, statin, ACE/ARB if needed and will discontinue anticoagulation

  • sublingual nitroglycerin 0.4 mg q5min PRN up to three doses

  • pt received counseling on smoking cessation, diet, and exercise

  • counseled to avoid NSAIDs and steroids

  • primary care follow-up, cardiology follow-up, and referral to cardiac rehabilitation On DC

Type 2 NSTEMI (supply–demand mismatch)

  • Myocardial injury likely secondary to ((sepsis or severe infection, tachyarrhythmias (especially AF with RVR), blood pressure extremes (hypertensive crisis or hypotension/shock), anemia, hypoxemia/respiratory failure))

  • chest discomfort with abrupt-onset, pressure-like chest pain located in the center of the chest, with radiation to the left shoulder or neck pain not relieved by rest

  • CAD risk factors ( HTN, DM HLD, Obesity, smoking, ..

  • family history( CAD in family age <60)

  • physical ( JVP, carotid bruie, murmur, long sound, peripheral pulses, extemity hot or cold extemirty , edema)

  • Hemodynamics/vitals

  • Echocardiogram:

  • previous cardiac testing:

  • CXR/CT:

  • Troponin:

  • Pertinent Initial labs:CBC, CMP, magnesium, and coagulation panel.

Plan

  • Telemetry, serial ECG/troponin until down trending.

  • Manage by treating the underlying disturbance

  • Consider echocardiography to assess LV function and wall-motion abnormalities

  • Outpatient ischemic evaluation may be indicated based on echocardiographic findings and clinical course