The document discusses the diagnosis and management of non-ST elevation acute coronary syndromes (NSTE ACS), including defining NSTE ACS, assessing risk through patient history, physical exam, and investigations, and providing medical therapy including antiplatelet agents, anticoagulants, and risk factor modification. It also addresses evaluating specific patient cases presenting with chest pain and evaluating treatment options.

1. Acute Coronary Syndromes
Non STE ACS
Salah Abusin, MD, MRCP, ABIM, ABIM (Card)
Interventional Cardiologist
Dubuque, IA, USA

2. NSTE ACS
• Definition
• Spectrum (Pathology, Clinical Presentation)
• Clinical Assessment – Careful History
• Risk Stratification
– History
– Physical Examination
– Investigations
• Medical Therapy
• When to consult/refer to Cardiology?

3. Acute Coronary Syndromes
• Acute Myocardial Ischemia caused (usually) by
coronary plaque rupture with superimposed
intracoronary thrombosis & associated with
increased risk of cardiac death
• Non ST Elevation Myocardial Infarction is
defined as elevation of cardiac enzymes in a
patient with ACS without ST Elevation on the
ECG
Hurst’s the Heart, 12nd
Edition

4. ACS Spectrum
AHA.ACC 2004 STEMI guidelines

5. Netter’s Cardiology, 2nd
Edition, 2010

6. Clinical Presentation
• Rest Angina
• New onset Angina
– CCS III or IV at least
• Angina of increasing severity, duration, or
frequency
Braunwald E. Unstable angina: a classification. Circulation 1989;80: 410–4.

7. Canadian Cardiovascular Society (CCS)
Classification of Angina
I
Ordinary physical activity, such as walking and climbing stairs, does not
cause angina. Angina present with strenuous or rapid or prolonged
exertion at work or recreation
II
Slight limitation of ordinary activity. Walking or climbing stairs rapidly,
walking uphill, walking or stair climbing after meals, in cold, or when under
emotional stress or only during the few hours after awakening. Walking
more than two blocks on the level and climbing more than one flight of
stairs at a normal pace and in normal conditions.
III
Marked limitation of ordinary physical activity. Walking one to two blocks
on the level and climbing more than one flight of stairs in normal
conditions.
IV
Inability to carry on any physical activity without discomfort/anginal
syndrome may be present at rest.
Goldman L et al: Circulation 64:1227, 1981.

8. Importance of Clinical Assessment
• NSTE ACS is a clinical diagnosis supported by
ECG changes and elevation of cardiac enzymes
• Risk factors are NOT to be used for diagnosis,
but for risk stratification
• Elevated Biomarkers alone should not be used
to establish the diagnosis of NSTE ACS in the
absence of the appropriate clinical setting

9. Ahmed
• Ahmed is a 38 year old male who drives a
rickshaw. He has no atherosclerotic risk factors
apart from mild obesity
• While driving his rickshaw last night, he felt
pressure in the middle of his chest that lasted for
10 minutes, and spontaneously subsided; he was
concerned so went home early
• The same pain recurred and woke him from sleep
that night
• He comes to you for evaluation that am, and he is
in a hurry because he wants to go back to work
ASAP

10. Hamid
• Haj Hamid is an 75 year old male, with diabetes,
hypertension, and remote history of stroke.
• He has been getting chest pain for several years, it
lasts for several hours and occurs at rest
• The pain does not stop him from doing the 5 prayers
in the local mosque which is about 10 blocks from his
house
• His neighbor recently died of a heart attack and he is
very concerned.

11. Problem 1
• Which patient has ACS Ahmed or Hamid or
both?

12. Risk Stratification
History – Higher Risk
• Chest Pain
– Prolonged, ongoing Chest pain at rest
– Accelerating Symptoms
• Risk Factors
– Age, Prior MI, Atherosclerotic Risk Factors
• Prior Aspirin Use

13. Risk Stratification
Physical Examination– Higher Risk
• Hemodynamic Instability
– Hypotension
– Tachycardia
– Hypoxemia (Heart failure)
• Signs of Heart Failure
– JVP raised
– S3
– Chest crackles
– LE edema
• New Mitral regurgitation murmur

14. Risk Stratification
Investigations – Higher Risk
• ECG
– ST Changes (depression, transient elevation)
– T wave Changes (depression, biphasic)
– New Bundle Branch Block (right or left)
– VT (sustained or non sustained)
• Elevated Cardiac Biomarkers

15. Problem 2
• Mona is 56 year old female with DM & HTN
• She had history of CAD, stable angina, and
went to Jordan last year for check up; she had
tests done that ended up with placing a
coronary stent
• She felt generally unwell with fatigue,
headache for the last 2 days
• She has no chest pain or shortness of breath
or recurrence of her prior anginal symptoms

16. • Her medications include Aspirin, Plavix,
metoprolol, atorvastatin & lisinopril
• Clinical Examination is unremarkable, apart
from BP 180/90
• Troponin 0.5 (upper normal limit is 0.05)
• Rest of Labs are normal

18. What would you like to do next?

19. CT Head
• Showed intracranial hemorrhage

20. TIMI Risk Score
• age 65 y or older;
• at least 3 risk factors for CAD;
• prior coronary stenosis of 50% or more;
• ST-segment deviation on ECG presentation;
• at least 2 anginal events in prior 24 h;
• use of aspirin in prior 7 d;
• elevated serum cardiac biomarkers

22. Problem 3
• It is 11pm in the Emergency Room in a major Chicago
Hospital; the nursing supervisor had already called you to
tell you that there are having a bed shortage
• You are evaluating a 58 year old male with history of one
episode of chest pain at rest that lasted for 30 minutes
• He has no risk factors
• Physical Examination is unremarkable apart from BP
150/90
• First Troponin is negative
• Admit overnight or Discharge with follow up in 2 days?

23. • You decide to admit the patient for
monitoring overnight
• His second troponin comes back at 2.4
• He is chest pain free since admission
• What medications would you like to
prescribe?

24. Medical Therapy - Principles
• Relief of Angina
• Dual Antiplatelet Therapy
• Anticoagulation
• ACEI/ARB for Acute MI (especially with LV
dysfunction)
• Aldosterone Blockers for Acute MI with LV dysfunction
• Risk Factor Modification
– Lipid Control
– BP Control

25. Dual Antiplatelet Therapy
• Aspirin
– once daily (lifelong)
– 300 or 325mg as initial dose
– 81mg as maintenance dose
• Clopidogrel
– 300 or 600mg (depending on timing of PCI)
– Continue for one year (regardless of whether
PCI/CABG is performed)

26. Newer Antiplatelet Agents
• Higher Efficacy, More reliable antiplatelet activity
• Prasugrel
– Thienopyridine
– P2Y12 blocker recently approved
– For administration at the time of PCI
• Ticagrelor
– Non thienopyridine
– P2Y12 blocker recently approved
– Approved for ACS

27. Anticoagulation – Unfractionated Heparin
• IV loading dose at 60 u/kg (maximum of dose
of 4000 u)
• Maintenance dose of 12u/kg/hr (maximum of
1000 u/hr)
• Target APTT 1.5x to 2x upper limit of normal
• Continue for minimum of 48 hrs or till PCI is
performed

28. Anticoagulation – Enoxaparin
• 1mg/kg SQ q12 hours
• Every 24hours if Cr Cl < 30
• Continue for minimum of 48 hrs or till PCI is
performed

29. Anticoagulation – Fondaparinux
No PCI planned/conservative strategy
• 2.5mg SQ every 24 hours
• Avoid if Cr Cl < 30
• Should Not be given if PCI is contemplated

30. Problem - continued
• You admit the patient to telemetry unit
• You start
– Aspirin 325mg
– Clopidogrel 600mg loading dose
– Heparin drip
– Atorvastatin 80mg
– Metoprolol 25mg q12 hours
– NTG prn as needed for chest pain

31. 2am
• The nurse calls you that the patient is now
having chest pain again.
• She administers NTG sublingual and performs
the vital signs and repeats the ECG
• You come to evaluate the patient
• He is sweaty, and having ongoing chest pain
• HR 90/min, BP 160/80
• His PTT is in the target range

33. What would you like to do next?

34. • You order 1mg of IV morphine and start the
patient on nitroglycerin drip
• His chest pain improves and he says he feels
better, but he still continues to have mild
chest pain, and looks ill
• You call the Interventional Cardiologist oncall
who decides to activate the Cath Lab

35. • Coronary Angiography reveals a 99% stenosis
in the mid LAD artery with ulcerated
appearance
• A drug eluting stent is placed in the mid LAD
artery
• The patient is transferred back to the
telemetry unit because the CCU is full
• His heparin drip is stopped in the Cath Lab

36. • The patient is monitored for another 24 hours
• Echocardiogram is performed and shows LVEF
60%, normal valves
• Fasting glucose is 110mg/dl
• LDL 100mg/dl
• Rest of labs are within normal limits

37. • Today is Day 3 since his admission
• HR 60/min, BP 145/80
• Chest clear
• His right femoral artery site looks good

38. • His current medications are
– Aspirin 325mg once daily
– Clopidogrel 75mg once daily
– Atorvastatin 80mg once daily
– Metoprolol 25mg twice daily
• The patient is ready for discharge
• Would you like to make any changes to this
medication list?