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non ST segment elevated myocardial infarction (nonSTEMI, NSTEMI)

Myocardial infarction without elevation of the electrocardiogram ST segment. (see non ST segment elevation acute coronary syndrome, NSTEACS) Clinical manifestations: - see acute coronary syndrome & myocardial infarction Laboratory: - markers of myocardial infarction positive - serum troponin I elevated - at presentation & 1 hour later [11,12] - within 6 hours (performance measure) [10] Special laboratory: - electrocardiogram shows no ST segment elevation - coronary angiography no routinely indicated - indications - hemodynamic instability - heart failure - recurrent angina at rest despite therapy - new or worsening murmur of mitral regurgitation - sustained ventricular tachycardia Management: 1) thrombolytics not indicated 2) initial medical management: a) oxygen b) aspirin c) P2Y12 inhibitor loading dose (300-600 mg of clopidogrel) d) analgesia: nitrates vs IV fluids, morphine e) beta-blocker (avoid if acute heart failure, pulmonary edema) 3) intermediate to high-risk patients a) glycoprotein IIb/IIIa inhibitor [2] b) unfractionated heparin or LMW heparin for 48 hours - LMW heparin not recommended for patients with renal insufficiency [5,13] - may be no benefit to heparin (see unstable angina) 4) the TIMI risk score is used to predict risk of death or nonfatal MI in patients presenting with unstable angina or NSTEMI [2] - risk-score stratification (quality measure) [10] 5) coronary angiography with revascularization - PCI vs CABG - revascularization has improved mortality in patients with NSTEMI [9] - revascularization (within 2 hours) if refractory chest pain, severe heart failure, worsening mitral regurgitation, hemodynamic instability or sustained ventricular arrhythmias - revascularization (within 12-24 hours) in stabilized high-risk patients if TIMI score: 5-7 [10], 3-7 [17], GRACE score: > 140, rising serum troponin, or new ST-segment depression (quality measure) [10] - > 3% risk of in hospital death [17] - PCI not indicated within 6 hours in the absence of LBBB [2] - delayed PCI within 72 hours (not high risk, TIMI score: 2, GRACE score: 109-140) - ischemia guided: refractory or recurrent angina, ischemia on stress testing, HFrEF (low risk: TIMI score: 0-1; GRACE score: < 109) - composite of myocardial infarction, stroke, death, & urgent revascularization less frequent with invasive strategy in octagenarians than with conservative approach (41% vs. 61%) [8] - harm of PCI exceeds benefit [7] - no mortality benefit for PCI [7] - risk of MI higher with PCI than medical management [7] - no benefit for routine PCI after NSTEMI in frail elderly [16] - revascularization not associated with reduced mortality with elderly with NSTEMI [19] 6) recovery - clopidogrel or ticagrelor plus aspirin 81 mg for at least 1 year [2] - aspirin 81 mg + prasugrel only in patients after PCI [2] - statin - continue or begin within 24-96 hours [2] - target serum LDL cholesterol < 70 mg/dL - ACE inhibitor or angiotensin receptor antagonist (ARB) [5] - aldosterone antagonist at discharge for eligible patients - LVEF < 40%, heart failure during index hospitalization [10,18] 7) noninvasive stress testing before discharge in medically- treated patients (performance measure) [10] 8) post-MI non-cardiac surgery: delay (if possible) 4-6 weeks (uncomplicated MI) - 4-6 weeks for recipients of bare-metal stents - 6-12 months for recipients of drug-eluting stents [2] 9) cardiac rehabilitation - reduces risk of all-cause mortality & cardiovascular mortality [18] 10) treat depression 11) see myocardial infarction

Related

non ST segment elevation acute coronary syndrome (NSTEACS)

General

myocardial infarction (MI); heart attack

References

  1. Gibler WB, Cannon CP, Blomkalns AL, Char DM, Drew BJ, Hollander JE, Jaffe AS, Jesse RL, Newby LK, Ohman EM, Peterson ED, Pollack CV; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; Quality of Care and Outcomes Research Interdisciplinary Working Group; Society of Chest Pain Centers. Practical implementation of the Guidelines for Unstable Angina/ Non-ST-Segment Elevation Myocardial Infarction in the emergency department. Ann Emerg Med. 2005 Aug;46(2):185-97. PMID: 16046952 http://circ.ahajournals.org/cgi/content/abstract/111/20/2699
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 18. American College of Physicians, Philadelphia 2006, 2012, 2015, 2018. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Wright SR et al 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline) J Am Coll Cardiol. 2011 Mar 23 PMID: 21450428 http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.02.009
  4. Van Horn SE Jr, Maniu CV. Management of non-ST-Segment Elevation Myocardial Infarction. Med Clin North Am. 2007 Jul;91(4):683-700; PMID: 17640542
  5. Anderson JL, Adams CD, Antman EM et al ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157. PMID: 17692738 - Anderson JL, Adams CD, Antman EM et al. 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jun 11;61(23):e179-347. PMID: 23639841 Free full text
  6. Alexander KP, Newby LK, Cannon CP et al Acute coronary care in the elderly, part I: Non-ST-segment- elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007 May 15;115(19):2549-69. Review. PMID: 17502590
  7. The NNT: Early Invasive Management for Acute Coronary Syndromes. http://www.thennt.com/nnt/early-invasive-management-for-acute-coronary-syndromes/ - Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD004815 PMID: 20238333
  8. Tegn N, Abdelnoor M, Aaberge L et al Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet. 2016;387(10023):1057-1065. Jan 12, 2016 PMID: 26794722 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2901166-6/abstract - Psaltis PJ, Nicholls SJ Management of acute coronary syndrome in the very elderly. Lancet. Jan 12, 2016 PMID: 26794723 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2900036-2/abstract
  9. Hall M et al. Association of clinical factors and therapeutic strategies with improvements in survival following non-ST-elevation myocardial infarction, 2003-2013. JAMA 2016 Aug 30 PMID: 27574717 http://jama.jamanetwork.com/article.aspx?articleid=2546640
  10. Writing Committee Members, Jneid H, Addison D, Bhatt DL et al 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. J Am Coll Cardiol. September 2017 PMID: 28943066 http://www.onlinejacc.org/content/early/2017/09/14/j.jacc.2017.06.032
  11. Reichlin T, Twerenbold R, Wildi K et al Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. CMAJ. 2015 May 19;187(8):E243-52 PMID: 25869867 Free PMC Article http://www.cmaj.ca/content/early/2015/04/13/cmaj.141349.full.pdf
  12. Twerenbold R, Neumann JT, Sorensen NA Prospective Validation of the 0/1-h Algorithm for Early Diagnosis of Myocardial Infarction. J Am Coll Cardiol. 2018 Aug 7;72(6):620-632. PMID: 30071991
  13. NEJM Knowledge+ Question of the Week. Nov 19, 2019 https://knowledgeplus.nejm.org/question-of-week/53/
  14. Kofoed KF et al Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. Circulation. 2018 Dec 11;138(24):2741-2750. PMID: 30565996 Free article.
  15. Jobs A, Mehta SR, Montalescot G et al Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet. 2017 Aug 19;390(10096):737-746. PMID: 28778541 Review.
  16. Sanchis J, Bueno H, Minana G et al Effect of Routine Invasive vs Conservative Strategy in Older Adults With Frailty and Non-ST-Segment Elevation Acute Myocardial Infarction. A Randomized Clinical Trial. JAMA Intern Med. Published online March 6, 2023 PMID: 36877502 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2802028
  17. NEJM Knowledge+ Question of the Week. July 11, 2023 https://knowledgeplus.nejm.org/question-of-week/69/ - Amsterdam EA, Wenger NK, Brindis RG et al 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-e228. PMID: 25260718 Free article.
  18. NEJM Knowledge+
  19. Kunadian V, Mossop H, Shields C et al. Invasive Treatment Strategy for Older Patients with Myocardial Infarction. N Engl J Med. 2024. Sep 1. PMID: 39225274 https://www.nejm.org/doi/10.1056/NEJMoa240779