❑ Consider continuous ECG monitoring in patients whose initial ECG is non-diagnostic and who are at intermediate/high risk of ACS (LOE: IIB) ❑ Consider supplemental ECG leads V7 to V9 in patients whose initial ECG is non-diagnostic and who are at intermediate/high risk of ACS (LOE: IIB) If ANY of the following findings is present, use the Sgarbossa's criteria for the diagnosis of MI: ❑ Transient ST-segment elevation ❑ Findings on ECG that may mask signs of ischemia. ❑ ST-segment depression (carries the poorest prognosis) - If patient has anterior ST-segment depression indicative of true posterior MI, manage patient according to STEMI guidelines. If high suspicion of ACS and normal ECG, repeat ECG every 15-30 minutes during the first hour (LOE: IC) ❑ Perform ECG within 10 minutes of patient arrival to the ED (LOE: IC) ❑ Presence of S4 during cardiac auscultation ❑ Paradoxical splitting of S2 ❑ New-onset murmur suggestive of mitral regurgitation (late systolic murmur heard in mitral region) ❑ Perform a thorough cardiovascular physical examination and search for signs of myocardial ischemia, signs of HF, and signs of other non-ischemic causes of the patient's symptoms that might suggestive alternative diagnoses: ❑ Known personal history of CAD ❑ Family history of early CAD ❑ Known risk factors for CAD (dyslipidemia, HTN, diabetes, smoking, peripheral vascular disease) ❑ Associated symptoms of palpitations, nausea, vomiting, diaphoresis, dyspnea, abdominal pain, lightheadedness, or syncope ❑ Radiation to both arms, jaw, neck, back or epigastrium ❑ No relief with medications ❑ Sudden-onset ❑ Located in retrosternal region ❑ Sensation of heaviness, tightness, pressure, or squeezing ❑ Duration> 10 minutes (but usually less than half an hour) Identify cardinal findings of unstable angina/ NSTEMI : īoxes in the red color signify that an urgent management is needed. The following algorithm is derived from the 2014 AHA/ACC guideline for the management of patients with Non-ST-elevation acute coronary syndromes (either unstable angina or non-ST-elevation myocardial infarction). 2014 64(24):e139-e228 FIRE: Focused Initial Rapid EvaluationĪ Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. ❑ Patient or clinician preference in the absence of high-risk featuresĪdapted from Amsterdam et al. ❑ Low-risk Troponin-negative female patients ❑ Low-risk score (either GRACE risk score < 109 or TIMI risk score = 0-1) ❑ None of the requirements for any of the invasive (either immediate, early, or delayed) strategies was met ❑ GRACE risk score 109-140 or TIMI risk score ≥ 2 ❑ Reduced LV systolic function (LVEF < 40%) ❑ Known history of renal insufficiency (defined as eGFR < 60 ml/min/1.73 m2) ❑ None of the requirements for immediate/early invasive strategies was met ❑ New/presumably new ST-segment depression ❑ None of the requirements for immediate invasive strategy were met ❑ Recurrent angina or ischemia at rest or with low-level activities despite intensive pharmacologic therapy ❑ Signs or symptoms of either heart failure or new/worsening mitral regurgitation ischemia-guided strategy among patients with NSTE-ACS. Shown below is a table that lists the factors that are associated with appropriate selection of invasive strategy vs. Post-percutaneous coronary interventionįor a complete list of causes, click here for unstable angina and here for NSTEMI.Atherosclerotic plaque rupture and subsequent coronary thrombus (most common cause).Unstable angina and NSTEMI are life-threatening conditions and must be treated as such irrespective of the causes. Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Unstabel angina and NSTEMI might not be differentiated early following the occurrence of symptoms because cardiac biomarkers may require a few hours to rise. NSTEMI is differentiated from unstable angina by the presence of elevated cardiac biomarkers secondary to myocardial injury. These conditions have a similar clinical presentation characterized by an acute onset of chest pain that starts on minimal exertion, rest or sleep, lasts at least 20 minutes (but usually less that half an hour) and, is not relieved by medications or rest. Unstable angina and non ST elevation myocardial infarction ( NSTEMI) belong to two different ends of the spectrum of acute coronary syndrome. Invasive Strategyĭosing of Parenteral Anticoagulants During PCI Andrea Tamayo Soto Unstable angina/ NSTEMI Resident Survival Guide Microchapters Associate Editor(s)-in-Chief: Yazan Daaboul, M.D.
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