non ST segment elevation acute coronary syndrome (NSTEACS)
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Introduction
Acute coronary syndrome without elevation of the electrocardiogram ST segment.
Clinical manifestations
Laboratory
- markers of myocardial infarction negative
- serum troponin I normal
Diagnostic procedures
- electrocardiogram shows no ST segment elevation
Complications
- overmedication (common)
- bleeding, longer hospital stays, death[8]
Management
- ischemia-guided strategy based on TIMI score or GRACE score[11][13]
- also see unstable angina
- thrombolysis not indicated[11]
- immediate percutaneous coronary intervention (within 2 hours)
- if transfer can be facilitated within 2 hours of hospital arrival[3]
- benefits high-risk patients only
- recurrent angina or myocardial ischemia
- elevated troponin I (NSTEMI)
- heart failure
- new or worsening mitral regurgitation
- sustained ventricular tachycardia
- hemodynamic instability
- STEMI, LBBB, posterior wall MI[3]
- bivalirudin vs unfractionated heparin at the time of PCI roughly equivalent[16]
- early percutaneous coronary intervention (within 12-24 hours)
- no high-risk features (above)
- TIMI score >=3
- Grace score >= 141 (Grace 2.0 score)
- rising troponin levels
- new ST segment depression
- delayed percutaneous coronary intervention (within 72 hours)
- TIMI score = 2
- Grace score = 109-140 (Grace 2.0 score)
- ischemia guided
- TIMI score = 0-1
- Grace score < 108 (Grace 2.0 score)
- early coronary angiography & revascularization (within 12-24 hours)
- may benefit* elderly (> 65) more than younger patients
- reduces cardiovascular events for median of 5.3 years vs conservative management in elderly >= 80 years[15]
- both early & delayed interventions are safe & effective[10]
- pretreatment with P2Y12 inhibitor (clopidogrel, ticagrelor)
- 16% reduction in major cardiovascular events
- 32% increase in major bleeding
- no change in mortality[14]
- may benefit* elderly (> 65) more than younger patients
- routine coronary angiography with revascularization[4][6]
- enoxaparin vs unfractionated heparin[2][3]
- 30 day mortality 3% in both groups
- 30 day non-fatal myocardial infarction plus death rate (11% vs 10%) in favor of enoxaparin[3]
- bleeding similar in both groups[4]; > in enoxaparin group (9% vs 8%)[3]
- discharge medications
- clopidogrel or ticagrelor + aspirin 81 mg for up to 12 months, then aspirin 81 mg QD[13]
- ACE inhibitors/ARBs if LVEF < 0.40, hypertension, diabetes mellitus, or stable chronic kidney disease, unless contraindicated[13]
- high-intensity statin therapy[13]
- consider beta-blocker if LVEF < 0.40[13]
* lower rate of myocardial infarction or rehospitalization for acute coronary syndrome (8% vs 13% within 30 days, 17% vs 22% within 6 months)
More general terms
Additional terms
References
- ↑ Journal Watch 24(18):142, 2004 Bach RG, Cannon CP, Weintraub WS, DiBattiste PM, Demopoulos LA, Anderson HV, DeLucca PT, Mahoney EM, Murphy SA, Braunwald E. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med. 2004 Aug 3;141(3):186-95. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15289215
- ↑ 2.0 2.1 Journal Watch 24(18):142, 2004 Ferguson JJ, Califf RM, Antman EM, Cohen M, Grines CL, Goodman S, Kereiakes DJ, Langer A, Mahaffey KW, Nessel CC, Armstrong PW, Avezum A, Aylward P, Becker RC, Biasucci L, Borzak S, Col J, Frey MJ, Fry E, Gulba DC, Guneri S, Gurfinkel E, Harrington R, Hochman JS, Kleiman NS, Leon MB, Lopez-Sendon JL, Pepine CJ, Ruzyllo W, Steinhubl SR, Teirstein PS, Toro-Figueroa L, White H; SYNERGY Trial Investigators. Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial. JAMA. 2004 Jul 7;292(1):45-54. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15238590
- ↑ 3.0 3.1 3.2 3.3 3.4 3.5 Petersen JL, Mahaffey KW, Hasselblad V, Antman EM, Cohen M, Goodman SG, Langer A, Blazing MA, Le-Moigne-Amrani A, de Lemos JA, Nessel CC, Harrington RA, Ferguson JJ, Braunwald E, Califf RM. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-Segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004 Jul 7;292(1):89-96. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15238596
- ↑ 4.0 4.1 4.2 4.3 Mehta SR et al, Routine vs Selective Invasive Strategies in Patients with Acute Coronary Syndromes. A Collaborative Meta-analysis of Randomized Trials. JAMA 293(33), 2908, 2005
- ↑ 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. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/16046952 <Internet> http://circ.ahajournals.org/cgi/content/abstract/111/20/2699
- ↑ 6.0 6.1 6.2 de Winter RJ, Windhausen F, Cornel JH, Dunselman PH, Janus CL, Bendermacher PE, Michels HR, Sanders GT, Tijssen JG, Verheugt FW; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med. 2005 Sep 15;353(11):1095-104. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16162880
Boden WE. Acute coronary syndromes without ST-segment elevation--what is the role of early intervention? N Engl J Med. 2005 Sep 15;353(11):1159-61. No abstract available. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16162887 - ↑ Fox KA, Poole-Wilson P, Clayton TC, Henderson RA, Shaw TR, Wheatley DJ, Knight R, Pocock SJ. 5-year outcome of an interventional strategy in non-ST- elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet. 2005 Sep 10-16;366(9489):914-20. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16154018
- ↑ 8.0 8.1 Alexander, KP et al for the CRUSADE Investigators Excess dosing of antiplatelet and antithrombin agent in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA 2005, 294:3108 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16380591
- ↑ 9.0 9.1 Lagerqvist B et al, 5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation aute coronary syndome. Lancet 2006, 368:998 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16980115
- ↑ 10.0 10.1 Mehta SR et al, Early versus Delayed Invasive Intervention in Acute Coronary Syndromes NEJM 2009, 360:2165-2175 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19458363 <Internet> http://content.nejm.org/cgi/content/short/360/21/2165
Hillis LD, Lange RA Optimal Management of Acute Coronary Syndromes NEJM 2009, 360:2237-2240 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19458369 <Internet> http://content.nejm.org/cgi/content/extract/360/21/2237 - ↑ 11.0 11.1 11.2 Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 18, 19. American College of Physicians, Philadelphia 2006, 2012, 2018, 2022.
- ↑ Jneid H et al 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update). A report of the American College of Cardiology Foundation/American Heart Association Task Force of Practice Guidelines. http://circ.ahajournals.org/content/early/2012/07/16/CIR.0b013e318256f1e0.full.pdf+html
- ↑ 13.0 13.1 13.2 13.3 13.4 13.5 Amsterdam EA et al 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation. Sept 23, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25249586 <Internet> http://circ.ahajournals.org/content/early/2014/09/22/CIR.0000000000000133
Amsterdam EA 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. Circulation. Sept 23, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25249585 <Internet> http://circ.ahajournals.org/content/early/2014/09/22/CIR.0000000000000134 - ↑ 14.0 14.1 Bellemain-Appaix A et al Reappraisal of thienopyridine pretreatment in patients with non-ST elevation acute coronary syndrome: a systematic review and meta-analysis. BMJ 2014;349:g6269 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/25954988 <Internet> http://www.bmj.com/content/349/bmj.g6269
- ↑ 15.0 15.1 Berg ES, Tegn NK, Abdelnoor M, et al. Long-Term Outcomes of Invasive vs Conservative Strategies for Older Patients With Non-ST-Segment Elevation Acute Coronary Syndromes. J Am Coll Cardiol. 2023 Nov 21;82(21):2021-2030 PMID: https://www.ncbi.nlm.nih.gov/pubmed/37968019 Free article https://www.sciencedirect.com/science/article/pii/S0735109723075782
- ↑ 16.0 16.1 NEJM Knowledge+
Valgimigli M et al Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes. N Engl J Med. Sept 1, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26324049 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1507854
Berger PB Finding the Proper Context for the MATRIX Trial. N Engl J Med. Sept 1, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26324050 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1509637