LITERATURE
THREE CLINICAL ENTITIES: Unstable Angina, NSTEMI, STEMI
Unstable Angina – chest pain + EKG changes but normal troponin and CK-MB
NSTEMI (Type 1 due to plaque rupture) – EKG changes + troponin or CK-MB
STEMI – complete occlusion of coronary artery; chest pain + ST elevations + troponin
Unstable Angina
- Characteristics of chest pain
- increasing in duration, intensity, frequency OR
- resistant to nitroglycerin OR
- new onset severe chest pain with normal activity OR
- resting chest pain OR
- chest pain within 2 weeks after MI
- EKG changes
- ST depression > 0.5 mm
- T-wave inversions > 3mm
- Transient ST elevations last less than 20 minutes
UA/NSTEMI
- Use TIMI score to risk stratify patients presenting with CP suspicious for unstable angina vs. NSTEMI
- TIMI score estimates risk of new or recurrent MI, severe recurrent ischemia requiring re-vascularization, and all-cause mortality in patients presenting with unstable angina or NSTEMI
- “AMERICA” mnemonic – 1 point for each
- Age > 65
- Markers – elevated troponin
- EKG w/ ST depressions of 0.5 mm in contiguous leads
- Risk factors of 3 or more
- HTN > 140/90 or on anti-hypertensives
- Cigarette smoker
- HDL < 40
- Diabetic
- Family hx of pre-mature CAD
- male 1st degree < 55 y/o, female 1st degree < 65 yo
- Ischemia –2 or more angina events in 24 hours
- CAD – known diagnosis w/ CA stenosis > 50%
- Aspirin use in the past 7 days
STEMI
- Door to PCI Time 90min
- If no PCI available, fibrinolysis within 30 minutes of presentation with immediate transfer to facility capable of PCI
- ALL PATIENTS WITH STEMI –need ASA, antiplatelet (P2Y12 or glycoprotein IIb/IIIa inhibitor), BB (oral within 24 hours, unless contraindicated), ACE-I, statin and referral to cardiac rehabilitation
