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Author: Admin | 2025-04-28
For all clinically unstable adult patients diagnosed with NSTEMI as soon as possible and at least within 24 hours of becoming clinically unstable.Clinically unstable patients are defined by the following clinical features:Ongoing or recurring pain despite treatmentHaemodynamic instability (low blood pressure, shock)Dynamic ECG changesLeft ventricular failureRisk stratificationAfter the diagnosis of NSTEMI has been confirmed and initial pharmacological treatment offered, formal risk stratification using an established scoring system is recommended.Categorisation based on 6-month mortality of patients diagnosed with unstable angina or NSTEMI aids in providing appropriate short-term interventions and treatment.The Global Registry of Acute Cardiac Events (GRACE) scale predicts 6-month mortality for patients admitted with ACS. Low risk (predicted 6-month mortality For patients who are assessed as low risk, consider conservative management without coronary angiography. However, younger patients may benefit from coronary angiography and PCI.Offer dual antiplatelet therapy:Ticagrelor if bleeding risk not highClopidogrel or aspirin only if high bleeding riskIn low-risk patients, consider ischaemia testing before discharge. If ischaemia is present on testing, consider coronary angiography and possible PCI.Left ventricular function should be assessed prior to discharge.High or moderate risk (predicted 6-month mortality >3%)If no contraindications, high or moderate risk patients should be offered coronary angiography within 72 hours, with subsequent PCI if required.Patients undergoing coronary angiography should be offered dual antiplatelet therapy with either prasugrel or ticagrelor. Clopidogrel can be used if a patient is receiving ongoing anticoagulation for another indication.If undergoing PCI, patients should be offered fractionated heparin.Left ventricular function should be assessed prior to discharge.Long term managementLong term management of ACS is essentially the same for STEMI and NSTEMIs.All patients with a diagnosis of NSTEMI, regardless of their risk stratification, require long term management and prevention strategies.Drug therapyThe following drug regime is recommended for all patients post NSTEMI and STEMI to reduce the risk of future ACS (secondary prevention) and improve myocardial function:ACE inhibitor or ARB: continued indefinitelyDual antiplatelet therapy (aspirin plus a second agent): for up to 12 monthsBeta-blocker for at least 12 months: continued indefinitely in the presence of reduced left ventricular ejection fractionStatin: continued indefinitelyLifestyleLifestyle changes and education are important in reducing the risk of a subsequent cardiovascular event. Advice should include:Eating a Mediterranean diet and increasing fruit and vegetable intakeRegular physical activity: 20-30 minutes a dayLow-risk drinking: no more than 14 units a weekSmoking cessationMaintaining a healthy body weightCardiac rehabilitationCardiac rehabilitation should be offered to all patients with an NSTEMI, ideally before hospital discharge.These programs involve:Advice on lifestyle, driving, flying and sexTailored physical activityStress managementHealth and lifestyle educationComplicationsMechanical complications such as papillary muscle rupture, ventricular aneurysm and free wall rupture are rare post-NSTEMI.8Non-mechanical complications include arrhythmias, thromboembolic complications, heart failure, pericarditis, and depression.Though all-cause mortality is higher for STEMI patients vs NSTEMI patients during the initial hospital presentation, there is evidence that of those surviving hospital discharge, NSTEMIs patients have a worse long-term prognosis.In 2013, the 180-day all-cause mortality was 7.6%. for cases hospitalised with NSTEMI in the UK.9ReviewersDr Nicholas TaylorEmergency Medicine physician with an interest in acute cardiologyAssociate Dean Phase 2 at the
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