Most pt’s will present with prolonged or recurrent central chest discomfort but others (elderly, DM, women) may present with atypical sx. Risk = DM & stress
Most pt’s with NSTEMI are normal on PE. An abnormal ECG, esp dynamic ST-segment deviation (≥0.5mm) or new T-wave inversion (≥2mm) will confirm the dx, but the ECG may be normal or show minor changes in up to 50% cases.
TIMI Score Calculation (1 point for each):
- Age >= 65
- Aspirin use in the last 7 days (patient experiences chest pain despite ASA use in past 7 days)
- At least 2 angina episodes within the last 24hrs
- ST changes of at least 0.5mm on admission EKG
- Elevated serum cardiac biomarkers
- Known Coronary Artery Disease (CAD) (coronary stenosis >= 50%)
- At least 3 risk factors for CAD, such as:
- Hypertension -> 140/90 or on antihypertensives
- current cigarette smoker
- low HDL cholesterol (< 40 mg/dL)
- diabetes mellitus
- Family history of premature CAD (CAD in male first-degree relative, or father less than 55, or female first-degree relative or mother less than 65).
Score Interpretation:
% risk at 14 days of: all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring urgent revascularization.
- Score of 0-1 = 4.7% risk
- Score of 2 = 8.3% risk
- Score of 3 = 13.2% risk
- Score of 4 = 19.9% risk
- Score of 5 = 26.2% risk
- Score of 6-7 = at least 40.9% risk
‘TIMI risk’ estimates mortality following acute coronary syndromes. TIMI risk can be calculated on the TIMI website under “Clinical Calculators.” [2]
Management
- Aspirin 300mg AND Clopidogrel 600mg or Ticagrelor 90mg BD
- Clexane: 1mg/kg BD or >75yr 0.75mg/kg (48-72hrs)
- If angiography scheduled: omit SC anticoagulation
- β- blocker – Metoprolol 25mg BD
- Ramipril 2.5mg daily
- Atorvastatin 80mg nocte
- Early coronary angiography (within 48hrs) + revascularitsation