Unstable Angina (UA) and

Non ST Elevation Myocardial Infarction

(NSTEMI)
5,315,000 annual ER presentations for chest pain

1,433,000 annual U.S. hospital admissions for

UA/NSTEMI

50 patients per month at BIDMC coded as:

AMI, SUBENDOCARDIAL ISCHEMIA
 Unstable Angina +
Non-ST-Elevation MI +
ST-Elevation MI

Acute Coronary Syndromes (ACS)

UA + NSTEMI
(life-threating but STEMI
not medical emergency) (medical emergency)
 Ischemic Discomfort
Acute Coronary Syndrome
Presentation

Working Dx

ECG No ST Elevation ST Elevation

Non-ST ACS
Cardiac
Biomarker UA NSTEMI

Unstable Myocardial Infarction

Final Dx
Angina NQMI Qw MI
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358:1533-1538; Davies MJ. Heart 2000; 83:361-
366. Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 1. Reprinted with permission.
 Definitions
Unstable angina
New onset angina
Angina that occurs at rest
Angina that occurs with accelerating
frequency (crescendo angina)
May have EKG changes (ST depression)
Biomarkers will be negative
 Definitions
NSTEMI
Typical rise and fall of cardiac biomarkers plus at
least one of the following:
Anginal chest pain
Ischemic EKG changes (ST-depression)
Development of Q waves on EKG
Coronary intervention
Often cant tell UA from NSTEMI at presentation
Source: European Heart Journal ESC Guidelines for The Management of Acute Coronary Syndromes in patients
presenting without persistent ST-segment elevation 2015
 Ischaemic Risk Bleeding Risk
Assessment Assessment

GRACE Score CRUSADE Score

 Low Risk Intermediate High Risk Very High Risk
Risk
Non ST ACS 30 Day Death/MI Risk
<3% 3-8 % 8-15 % >15%

No higher risk features Rest pain < 20 min. Rest pain > 20 min. Prolonged recurrent
pains
Single short duration New onset/ Crescendo
(<10 min.) rest pain angina (Low threshold ECG ST depression < ST depression < 2mm
Crescendo severity) 2mm With CK-MB or Tn
angina/New onset ECG non-specific Deep T inversion ST depression > 2mm
angina (Mod severity) abnormalities or (e.g. > 5 mm) Multiple leads
6 Hour Observation normal T inversion > 2 mm With pain
ECG X 2 normal, Biomarkers normal Especially in > Transient ST > 1 mm
unchanged or non- or borderline 5 leads
specific ST s Increased baseline risk Isolated biomarker Hemodynamic
Negative biomarkers DM clearly +ve instability
X2 BP/CHF
Previous CABG/MI
Refractory ischaemia
Recent PCI
with ST shift

D Fitchett, SG Goodman M Gupta, A Langer. Can J Card 2002; 18 (11):1179-1190.

Anti-ischaemic

Anti-platelets

Anti-coagulation

Combining anti-platelet and anti-coagulant

1. Class I Level B
Early initiation of beta blocker treatment
Continue chronic beta-blocker therapy in Killip class III or
higher
2. Class I Level C
Sublingual or intravenous nitrates (patients with recurrent
angina, uncontrolled hypertension or signs of heart failure)
3. Class IIa Level B
Calcium channel blockers and nitrates (beta-blockers should
be avoided)
Oral Antiplatelet therapy
1. Class I Level A Dose
Aspirin : loading dose of 150 - 300mg
maintenance dose of 75 100 mg
A P2Y12 inhibitor (for 12 months)
2. Class I Level B
Tricagrelor : 180 mg loading dose, 90 mg twice
daily (for all patients at moderate to
high risk of ischaemic events)
Prasugrel : 60 mg loading dose, 10 mg daily
dose (in patients who are proceeding
to PCI if no contraindication)
Clopidogrel : 300-600 mg loading dose, 75 mg
daily dose (in patients who cant
receive ticagrelor or prasugrel or
who require oral anticoagulation)
Oral Antiplatelet therapy
1. Class IIb Level A
A P2Y12 inhibitor for a shorter duration of 3- 6
months after DES implant (in patients deemed at
high bleeding risk)
2. Class III Level B
Not recommended to administer prasugrel in
patients in whom coronay anatomy is not known
Intravenous Antiplatelet therapy
1. Class IIa Level C
GPIIb/IIa inhibitors during PCI for bailout situations or thrombotic
complications
2. Class IIb Level A
Cangrelor in P2Y12 inhibitor (nave patients undergoing PCI)
3. Class III Level A
Not recommended to administer GPIIb/Iia inhibitors

Long-term P2Y12 inhibition

Class IIb Level A
P2Y12 inhibitor administration in addition to aspirin beyond 1 year,
after careful assessment of the ischaemic and bleeding risks of the
patient
1. Class I Level B
Parenteral anticoagulation (to both ischaemic and bleeding
risks)
Fondaparinux : 25 mg s.c. daily
UFH :
70 -100 IU/kg i.v. (50-70 IU/kg if concomintant with
GPIIb/IIa inhibitions)
70-85 IU/kg i.v in patients on foundaparinux (50-60
IU/kg if concomintant with GPIIb/IIa inhibitions)
Enoxaparin : 1 mg/kg s.c. twice daily (or UFH)
2. Class I Level A
Bivalirudin : 0,75 mg/kg i.v. bolus, followed by
1,75 mg/kg/h for up to 4 h after
the procedure)
1. Class IIa Level B
Enoxaparin (for PCI in patients with s.c. enoxaparin)
2. Class IIb Level B
Additional ACT-guided i.v. boluses of UFH during PCI
3. Class IIa Level C
Discontinuation of anticoagulation after PCI, unless
otherwise indicated
4. Class III Level B
Not recommended to Crossover between UFH and LMWH
5. Class IIb Level B
Low-dose rivaroxaban : 2,5mg twice daily
for approximately 1 year
 ACC Guidelines for Management of UA/NSTEMI
Chest Pain

EKG

Follow ST
No ST ST Protocols

Possible Definite/Likely Definite/Likely

UA/NSTEMI UA/NSTEMI UA/NSTEMI with cath
MSO4 or PCI planned
MSO4 NTG
NTG MSO4
ASA NTG
ASA Beta Blockers
Beta Blockers ASA
Heparin Beta Blockers
Plavix Heparin
Plavix
IIB/IIIA Inhibitor
 SYMPTOMS SUGGESTIVE OF ACS

Definite ACS
Noncardiac Diagnosis Chronic Stable Angina Possible ACS

No ST-Elevation ST-Elevation
Treatment as ACC/AHA Chronic
indicated by Stable Angina
alternative diagnosis Guidelines
ST and/or T wave changes
Nondiagnostic ECG
Normal initial serum Ongoing pain
cardiac biomarkers
Positive cardiac
biomarkers
Observe Hemodynamic
abnormalities
12 h from symptom onset

Evaluate for
reperfusion therapy
No recurrent pain; negative Recurrent ischemic pain or
follow-up studies positive follow-up studies
Diagnosis of ACS confirmed
Stress study to provoke ischemia ACC/AHA STEMI
Consider evaluation of LV function if ischemia Guidelines
is present (tests may be performed either
prior to discharge or as outpatient)

Negative Positive Admit to hospital

Potential diagnoses: nonischemic Diagnosis of ACS confirmed Manage via acute ischemia pathway
discomfort; low-risk ACS or highly likely

Arrangements for outpatient follow-up Algorithm for evaluation and management of patients suspected of having ACS.
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1e157, Figure 2.
 Applying Classification of Recommendations
and Level of Evidence, 2011 COR/LOE Table
A recommendation with
Modified Level of Evidence B or C
does not imply that the
2011 recommendation is weak.
Many important clinical
questions addressed in the
guidelines do not lend
themselves to clinical trials.
Although randomized trials
are unavailable, there may
be a very clear clinical
Note: The COR/LOE consensus that a particular
table shown was test or therapy is useful or
effective.
drafted in 2011. Both
the new and modified *Data available from clinical
recommendations trials or registries about the
usefulness/ efficacy in
from the 2011 different subpopulations,
UA/NSTEMI Focused such as sex, age, history of
Update were graded diabetes, history of prior
myocardial infarction,
based on the latest history of heart failure, and
version of the prior aspirin use.
COR/LOE table. All of
For comparative
the unmodified effectiveness
recommendations recommendations (Class I
were graded on the and IIa; Level of Evidence A
and B only), studies that
previous COR/LOE support the use of
table, listed below. comparator verbs should
involve direct comparisons
of the treatments or
strategies being evaluated.
 Applying Classification of Recommendations and Level of Evidence,
Previous COR/LOE Table

Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk Benefit Risk Risk Benefit
Additional studies with Additional studies with No additional studies
focused objectives broad objectives needed
needed needed; Additional
registry data would be Procedure/Treatment
Procedure/ Treatment IT IS REASONABLE helpful should NOT be
SHOULD be to perform performed/administered
performed/ procedure/administer Procedure/Treatment SINCE IT IS NOT
administered treatment MAY BE CONSIDERED HELPFUL AND MAY BE
HARMFUL

-should -is reasonable -may/might be considered -is not recommended

-is recommended -can be useful/effective/ -may/might be reasonable -is not indicated
-is indicated beneficial -usefulness/effectiveness is should not be done
-is useful/effective/ -is probably recommended unknown/unclear/uncertain -is not useful/effective/
beneficial or indicated or not well established beneficial
-potentially harmful
 Applying Classification of Recommendations and Level of Evidence,
Previous COR/LOE Table

Class I Class IIa Class IIb Class III

Benefit >>> Risk Benefit >> Risk Benefit Risk Risk Benefit
Additional studies with Additional studies with No additional studies
focused objectives broad objectives needed; needed
needed Additional registry data
would be helpful Procedure/Treatment
Procedure/ Treatment IT IS REASONABLE to should NOT be
SHOULD be perform Procedure/Treatment performed/administered
performed/ procedure/administer MAY BE CONSIDERED SINCE IT IS NOT
administered treatment HELPFUL AND MAY
BE HARMFUL

Level A: Recommendation based on evidence from multiple randomized trials or meta-analyses

Multiple (3-5) population risk strata evaluated; General consistency of direction and magnitude of effect
Level B: Recommendation based on evidence from a single randomized trial or non-randomized studies
Limited (2-3) population risk strata evaluated
Level C: Recommendation based on expert opinion, case studies, or standard-of-care
Very limited (1-2) population risk strata evaluated
 Contingent on
Unstable angina syndrome
ST/T changes
Elevated cardiac enzymes or positive biomarkers
Extent of ischaemia
Recurrent ischaemia
Reproduced with
Permission of CHRC

Continuing Medical Implementation

...bridging the care gap
Reproduced with
Continuing Permission
Medical of CHRC
Implementation
...bridging the care gap