EKG
NSTEMI / unstable angina
EKG

NSTEMI / unstable angina

Recognize NSTE-ACS, risk stratify, and pick early vs delayed invasive strategy.

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◆Diagnosis

  • •Symptoms of angina + ST depression or T-wave inversion (no ST elevation)
  • •Troponin elevated → NSTEMI; troponin normal → unstable angina
  • •Get serial troponins (0 and 3–6 hr) — high-sensitivity rules out earlier

◆Risk stratification (TIMI score)

  • •TIMI risk factors (1 point each, score 0–7): age ≥65, ≥3 CAD risk factors, known CAD ≥50% stenosis, ASA use in last 7 days, ≥2 anginal episodes in 24 hr, ST changes ≥0.5 mm, +troponin
  • •TIMI ≥3 → early invasive strategy (cath within 24 hr)

◆Immediate management

  • •ASA 325 chewed + P2Y12 inhibitor (clopidogrel, ticagrelor, prasugrel)
  • •Anticoagulation: heparin (UFH) or enoxaparin
  • •β-blocker (unless contraindicated), statin (high-intensity), nitrate for symptoms
  • •Cath if high-risk features (hemodynamic instability, refractory angina, dynamic EKG changes, TIMI ≥3)

High-yield pearls

  • ◆Refractory chest pain despite max medical therapy = take to cath lab regardless of TIMI
  • ◆Type 2 MI: oxygen supply-demand mismatch (sepsis, anemia, tachycardia) — treat underlying, not necessarily cath
  • ◆GRACE score better predicts 6-month mortality; TIMI better for in-hospital decisions
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