Moderate Risk Acute Coronary Syndrome Management

Aka: Moderate Risk Acute Coronary Syndrome Management, NSTE-ACS Protocol, Non-ST elevation MI, Non-ST elevation Myocardial Infarction, Non-Q-Wave MI, Myocardial Ischemia Protocol, NSTEMI

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II. Background

  1. NSTE-ACS Protocol now includes both NSTEMI and Unstable Angina
    1. As of 2017, both diagnoses follow the same protocol

III. Epidemiology

  1. NSTEMI and Unstable Angina (NSTE-ACS) accounts for 70% of the 1.4 Million ACS cases in U.S. each year
    1. Kumar (2009) Mayo Clin Proc 84(10): 917-38 [PubMed]

IV. Indications: Suspected NSTEMI or Unstable Angina

  1. Electrocardiogram changes as below OR
  2. Troponin elevation (see below) OR
  3. Concerning history and findings despite non-diagnostic EKG and Serum Cardiac Markers

V. Criteria: Electrocardiogram

  1. EKGs should be done serially
    1. Acute Coronary Syndrome should not be excluded based on a single EKG
    2. Perform EKG at time of serial Troponins, as well as with changes in patient symptoms (e.g. increased Chest Pain)
    3. Formal guidelines define serial EKG as every 15-30 minutes for first hour of presentation (not evidence based)
  2. Myocardial Ischemia (Unstable Angina) or NSTEMI
    1. ST Depression >1 mm
    2. Symmetrical T-wave inversion in precordial leads (>0.2 mV)
    3. Dynamic ST Segment and T Wave changes with pain
  3. Less interpretable EKG findings increasing risk that Chest Pain has cardiac origin
    1. Bundle Branch Blocks
    2. Paced Rhythm

VI. Imaging: Echocardiogram

  1. Echocardiogram may assist in risk stratification of a patient with active Chest Pain
  2. Most helpful if completely normal
  3. Helpful also if significantly abnormal with wall motion abnormality (unless prior MI in the same region)

VII. Labs: Serum Troponin

  1. Serum Troponin at presentation and again at 3-6 hours after first Troponin
  2. Normal Troponins
    1. Two serial Troponins at adequate intervals exclude Myocardial Infarction
    2. Myocardial Ischemia and Unstable Angina are not fully excluded by serial Troponins
  3. Abnormal Troponins suggestive of Myocardial Infarction (NSTEMI)
    1. Increasing serial Troponins with >20% rise over baseline AND
    2. At least one Troponin above upper limit of normal

VIII. Management: Cardiac Angiography Indications

  1. Cardiac ischemia associated with one of the following
    1. Persistent or recurrent pain or EKG changes despite aggressive medical management
    2. Hemodynamic instability or ventricular Arrhythmia
    3. Acute Heart Failure
  2. Diagnostic findings
    1. Diffuse or widespread EKG changes
    2. Serum Cardiac Marker (e.g. Troponin) Increased >20% over baseline (with at least one above baseline)

IX. Management: Initial

  1. See MI Adjunctive Therapy
  2. Aspirin 324 mg chewable orally (on presentation) AND
  3. P2Y Receptor Antagonist (Clopidogrel or Ticagrelor)
    1. Keep in mind, will delay emergent CABG by 24 hours and elective CABG by 5-7 days
  4. Unfractionated Heparin
    1. Alternatively, Enoxaparin (Lovenox) or Fondiparinux may be used (but not if angiogram is planned)
    2. Heparin is considered a Class I recommendation for NSTEMI and definite Acute Coronary Syndrome
    3. Also start for those planned for cardiac catheterization in the next 24 hours
    4. No evidence of mortality benefit, but may decrease progression to Myocardial Infarction
    5. Risk of Heparin-related major bleeding is 4% (NNH 25)
  5. Glycoprotein IIB/IIIA Inhibitor (Eptifibatide, Tirofiban) Indications
    1. High risk patient (e.g. high risk features, Troponin positive)
    2. May be used as an alternative to P2Y Receptor Antagonist (e.g. Clopidogrel)

X. Management: Invasive - Angiography (PCI) Indications

  1. Immediate Invasive (within 2 hours)
    1. Refractory Angina
    2. Signs or symptoms of Heart Failure
    3. New or worsening Mitral Regurgitation
    4. Hemodynamic instability
    5. Recurrent Angina or ischemia at rest or low level activity despite intensive medical therapy
    6. Sustained Ventricular Tachycardia or Ventricular Fibrillation
  2. Early Invasive (within 24 hours)
    1. GRACE risk score >140
    2. Troponin Increase over time
    3. Presumably new ST depression
  3. Delayed Invasive (within 25 to 72 hours)
    1. Diabetes Mellitus
    2. Renal Insufficiency (GFR <60)
    3. Reduced LV Function (ejection fraction <40%)
    4. Early postinfarction Angina
    5. PCI within 6 months
    6. Prior CABG
    7. GRACE risk score 109 to 140
    8. TIMI Score 2 or more

XI. Management: Other measures

  1. See MI Adjunctive Therapy
  2. Beta Blocker
    1. Improves mortality, cardiac remodeling if started in first 24 hours of STEMI, NSTEMI and ST depression ACS
    2. May be started in Emergency Department or by hospitalist service (need not be immediate)
      1. Delay Beta Blockers if hypotensive, bradycardic or concern for Cardiogenic Shock
      2. Consider starting Beta Blocker in emergency department for additional indications
        1. Refractory Hypertension despite nitrates
        2. Rate control of Atrial Fibrillation or Atrial Flutter

XII. References

  1. Orman and Mattu in Herbert (2017) EM:Rap 17(12): 5-6
  2. Orman and Mattu in Herbert (2015) EM:Rap 15(5): 9-10
  3. (2000) Circulation 102(suppl I):I172-203 [PubMed]
  4. Amsterdam (2014) Circulation 130(23): 2354-94 [PubMed]
  5. Anderson (2017) N Engl J Med 376(21):2053-64 +PMID:28538121 [PubMed]
  6. Switaj (2017) Am Fam Physician 95(4): 232-40 [PubMed]

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Related Studies

Ontology: Myocardial Ischemia (C0151744)

Definition (MSHCZE) Onemocnění srdce charakterizované nedostatečným prokrvením – ischemií. Porušeno je zásobení kyslíkem (hypoxie) a živinami i odvádění zplodin látkové výměny (vzniká lokální acidóza, iontové změny). Podkladem je zúžení (popř. uzávěr) koronárních tepen obv. aterosklerózou (aterosklerotický plát, trombóza, spasmus). Hlavními projevy ICHS jsou zejména angina pectoris a infarkt myokardu. Označují se jako bolestivé (algické) formy. Dalšími projevy ICHS mohou být arytmie nebo srdeční selhání (ischemie zvyšuje elektrickou nestabilitu myokardu a má negativní působení na kontraktilitu). K vzniku ICHS přispívají faktory, které jsou rizikovými faktory aterosklerózy (zejm. hyperlipoproteinemie, hypertenze, diabetes, kouření, stres atd.). V diagnóze se uplatňuje EKG, zátěžové testy (ergometrie), klidová i zátěžová echokardiografie, thalliový scan, biochemické vyšetření u akutní ischemie (infarktu). Zúžení koronárních tepen se zjišťuje koronarografií. V léčbě se používají nitráty, betablokátory, antagonisté kalcia, antiagregační léčba aj. V řadě případů se provádějí zákroky přímo na věnčitých tepnách – na otevřeném srdci (bypass) nebo perkutánně katetrizací (PTCA, stent). (cit. Velký lékařský slovník online, 2012 http://lekarske.slovniky.cz/ )
Definition (NCI) A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries, to obstruction by a thrombus, or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (myocardial infarction).
Definition (CSP) blood deficiency in the myocardium caused by a constriction or obstruction of its blood vessels; frequently occurs in conjunction with hypoxia, which is reduction in oxygen supply.
Definition (MSH) A disorder of cardiac function caused by insufficient blood flow to the muscle tissue of the heart. The decreased blood flow may be due to narrowing of the coronary arteries (CORONARY ARTERY DISEASE), to obstruction by a thrombus (CORONARY THROMBOSIS), or less commonly, to diffuse narrowing of arterioles and other small vessels within the heart. Severe interruption of the blood supply to the myocardial tissue may result in necrosis of cardiac muscle (MYOCARDIAL INFARCTION).
Concepts Disease or Syndrome (T047)
MSH D017202
ICD9 410-414.99
ICD10 I20-I25.9 , I20-I25
SnomedCT 155303000, 41702007, 32598000, 155322009, 194795001, 195540001, 194878003, 271430002, 233822007, 2610009, 414545008, 414795007
LNC LP31567-8, MTHU024507
English Disease, Ischemic Heart, Diseases, Ischemic Heart, Heart Disease, Ischemic, Heart Diseases, Ischemic, Ischemic Heart Disease, Ischemic Heart Diseases, Ischemia, Myocardial, Myocardial Ischemia, MYOCARDIAL ISCHAEMIA, Ischemias, Myocardial, Myocardial Ischemias, MYOCARDIAL ISCHEMIA, Ischaemic heart disease NOS, Ischaemic heart diseases, Ischemic heart diseases, HEART DIS ISCHEMIC, ISCHEMIC HEART DIS, Cardiac ischaemia, myocardial ischemia (diagnosis), myocardial ischemia, IHD, Ischemia myocardial, Myocardial Ischemia [Disease/Finding], cardiac ischaemia, Disease;ischaemic heart, ihd, cardiac ischemia, myocardial ischaemia, myocardial ischemia/hypoxia, Ischemic heart diseases (I20-I25), Ischaemic heart disease (disorder), Ischemic heart disease NOS (disorder), Myocardial ischaemia (disorder), Ischaemia myocardial, Ischaemic heart disease NOS (disorder), ischemic heart disease, ischemic heart disease (diagnosis), ISCHEMIC HEART DISEASE, DISEASE, ISCHEMIC HEART, HEART DISEASE, ISCHEMIC, ischemia; heart, ischemia; myocardial, myocardium; ischemic, Ischemic heart disease, NOS, Ischaemic heart disease, NOS, Myocardial ischemia, NOS, Ischemic heart disease, IHD - Ischaemic heart disease, IHD - Ischemic heart disease, Ischaemic heart disease, Myocardial ischaemia, Myocardial ischemia, Cardiac ischemia, Ischemic heart disease (disorder), Myocardial ischemia (disorder), Ischemic heart disease NOS, Disease;ischemic heart, ischaemic heart disease
Portuguese ISQUEMIA MIOCARDICA, Isquemia cardíaca, Isquemia do miocárdio, Cardiopatia isquémica, Cardiopatia Isquêmica, Isquemia miocárdica, Doença Isquêmica do Coração, Isquemia Miocárdica
Spanish ISQUEMIA MIOCARDICA, ECI, Isquemia miocárdica, Enfermedad isquémica cardiaca, Isquemia cardiaca, Cardiopatía isquémica, cardiopatía isquémica, SAI (trastorno), Ischaemic heart disease NOS, cardiopatía isquémica, SAI, cardiopatía isquémica (concepto no activo), Ischemic heart disease NOS, enfermedad cardíaca isquémica, SAI, Isquemia de miocardio, cardiopatía isquémica (trastorno), cardiopatía isquémica, enfermedad cardíaca isquémica, enfermedad isquémica del corazón, isquemia miocárdica (trastorno), isquemia miocárdica, Cardiopatía Isquémica, Isquemia Miocárdica
Dutch hartischemie, IHD, ischemische hartziekte, ischemie myocard, ischemische hartaandoening, ischemie; hart, ischemie; myocard, myocard; ischemie, myocardischemie, Hartziekte, ischemische, Ischemie, myocard-, Ischemische hartziekte, Myocardischemie
French Ischémie cardiaque, Maladie cardiaque ischémique, IC, Cardiopathie ischémique, ISCHEMIE DU MYOCARDE, Ischémie myocardique, Ischémie du myocarde
German Myokardischaemie, ischaemische Herzkrankheit, IHD, kardiale Ischaemie, MYOKARDIALE ISCHAEMIE, myokardiale Ischaemie, Herzkrankheit, ischämische, Herzmuskelischämie, Ischämie, Myokard-, Ischämische Herzkrankheit, Myokardischämie
Italian Cardiopatia ischemica, Ischemia cardiaca, Ischemia miocardica
Japanese 心虚血, ｼﾝｷｮｹﾂ, ｷｮｹﾂｾｲｼﾝｼｯｶﾝ, ｼﾝｷﾝｷｮｹﾂ, 心筋虚血, 虚血-心筋, 虚血性心疾患, 心疾患-虚血性, 心臓疾患-虚血性, 虚血性心臓疾患
Swedish Myokardischemi
Finnish Sydänlihaksen iskemia
Russian ISHEMICHESKAIA BOLEZN' SERDTSA, SERDTSA ISHEMICHESKAIA BOLEZN', ISHEMIIA MIOKARDA, MIOKARDA ISHEMIIA, MIOKARDIAL'NAIA ISHEMIIA, ИШЕМИЧЕСКАЯ БОЛЕЗНЬ СЕРДЦА, ИШЕМИЯ МИОКАРДА, МИОКАРДА ИШЕМИЯ, МИОКАРДИАЛЬНАЯ ИШЕМИЯ, СЕРДЦА ИШЕМИЧЕСКАЯ БОЛЕЗНЬ
Czech Ischemie myokardu, Myokardiální ischemie, Ischemická choroba srdeční, Srdeční ischemie, ischémie myokardu, myokard - ischémie, ICHS, ischemická choroba srdeční
Croatian MIOKARD, ISHEMIJA
Polish Niedokrwienie mięśnia sercowego, Choroba niedokrwienna serca
Hungarian Cardialis ischaemia, Szív ischaemia, Szív ischaemiás betegsége, myocardialis ischaemia, Ischaemiás szívbetegség, Szívizom ischaemiája, Szívizom ischaemia, ISzB
Norwegian Ischemisk hjertesykdom, Myokardiskemi, Myokardischemi, Iskemisk hjertesykdom
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Non-Q wave MI (C0860155)

Concepts Disease or Syndrome (T047)
Dutch non-Q-golf MI
French IM sans onde Q
German MI ohne Q-Welle
Italian Infarto miocardico non-Q
Portuguese EM sem onda Q
Spanish IM sin onda Q
Japanese 非Ｑ波心筋梗塞, ﾋQﾊｼﾝｷﾝｺｳｿｸ
Czech Non-Q IM
English non-q wave mi, non q wave mi, mi non q wave, mi non-q wave, Non-Q wave MI
Hungarian Nem-Q hullám MI
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute Coronary Syndrome (C0948089)

Definition (MSH) An episode of MYOCARDIAL ISCHEMIA that generally lasts longer than a transient anginal episode that ultimately may lead to MYOCARDIAL INFARCTION.
Definition (NCI_CTCAE) A disorder characterized by signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Definition (NCI) Signs and symptoms related to acute ischemia of the myocardium secondary to coronary artery disease. The clinical presentation covers a spectrum of heart diseases from unstable angina to myocardial infarction.
Concepts Disease or Syndrome (T047)
MSH D054058
SnomedCT 393587009, 394659003
Japanese 急性冠動脈症候群, ｷｭｳｾｲｶﾝﾄﾞｳﾐｬｸｼｮｳｺｳｸﾞﾝ
English Coronary Syndromes, Acute, Syndromes, Acute Coronary, Acute Coronary Syndromes, Acute Coronary Syndrome, Syndrome, Acute Coronary, Coronary Syndrome, Acute, Acute Coronary Syndrome [Disease/Finding], acute coronary syndromes, syndrome acute coronary, acute coronary syndrome (diagnosis), acute coronary syndrome, Acute coronary syndrome, Acute coronary syndrome (disorder), ACS - Acute coronary syndrome
Portuguese Síndrome Coronariana Aguda, Síndrome coronário agudo
Spanish Síndrome Coronario Agudo, síndrome coronario agudo (trastorno), síndrome coronario agudo, Síndrome coronario agudo
Finnish Akuutti sepelvaltimo-oireyhtymä
German Akutes Koronarsyndrom, akutes Koronarsyndrom
Italian Sindrome coronarica acuta
Russian KORONARNYI SINDROM OSTRYI, КОРОНАРНЫЙ СИНДРОМ ОСТРЫЙ
Swedish Akut koronarsyndrom
Czech Akutní koronární syndrom, akutní koronární syndrom
French Syndrome coronaire aigu, SCA (Syndrome Coronarien Aigu), Syndrome coronarien aigu
Polish Zespół wieńcowy ostry
Hungarian Acut coronaria syndroma
Norwegian Akutt koronarsyndrom, Koronarsyndrom, akutt, AKS
Dutch acuut coronairsyndroom
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute non-ST segment elevation myocardial infarction (disorder) (C1276061)

Concepts Disease or Syndrome (T047)
SnomedCT 401314000
English acute non-ST elevation myocardial infarction (diagnosis), acute non-STEMI, non-ST elevation myocardial infarction, acute non-ST elevation MI, acute non-ST elevation myocardial infarction, Acute non-ST segment elevation myocardial infarction (disorder), Acute non-ST segment elevation myocardial infarction, NSTEMI - Non-ST segment elevation MI
Spanish infarto agudo de miocardio sin elevación del segmento ST (trastorno), infarto agudo de miocardio sin elevación del segmento ST
Derived from the NIH UMLS (Unified Medical Language System)

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