CHEN WEN TING

NSTEMI (Non-ST-elevation myocardial infraction)

Prevention, Treatment
and Research
Reviewed by Gerhard Whitworth, RN
Hajira Basit; Ahmad Malik; Martin R. Huecker.
Michael Simons, MD Jeffrey A Breall, MD, PhD

Prevention

Gerhard Whitworth, RN：

NSTEMI or non-ST segment elevation myocardial infarction is a type of heart attack.

An NSTEMI differs from a STEMI, which is the most common type of heart attack, by
causing less damage to a person's heart.
An electrocardiogram or ECG that displays each heartbeat as a waveform is used to
determine if an NSTEMI or a STEMI has occurred in a person. When looking at the
waveforms of a person who has had an NSTEMI, they appear very distinct from those
of someone who has had a STEMI.
The damage to the heart from an NSTEMI is less serious than that from a STEMI.
However, any heart attack can be very frightening.
Prevention There are ways to reduce the chances of having an NSTEMI and
improving overall heart health.
Steps people can take to reduce their risk of an NSTEMI include:
having a healthy, nutritious, and balanced diet, including fruits, vegetables, healthy
fats, and whole grains reducing and limiting foods that are high in saturated and
trans fats exercising regularly, recommended as at least 30 minutes five times a week
managing stress levels quitting a smoking habit remaining at a healthy weight
If a person has diabetes, high cholesterol, or high blood pressure, it is essential to
manage these conditions well. Not doing so could increase the risk of a heart attack.
If a person is deemed to be at risk of having a heart attack, it is advisable for them to
take precautions so that they are prepared. They should ensure emergency contact
numbers, a list of current medications and any allergens are to hand whenever they
are heading out or going away, in case a heart attack occurs.

Hajira Basit; Ahmad Malik; Martin R. Huecker.

Treatment
Initial management strategies aim to reduce cardiac ischemia and prevent death.
Oxygen, aspirin, and nitrates are administered based on initial concern for ACS and
prior to definitive diagnosis. Subsequent treatment depends on confirmation of
diagnosis or high index of suspicion with or without definitive diagnosis.

Oxygen was previously recommended for all patients presenting with concern for
ACS, but newer data suggests this strategy may be harmful in patients who otherwise
do not warrant supplemental oxygen. Supplemental oxygen is now recommended in
patients with oxygen saturation less than 90%, those with respiratory distress, or when
high risk features of hypoxemia are present.

Chewable, non-coated, aspirin 324 mg should be given to all patients who present
with concern for ACS unless otherwise contraindicated. Patients who cannot take
aspirin may be given Clopidogrel 300-600 mg or Ticagrelor 180 mg as a loading dose
for antiplatelet therapy.

Patients with ongoing symptoms should receive 0.4 mg sublingual nitroglycerin every
5 minutes for up to three doses or until pain is relieved, unless otherwise
contraindicated. Contraindications include recent use of phosphodiesterase inhibitors
and hypotension. Nitrates should be used with extreme caution in patients with
concern for right sided infarction. Continuous intravenous nitroglycerin should be
considered in patients with persistent signs of heart failure or hypertension.

Many patients will present with concern for ACS but will not have positive findings
of ischemic ECG changes or positive troponin on initial workup. These patients may
be observed with serial ECG and troponin measurements every 3 to 6 hours.
Patients also may undergo provocative testing such as the treadmill stress test or
myocardial perfusion imaging prior to discharge or within 72 hours. Low risk
patients often may be discharged with referral for further outpatient testing after
initial ACS is ruled out.

In patients where NSTEMI has been definitively diagnosed or is highly likely,

anticoagulation should be initiated. Protocols will vary by institution, so cardiology
consultation should be obtained if readily available. This is especially true when there
is the possibility of percutaneous intervention, as this may change anticoagulation
strategies. Unfractionated heparin with bolus dosing and continuous infusion is
commonly used, with most institutions having protocols available. Other strategies
may include the use of enoxaparin, bivalirudin, fondaparinux, and dual antiplatelet
therapies. Fibrinolytic therapies should not be used in NSTEMI.

When NSTEMI has been diagnosed, patients should be admitted to cardiac care units
for further management. Beta blocker therapy should be started within 24 hours after
presentation in patients who do not have a contraindication. Contraindications include
signs of heart failure, hypotension, heart conduction block, or reactive airway disease.
Unless otherwise contraindicated, ACE Inhibitors should be initiated in patients with
an ejection fraction less than 40%, hypertension, diabetes, or chronic kidney disease.
High-dose statins should be initiated for cholesterol management. Invasive and non-
invasive testing strategies are employed. Both early intervention strategies with
diagnostic angiography and intervention are applied as indicated, and conservative
medical management strategies are employed. The rationale for choosing one strategy
over the other is often patient and institution specific and beyond the scope of this
review.

Michael Simons, MD Jeffrey A Breall, MD, PhD

Research
According to a study by the American Heart Association, data show that women aged
35 to 54 have a heart attack rate that has risen from 21% to 31%, while men have
risen from 30% to 33%.

The rate of acute myocardial infarction between 40 and 49 years also increased, and
more men than women.

According to the analysis of health insurance hospitalization data, the National

Health Service found that the incidence of acute myocardial infarction was more
than 70 years old between 2009 and 2013, but 30% for men aged 40-49 and 13.9%
for women. This group of people is the main force of society and family. Once it falls,
the consequences are worrying.