Non-ST Segment Elevation Acute Coronary Syndrome
Non-ST Segment Elevation Acute Coronary Syndrome
1. Which of the following best describes Non-ST Segment Elevation Acute Coronary Syndrome (NSTE-ACS)?
NSTE-ACS includes unstable angina and NSTEMI, characterized by the absence of persistent ST-segment elevation on ECG but with evidence of ischemia.
2. NSTE-ACS includes which of the following conditions?
NSTE-ACS encompasses both unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI).
3. Which biomarker is most specific for diagnosing myocardial infarction in NSTE-ACS?
Cardiac troponins are the most sensitive and specific markers for myocardial injury and are key in differentiating NSTEMI from unstable angina.
4. Which ECG finding is most commonly associated with NSTE-ACS?
NSTE-ACS is typically associated with ST-segment depression or T-wave inversion, not persistent elevation.
5. What is the main difference between unstable angina and NSTEMI?
The presence of elevated cardiac troponins distinguishes NSTEMI from unstable angina.
6. Which risk score is widely used to estimate short-term mortality in patients with NSTE-ACS?
The GRACE score estimates in-hospital and 6-month mortality and helps guide intensity and timing of therapy in NSTE-ACS.
7. In NSTE-ACS, which antiplatelet regimen is recommended early unless contraindicated?
Early dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., clopidogrel, ticagrelor) reduces ischemic events in NSTE-ACS when not contraindicated.
8. Which anticoagulant is commonly used during the initial management of NSTE-ACS?
Anticoagulation (unfractionated heparin or LMWH) is used during early management and around invasive procedures; fibrinolysis is not indicated for NSTE-ACS.
9. High-sensitivity troponin testing in suspected NSTE-ACS is useful because it:
High-sensitivity troponin assays detect small degrees of myocardial injury and help distinguish NSTEMI from unstable angina; results must be interpreted with clinical context (renal disease may raise troponin).
10. Which of the following is an indication for an early invasive strategy (coronary angiography within 24 hours) in NSTE-ACS?
High-risk features such as hemodynamic instability, refractory chest pain, or high-risk scores prompt early invasive evaluation and possible revascularization.
11. Which antiplatelet agent is preferred over clopidogrel in many guidelines for high-risk NSTE-ACS due to faster/more potent platelet inhibition?
Ticagrelor is often preferred for many NSTE-ACS patients because of more consistent and rapid platelet inhibition; prasugrel is usually reserved for PCI-treated patients without contraindications.
12. Which therapy is NOT indicated for routine use in NSTE-ACS in the absence of specific indications?
Fibrinolytic therapy is not routinely used in NSTE-ACS (it’s for STEMI). Other measures—beta-blockers, statins, and nitrates—are commonly used when appropriate.
13. A 12-lead ECG in NSTE-ACS may show which of the following patterns most suggestive of ischemia?
Dynamic ST-segment depression or T-wave inversion is suggestive of ischemia in NSTE-ACS; findings may be transient and require serial ECGs.
14. In the immediate management of chest pain from suspected NSTE-ACS, which medication should be given unless contraindicated?
Immediate administration of chewable aspirin is a cornerstone of initial therapy for suspected ACS unless there is a clear contraindication.
15. Which comorbidity commonly complicates interpretation of troponin levels in suspected NSTE-ACS?
Chronic kidney disease can chronically elevate troponin levels and complicate interpretation; trends and clinical context are key.
16. Which of the following is a common long-term secondary prevention after NSTE-ACS?
Secondary prevention includes high-intensity statin therapy, antiplatelet therapy as indicated, blood pressure control, smoking cessation, and lifestyle changes.
17. Which in-hospital complication is a direct mechanical complication of transmural myocardial infarction and less common in NSTE-ACS?
Mechanical complications like ventricular septal rupture are classically seen after large transmural infarctions (more typical of STEMI) and are less common in NSTE-ACS.
18. After an initial conservative (ischemia-guided) strategy, which finding would most likely prompt delayed invasive angiography?
Recurrent ischemic symptoms or dynamic changes in ECG/troponin during observation warrant prompt invasive assessment.
19. Which coronary lesion feature found on angiography most strongly favors referral for coronary artery bypass grafting (CABG) rather than PCI?
Left main coronary artery disease or complex multivessel disease with impaired LV function often favor CABG for better long-term outcomes.
20. Which statement about in-hospital oxygen therapy for NSTE-ACS is correct?
Routine oxygen in normoxemic patients may not be beneficial and can be harmful; give supplemental oxygen when SpOâ‚‚ is below threshold or patient has distress.
| Short Question | Answer |
|---|---|
| 1. What does NSTE-ACS stand for? | Non-ST Segment Elevation Acute Coronary Syndrome |
| 2. Which two conditions are included in NSTE-ACS? | Unstable angina and Non-ST-elevation myocardial infarction (NSTEMI) |
| 3. Most specific biomarker for myocardial injury in NSTE-ACS? | Cardiac troponins |
| 4. Typical ECG finding in NSTE-ACS? | ST-segment depression or T-wave inversion |
| 5. Key difference between unstable angina and NSTEMI? | NSTEMI has elevated cardiac troponins; unstable angina does not |
| 6. Risk score commonly used in NSTE-ACS? | GRACE score |
| 7. First-line antiplatelet regimen? | Dual antiplatelet therapy: aspirin + P2Y12 inhibitor |
| 8. Commonly used anticoagulants in NSTE-ACS? | Unfractionated heparin or low-molecular-weight heparin |
| 9. Advantage of high-sensitivity troponin testing? | Detects small myocardial injuries, enabling early NSTEMI diagnosis |
| 10. Indication for early invasive strategy? | Hemodynamic instability, refractory angina, or high-risk scores |
| 11. Preferred P2Y12 inhibitor for high-risk patients? | Ticagrelor (unless contraindicated) |
| 12. Therapy not indicated routinely in NSTE-ACS? | Fibrinolytic therapy |
| 13. ECG finding suggestive of ischemia in NSTE-ACS? | Transient ST depression or dynamic T-wave changes |
| 14. First medication given unless contraindicated? | Chewable aspirin |
| 15. Condition complicating troponin interpretation? | Chronic kidney disease |
| 16. Key component of long-term secondary prevention? | High-intensity statin therapy with lifestyle changes |
| 17. Mechanical complication less common in NSTE-ACS? | Ventricular septal rupture |
| 18. Finding prompting delayed invasive angiography? | Recurrent angina or dynamic ECG/troponin changes |
| 19. Coronary disease pattern favoring CABG? | Left main disease or complex three-vessel disease with LV dysfunction |
| 20. When to give oxygen therapy in NSTE-ACS? | Only if SpOâ‚‚ < 90% or patient in respiratory distress |
| Key SEO Point | Summary |
|---|---|
| Definition of NSTE-ACS | An acute coronary syndrome without persistent ST-segment elevation, including unstable angina and NSTEMI. |
| NSTE-ACS Subtypes | Comprises unstable angina (no biomarker rise) and non-ST-elevation myocardial infarction (biomarker elevation). |
| Typical Symptoms | Chest pain, pressure, or discomfort, often with radiation and associated symptoms like dyspnea or diaphoresis. |
| ECG Changes | ST-segment depression, transient ST elevation, or T-wave inversion are common findings. |
| Biomarkers | High-sensitivity troponin is the most specific and sensitive marker for myocardial injury in NSTEMI. |
| Risk Stratification | GRACE and TIMI scores guide prognosis and management decisions in NSTE-ACS patients. |
| Initial Management | Includes aspirin loading, P2Y12 inhibitor, anticoagulation, nitrates, and beta-blockers if no contraindications. |
| Dual Antiplatelet Therapy | Combines aspirin with clopidogrel, prasugrel, or ticagrelor to reduce thrombotic events. |
| Anticoagulation Role | Unfractionated heparin or low-molecular-weight heparin is used during hospitalization to prevent clot propagation. |
| Invasive Strategy Timing | High-risk patients benefit from early angiography within 24 hours; very high-risk within 2 hours. |
| Conservative Strategy | Low-risk patients may be managed with optimized medical therapy and delayed angiography if indicated. |
| Beta-Blocker Use | Reduces myocardial oxygen demand and risk of arrhythmias when not contraindicated. |
| High-Intensity Statin Therapy | Initiated early to stabilize plaques and improve outcomes regardless of baseline cholesterol levels. |
| Avoidance of Fibrinolysis | Thrombolytics are not indicated in NSTE-ACS and may increase bleeding risk without benefit. |
| Oxygen Therapy Indications | Only given if oxygen saturation <90% or patient has respiratory distress. |
| Troponin Interpretation Pitfalls | Chronic kidney disease and other conditions can cause elevated troponin without acute MI. |
| CABG Indications | Considered for left main disease, complex multivessel disease, or poor PCI anatomy. |
| Long-Term Secondary Prevention | Includes DAPT duration as indicated, statins, ACE inhibitors/ARBs, beta-blockers, and lifestyle modification. |
| Prognosis Factors | Outcome depends on patient age, comorbidities, LVEF, extent of coronary disease, and treatment timing. |
Non–ST Segment Elevation Acute Coronary Syndrome (NSTE-ACS) is a critical cardiac emergency that includes unstable angina and non–ST elevation myocardial infarction (NSTEMI). It results from partial blockage of a coronary artery, leading to reduced blood flow to the heart muscle without full-thickness infarction. Recognizing its subtle ECG changes, elevated cardiac biomarkers, and prompt risk stratification is essential for improving survival. This guide covers key diagnostic criteria, pathophysiology, management strategies, and latest guideline updates
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GRACE score
GRACE score is a risk assessment tool used to predict in-hospital and 6-month mortality in patients with Acute Coronary Syndrome (ACS), including NSTEMI. It’s recommended by guidelines like the European Society of Cardiology for assessing mortality risk in NSTEMI patients. A GRACE score above 140 indicates a high risk of in-hospital mortality.
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