HARD CASES OF NSTEMI –

ACS – INTERACTIVE CASE

ACHMAD LEFI, MD, FIHA, FAsCC
NSTEMI vs STEMI : Pathophysiology
 Prognosis of NSTEMI : Don’t Underestimate
Prognosis: Poor Undertreated
Probability of dying

Days after presentation

 Case
• Male, 59 years old
Anamnesa
• Blood pressure: 100/60 mmHg
• Rh -/- Wh-/-
• Risk factor: Dyslipidemia,Smokers (30 years)
• Laboratorium:
 CKMB: 667.8
 Troponin I: 8.7
ECG (5/10/2016)
 What’s your working Diagnosis???

a. STEMI
b. NSTE-ACS with ongoing ishaemia or
haemodynamic instability
c. NSTE-ACS without ongoing ischaemia or
haemodynamic instability
d. NSTE-ACS unlikely
 What’s next step?
Risk Assesment & ECG Monitoring
• Method for risk asssessment
• ECG motoring : < 24 hours vs > 24 hours
 Method for Risk Assessment
Ischaemic Risk Assessment Bleeding Risk Assessment

• GRACE Risk Score • CRUSADE Bleeding

• TIMI Risk Score Score
Ischaemic Risk Assessment
GRACE Score & TIMI Score

Patient GRACE Score TIMI Score

Score 114 5 points
 Result
Ischaemic Risk Assessment
Bleeding Risk Assessment
CRUSADE
Enter Values in drop-down boxes below:
Baseline 37 – 39.9 Prior Vascular Yes
Hematokrit Disease
GFR: Cockcroft- 91 – 120 Diabetes No
Gault Mellitus
Heart rate on < 71 Signs of CHF No
admission on admission
Systolic Blood 91 – 100 Sex No
pressure on
admission
 Recommended duration of
monitoring

Clinical Presentation Unit Rhythm Monitoring

Unstable Angina Regular ward or None
discharge
NSTEMI at low risk for Intermediate care unit or ≤ 24 hour
cardiac arrhytmias coronary care unit
NSTEMI at intermediate Intensive/coronary care > 24 hour
to high risk for cardiac units or intermediate care
arrhthmias unit
 Management of NSTEMI
• Anti thrombotic
• Anticoagulan
 Invasive stragtegy
• Do we need invasive strategy ?
• Risk criteria mandating invasive strategy in
NSTE-ACS
 Determine Risk Criteria
ESC Guideline AHA guideline

Immediate - Haemodynamic instability or cardiogenic shock - Refactory angina

invasive - Recurrent or ongoing chest pain refractory to
(within 2 h) medical treatment
- Life-threatening arrhytmias or cardiac arrest
- Mechanical complications of MI
- Acute heart failure with refractory angina or ST
deviation
- Recurrent dynamic ST –or T- wave changes,
particularly with intermittent ST-elevation
Class of Recommendation: I
Level of Recommendation: C
- Signs or symptoms of HF or new or
worsening mitral regurgitaion
- Hemodynamic instability
- Recurrent angina or ischemia at rest or
with low-level activities despite intensive
medical therapy
- Sustained VT or VF

Early invasive - Rise or fall in cardiac troponin compatible with MI - None of the above, but GRACE risk score
(within 24 h) - Dynamic ST –or T- wave changes (symptomatic or > 140 Temporal change in Tn
silent) - New or presumably new ST depression
- GRACE Score > 140
Class of Recommendation: I
Level of Recommendation: C
Delayed - Diabetes mellitus - None of the above but diabetes mellitus,
invasive - Renal insufficiency (eGFR <60 mL/min/1,73 m2) Renal insufficiency (GFR < 60
(within 25 – - LVEF < 40% or congestive heart failure mL/min/1,73 m2)
72 h) - Early post-infarction angina recent PCI - Reduced LV systiolic function (EF < 0,40)
- Prior CABG - Early postinfarction angina
- GRACE risk score > 109 and < 140 - PCI with 6 mo
- Or recurrent symptoms or known ischaemia on - Prior CABG
non-invasive testing - GRACE risk score 109 – 140; TIMI score ≥
Class of Recommendation: I 2
Level of Recommendation: A
Where is the position in Flow chart?
ESC Guideline

Source:
Roffi, M., et al. 2015.
2015 ESC Guidelines for
the management of acute
coronary syndromes in
patients presenting
without persistent ST-
segment elevation. Eur.
Heart J. :1–59
Where is the position in Flow chart?
AHA Guideline

Source: Amsterdam, et al. 2014. 2014 AHA/acc

guideline for the management of patients with
Non-ST-Elevation acute coronary syndromes: A
report of the American College of
Cardiology/American Heart Association Task
Force on Practice Guidelines. J. Am. Coll.
Cardiol. 64(24):e139–e228.
Coronary Angiography
 Revascularisasi modalities
• PCI vs CABG
Percutaneus Coronary Intervention
(PCI)
 Hospital discharge and post
discharge management
• When to discharge :
• Longterm management :
 Measurement of cardilogist profesional
performance : What’s indicators ?
• Variations in the application of evidence-based strategies
are associated with significant differences in outcome.
• Underutilization of evidence-based treatments is common.
• Adherence to guidelines has been correlated with
improvements in patient outcomes in ACS, including
reduced mortality.
• Continuous monitoring of performance indicators is
strongly encouraged to enhance the quality of treatment
and minimize unwarranted variations in evidence-based
care.
 Performance measures in NSTE-ACS
• Compliance of using aspirin, ticagrelor/prasugrel/clopidogrel,
fondaparinux/bivalirudin/UFH/enoxaparin, beta-blocker at discharge
in patients with LV dysfunction, statins, ACE-inhibitor or ARB in
patients with systolic LV dysfunction or heart failure, hypertension or
diabetes
• Compliance of using early invasive procedures in intermediate -to
high- risk patients
• Smoking cessation advice/conselling
• Enrolment in a secondary prevention/cardiac rehabilitation
programme
• Development of regional and/or national programmes to measure
performance indicators systematically and provide feedback to
individual hospitals
 Conclusion
Facing NSTEMI had to do diagnosis
validation, risk assessment (ischemic,
bleeding), management, medical treatment,
invasive strategy (based on risk criteria)
 Thank You
For Your Kind Attention
Ischaemic Risk Assessment
GRACE SCORE
Ischaemic Risk Assessment
TIMI Risk Score