Be Still My Heart... A Case of Type I NSTEMI

Dr. Hegarty presented a classic bread & butter case today of an older man with multiple CV risk factors who presented with acute typical angina, found to have diffuse ST depressions on EKG and elevated troponin, concerning for a Type I NSTEMI.

There are many juicy learning points from this case, but let’s start with a review of the spectrum of ACS!

ACS spectrum snip.PNG

Pearls from Dr. Hegarty:

  • STE in aVR with diffuse ST depressions is a pattern we should recognize! The STE is reciprocal to diffuse ischemia, indicating left main CAD or multivessel disease. If you see this pattern, your patient may need a CABG!
  • One of the most important aspects of initial NSTE- ACS care is TRIAGE!

    • Criteria for Urgent Cath (Cath now!): STEMI, hemodynamic instability, electrical instability, pain not controlled with maximal therapy
    • Criteria for Early Cath (Cath within 24h): High risk patients with GRACE > 140, TIMI 2+, impressive EKG changes or troponinemia

Our most recent reference for management of NSTEMI is the 2014 AHA/ACC guidelines. Click here for a thorough and scintillating read, or see below for summary tables regarding initial management (nitrates/opiates, BBs, CCBs, statins) and antiplatelet/anticoagulant recommendations (aspirin, clopidogrel, heparin).

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