All right. Welcome back. So, last module we talked about ST-elevation MI. This time we're going to talk about non-ST-elevation MI, and the management is a bit different, specifically related to timing and which ones we medically manage versus revascularized. So, again, kind of as noted before, I showed you the incidence. The median age for these is 68, and males continue to outnumber females 3 to 2 for non-ST-elevated MI. Etiology is a little bit different with these. So, unlike the ST-elevation, the occlusion is not usually complete, so it's not 100%. And so what is happening is you're developing, patient's developing a non-transmural infarct, so it's not complete as far as the entire thickness of that myocardium. It's a portion, and so that makes a difference as far as management plan. It also creates an oxygen demand supply mismatch. So, there are times where you may have a 90 or 95% occlusion and at rest when the patient's not doing anything, they're not having any discomfort, but as soon as there's an increase in heart rate or any sort of activity, they develop pain and symptoms, and they now have that oxygen demand mismatch and that whole anaerobic, lactic acid build-up and that kind of thing. So, our goal when we're managing these patients is initial recognition and management and risk stratification. And then once we get them into the hospital, we've got decisions related to conservative treatment, related to ischemic guided strategies, or who gets revascularized and when, and then managing discharge. The other piece with these patients is that, again, similar to the STEMI patients, secondary prevention is very important along with long-term management. So, we're going to talk about all those things today. So, brief history, same kind of thing that we talked about with the chest pain and the STEMI patients. First of all, think about your ACLS to make sure that that is all stable. And then, talk to the patient, find out about the symptoms, onset, frequency, duration, severity, quality, associated symptoms. Again, all those things we've been talking about. And then risk factors, is this patient a patient that would likely have coronary disease? And physical exam. As you see, again, could be normal or could be signs of heart failure. Same kind of thing we saw with the STEMI patients. Some of these patients are quite stable and others are having some issues and therefore some physical exam findings. What are your diagnostics? Very similar, EKG with your goal of less than 10 minutes from presentation, because again, if they are STEMI, we need to get them to the lab quickly. Serial EKGs, if the pain is ongoing or the initial EKG is non-diagnostic or maybe the pain goes away and then comes back, but those serial EKGs can be very helpful in identifying these patients and risk stratifying. Serial troponin levels, because we want to know that troponin is going up, at what point that it peaks, and maybe when it starts to come back down. Remember, it peaks usually around that 12-hour mark. It starts to go up around the two to three hour mark for the traditional troponins. And then of course, the high sensitivity tend to go up sooner. Continuous monitoring is important for these patients, because again, they also can have risks of some arrhythmias. And then you want to get your lipids, your chemistry panel, your coagulation panel, your CBC. If you're worried about heart failure at all, go ahead and get a BNP. How do we manage these initially? So very similar to these STEMI patients before they go to the lab. So you want them on a cardiac monitor, get the IV started, get the labs drawn, oxygen if their SATs are less than 90%, hypoxic, hemodynamic support if they need it with pressors and that kind of thing if they're hypotensive, and then relief of that ischemic pain with nitroglycerin. Kind of lay this out. Again, extremely similar to what we saw with STEMI. So you want your antiplatelet therapy started. Anti-coagulation needs to be started because these patients too may have some thrombus formation. There could be a plaque rupture there. Your nitrates with a nitro drip if needed. And then morphine only if the pain, severe pain exists on maximum doses of nitrate. And then get them started on the data blocker and the high sensitivity. And then the high dose statin as early as possible unless contraindicated. Again, we're admitting these patients. So other things to think about, venous thromboembolism prophylaxis. So if they're going to be in the bed for more than 24 hours and the patient's not anti-coagulated, then you need to think about this. In this case, we're probably anti-coagulating these patients, but there's times that we don't. And so just remember your DVT prophylaxis. And then hyperglycemic control. If this patient is diabetic, some hospital programs actually have a diabetic service and may switch all their patients over to insulin management, even if they weren't on insulin before. If they are diabetic or there's a concern, and actually most programs include a hemoglobin A1C with their lab panel, that way you're identifying the diabetes or the hyperglycemia state if they have it. So another important piece from a secondary prevention and management standpoint. All right, this is where non-STEMIs get a little bit more complex for decision making. There are several different strategies. So early invasive strategy is for your refractory angina, hemodynamic or electrical instability, signs or symptoms of heart failure. So they are having continued early high risk findings and symptoms. We need to get them to the lab. We've not been able to calm them down with medication management. Then there's ischemic guided therapy. So these patients have a low risk to me or GRACE score. I'm going to show you those in a minute. And we will wait and see what their ischemic burden is before we decide to revascularize them versus just medically manage them. For the early invasive, these patients may have new ST changes or elevated troponins or that higher GRACE score. I'm going to show you the GRACE score again in a minute. And we may get them to the cath lab within the first 24 hours. And then there's a delayed invasive strategy for those patients that have additional risk factors. So if they've got some renal insufficiency, we may want to take some time to get them hydrated to minimize any acute kidney injury related to the IV dye. If their EF is down, we may, and again, is stable, we may want to manage their volume. If they've got heart failure and they can't lay flat, it's going to be difficult to put them on the cath lab table. Or if they've had previous PCI or CABG, the things have stabilized, we still may want to take them to the lab and take a look and see if they need further revascularization or if they've got that intermediate GRACE score. Basically by waiting that 24 to 72 hours, we're letting everything calm down. And we're taking them to the lab in a more controlled environment versus either an immediate invasive strategy or an early invasive within 24 hours. Again, these are all things that are shared decision making as you are working these patients up and trying best how to decide when to manage them. What I've presented here are the guideline recommendations. This is something to go back to your team and talk with them about best ways of managing. And both of these are pretty individual patient decisions. So I wanted to show you the GRACE score. It takes into account comorbidities. It takes into account vital signs. It takes into account labs, creatinine, and biomarkers. And so all of these have a score. And basically what they're doing is showing you the potential mortality. And so the higher the potential mortality, the more likely or the better decision would be to take them to the lab and get them revascularized. If it's low, then it was a low risk event, if you will. And so we can medically manage or look for further ischemia and see if there's going to be further issues. If they've completed their infarct and it's small, taking them to the lab, again, may be more risk than it is benefit. But those are the sorts of decisions that need to be made. What do we do with recurrent chest pain? So you get a call, patient's been in 18, 24 hours, now they're having more pain. Get an EKG and order some more troponins to assess if this is further ischemia. If ischemia is present, increase your beta blocker nitrates to decrease that myocardial oxygen demand and try to get them back pain free and ischemia free. If you can't, evaluating risk benefit of proceeding with left heart caths. And it is the treatment of choice unless the anatomy or the comorbidities preclude PCI. So that's your best option. If no ischemia is present, so in other words, they're having chest pain, but their EKG is unchanged and the troponins haven't changed, consider Dressler syndrome or post-infarct pericarditis. This is a pleuritic chest pain type symptom or a change pain with leaning forward that we see. Again, it is just what I said is post-infarct pericarditis. All right. So what do we do these patients long-term? So antiplatelet therapy, kind of dual antiplatelet therapy, similar to what we did with our STEMI patients, beta blockers, statins, ACE inhibitors, and then that nitroglycerin. So again, if these are new patients, they've not been on these medicines before, they're going home on a lot of new medicines. Now, most of these are, I shouldn't say most, but many of them are comorbidity type patients or comorbid type patients and may have already had a history of coronary disease and are already on a number of these meds. So just make sure that you've got them optimized and you have them on the appropriate doses. So additional considerations to think about in preparation for discharge. Similar to STEMI, anti-inflammatories need to be discontinued and discouraged. So patients need that education. If they have systolic dysfunction and their EF is 35% or less, assuring appropriate medical therapy and follow-up for the need of an ICD. So get those ACE inhibitors and beta blockers titrated and close follow-up those first few months, both for heart failure symptoms, as well as for systolic dysfunction management. Cardiac rehab referral is incredibly invaluable for all that secondary prevention, both phase one and phase two, patient education. They need to, again, understand their events, what happened. I was surprised I did a lot of post-hospital follow-up and how many patients just really didn't understand what happened. And it's not necessarily because the team and the inpatient side didn't do a good job of explaining, but remember these patients are bombarded with lots of information and they're sick. And so both at the time of discharge and the time of follow-up, that education is really important. They need to understand their medications. They need to understand the secondary prevention part of this, and they need to understand who to call and when. They can return to driving at one week if they're stable. If there's any concerns there, then you're going to push that farther out. If they've had any ventricular issues or syncopal issues, that's a whole nother kind of decision-making as far as driving. They need to be educated on any site management. So if they had a PCI or a diagnostic cast, making sure that they understand what to look for, and then certainly follow up back in the clinic within seven days. Lots of information for these patients and that early follow-up is really important for that short-term management. And then secondary prevention, hypertension, diabetes, smoking cessation, hyperlipidemia, diet, exercise, stress management. These patients, there's a lot of education that has to happen both at the time of discharge as well as an early follow-up. Cardiac rehab is extremely important and can provide a lot of this, both phase one and phase two. So these are things you need to make sure they're plugged into the right programs. All right. So let us, again, know if you have any questions or concerns, and we will look forward to any feedback that you might have. So thank you.

non-ST-elevation myocardial infarction

management strategies

risk stratification

revascularization decisions

patient education