SCHOOL OF ALLIED HEALTH SCIENCES

MAHATMA GANDHI MEDICAL COLLEGE

AND RESEARCH INSTITUTE

ANGIO FINDINGS IN PATIENTS WITH NON-ST

ELEVATION MYOCARDIAL INFARCTION

RICHU ABRAHAM
UIN: 1801312011

A DISSERTATION SUBMITTED TO
SRI BALAJI VIDYAPEETH
FOR THE AWARD OF
DEGREE IN B.SC CARDIAC CARE TECHNOLOGY
[2018 – 2023]
 SCHOOL OF ALLIED HEALTH SCIENCES
MAHATMA GANDHI MEDICAL COLLEGE
AND RESEARCH INSTITUTE

DECLARATION BY THE CANDIDATE

I hereby declare that this Undergraduate thesis entitled

“ANGIO FINDINGS IN PATIENTS WITH NON-ST
ELEVATION MYOCARDIAL INFARCTION ” is a bonafide
and genuine research work carried out by MR. RICHU ABRAHAM,
[UIN: 1801312011] in the Department of Cardiology, under the
guidance of Dr. GIRIDHARAN, Associate Professor and
Dr. KARTHIKEYAN, Assistant Professor Department of Cardiology,
Mahatma Gandhi Medical College and Research Institute, Puducherry.

(RICHU ABRAHAM)
B.Sc. cardiac care technology
SAHS, MGMCRI

Place: Puducherry
Date:
 SCHOOL OF ALLIED HEALTH
SCIENCES
MAHATMA GANDHI MEDICAL COLLEGE
AND RESEARCH INSTITUTE

CERTIFICATE

This is to certify that the Dissertation entitled“ ANGIO FINDINGS IN PATIENTS

WITH NON-ST ELEVATION MYOCARDIAL INFARCTION (UIN:1801312011) is a
bonafide record of original work carried out by MR. RICHU ABRAHAM,
[UIN: 1801312011] School of Allied Health Sciences, MGMCRI under our guidance and
supervision during the Internship period of B.Sc. Cardiac Care Technology from September
2022 to August 2023.

Guide: DR. GIRIDHARAN. S

Professor and Head
Department of Cardiology, MGMCRI ………….………………………

Co-Guide: DR. KARTHIKEYAN

Associate Professor
Department of Cardiology, MGMCRI ………….………………………

HOD: DR. GIRIDHARAN. S

Professor and Head
Department of Cardiology, MGMCRI .…………………………………

Prof. A.N. UMA

Principal,
School of Allied Health Sciences, MGMCRI ………………………………...
 ACKNOWLEDGEMENT

It is most appropriate that I begin by expressing my undying gratitude to the ALMIGHTY

GOD for giving me the strength both mentally and physically to complete this task.
I owe a deep sense of gratitude to my professors DR. GIRIDHARAN. S (Head of the
Department) and Dr. KARTHIKEYAN, Associate Professor and Dr. PARTHIBAN, Dr.
PREMNATH Assistant professor Department of Cardiology, Mahatma Gandhi Medical
College and Research Institute for their constant guidance, encouragement and immense
support throughout the project.
I am indebted to Principal Prof. A.N. UMA, School of Allied Health Sciences, MGMCRI for
helping me throughout my Undergraduate study.
I express my heartfelt gratitude to the backbone as leading light MR. KASI, Chief Cathlab
Technologist, Mahatma Gandhi Medical College, and Research Institute, for his constant
guidance, valuable lectures, motivation, encouragement, and support from the beginning of
the course to the end of the course.
I must give my sincere thanks to my parents, Mr. ABRAHAM JOHN and
Mrs. SINI ABRAHAM for the innumerable sacrifices for me. That has moulded me as a
person like I am today.
I owe my sincere thanks to my Ms. PREETHI / MS. SWATHI Tutor, SAHS and all the
faculty members of Department of Cardiology, Mahatma Gandhi Medical College, and
Research Institute for their help in innumerable ways which has made this dissertation
possible.
I am thankful to all my fellow colleagues, CATHLAB technicians, the nursing staffs and Post
graduate Doctors in the Department of Cardiology and other specialties for their help and
encouragement.

(RICHU ABRAHAM)
 CHECK LIST FOR SUBMISSION

Sl. No. Title of the study Page No.

Introduction
1. 7
2. Aim & Objectives 9

3. Review of literature 10

4. Methods 13

Methodology 14

5. Sample Size 15

6. Study Design 15

Result 16
7.

Discussion 19
8.

Summary 21
9.

References (Minimum 10) 22

10.
INTRODUCTION

Non ST elevation myocardial infarction (NSTEMI) is a result of acute imbalance between

myocardial oxygen demand and supply most commonly due to a reduction in myocardial
perfusion. Classically, it is thought that NSTEMI patients ultimately have a diagnosis of a
non Q wave MI; however 25% of patients with NSTEMI and elevated biomarker go on to
develop Q wave MI in the weeks to follow.

Non ST elevation acute coronary syndrome include a clinical spectrum that ranges from
unstable angina to NSTEMI. Nevertheless, it is recognized that this broad spectrum of
clinical presentation and outcomes results from common underlying pathophysiological, with
atherosclerotic plaque disruption and differing degree of associated thrombosis and distal
embolization.

While patients with NSTEMI, to comparison with those with ST- segment elevation. MI
(STEMI) have a greater prevalence of early culprit coronary artery patency they are also at
higher risk of recurrent ischemic event.

Patients presenting with chest pain or discomfort with suspected ACS require urgent
evaluation. The clinical spectrum of NSTEMI may range from patients free of symptoms at
presentation to individuals with ongoing ischemia, electrical or hemodynamic instability due
to large myocardium in jeopardy, or cardiac arrest secondary to malignant ventricular
ischemia.

ACUTE CORONARY SYNDROME

Patients with chest pain represent a very substantial proportion of all acute medical
hospitalization in Europe. It is important that patients with acute coronary syndrome (ACS)
are identified within this group by the medical service. ACS comprises of unstable angina
pectoris and myocardial infarction. Patients with symptoms suggestive of ACS area
diagnostic challenge, especially in individuals without clear symptoms of ECG features.

Myocardial under perfusion as described before from the basic pathophysiological

mechanisms in most condition of ACS. The leading symptom that initiates the diagnostic and
therapeutic cascade is chest pain, but the classification of patients is based on ECG findings
according to the European society of cardiology.

Chest complaints such as pain and pressure are challenging to interpret in primary care and
have extensive differential diagnosis. ACS can be divided into subgroups of:

● ST- segment elevation myocardial infarction(STEMI)

● Non-ST- segment elevation myocardial infarction (NSTEMI) and
● Unstable angina.

ACS carries significant morbidity and mortality and the prompt diagnosis and appropriate
treatment is essential. STEMI diagnosis and management are discussed elsewhere. Three
characteristics distinguish NSTEMI from STEMI.
 1. Patients with acute chest pain and persistent (>20min) ST-segment elevation.

Patients with ST- elevation ACS (STE-ACS) generally reflect acute total coronary occlusion.
Most of these patients will ultimately develop an ST- elevation myocardial infarction
(STEMI). Therapy of these patients is aimed at rapid, complete and sustained reperfusion by
primary angioplasty or fibrinolytic.

2. Patients with chest pain but without persistent ST-segment elevation.

These patients have ECG changes other than ST-segment elevation or no ECG changes at
presentation. The initial strategy is to alleviate ischemia and other symptoms, monitoring
with serial ECG and to repeat measurments of markers of myocardial necrosis. At
presentation in this hospital, the working diagnosis on ST- elevation ACS (NSTE-ACS)
based on blood tests will be further specified as non-ST elevation myocardial infarction
(NSTEMI) or unstable angina. In a certain of patients CHD will subsequently be excluded as
the cause of symptoms.

In NSTEMI the coronary artery is intermittently or incompletely occluded or both by platelet-

rich white thrombus that is recently formed from platelet aggregation at the site of a damaged
inner surface of a coronary artery. The trigger for this platelet aggregation is usually rupture
of an atherosclerotic plaque in an artery with <50% stenosis and causes subendocardial
ischemia. Subendocardial ischemia may present with ST segment depression or T wave
changes on ECG that are transient or dynamic in nature.

This white thrombus is in sharp contrast to the mature red blood cell and fibrin-rich red
mature thrombus which is the hallmark pathologic findings in patients with STEMI. Unlike
the platelet rich white thrombus a mature red thrombus results in a complete or persistent
coronary artery occlusion or both resulting in severe transmural ischemia characterized by
acute ST segment elevation on ECG.
Cardiovascular disease are the leading cause of death worldwide. Prompt recognition and
initiation of appropriate management can save live. NSTEMI is considered one of these top
cardiac emergencies carrying significant morbidity and mortality. This burden can highly be
reduced by proper management and adherence to protocol and guidelines.
 2.AIMS AND OBJECTIVES

AIM

The aim of this study is to describe the characteristics, management, and outcome of
NSTEMI in 40 patients attending Mahatma Gandhi medical college and research institute,
Puducherry.

OBJECTIVE
● The objective of this study is to describe the patho-physiology of acute coronary
syndrome.
● To review about the typical presentation of a patient for NSTEMI.
 3.REVIEW OF LITERATURE

NSTEMI is an acute ischemic event causing Cardiomyocyte death by necrosis in a clinical

setting consistent with an acute myocardial ischemia. The leading symptoms that initiates the
diagnostic and therapeutic cascade in patients with suspected ACS is chest pain but to make a
diagnosis of NSTEMI, one major criterion is the typical rise and gradual fall in cardiac
biomarkers (troponin or CKMB) in a addition to one or more of the following.

(i) Symptoms of ischemia.

(ii) Electrocardiography (ECG) changes.
(iii)Imaging evidence of new or presumed new loss of viable myocardium or regional
wall motion abnormality
(iv)Intracoronary thrombus detected on angiography or autopsy.

ACS is simply a mismatch in the myocardial oxygen demand and myocardial oxygen
consumption. While the cause of this mismatch in STEMI is nearly always coronary plaque
rupture resulting in thrombosis formation occluding a coronary artery there are several
potential causes of this mismatch in NSTEMI. There may be a flow-limiting condition such
as a stable plaque, vasospasm as in Prinzmetal angina coronary embolism or coronary
arteritis.

Non coronary injury to the heart such as contusion, myocarditis or presence of cardio-toxic
substances can also produce NSTEMI. Finally conditions relatively unrelated to the coronary
arteries or myocardium itself such as hypotension, hypertension, tachycardia, aortic stenosis
and pulmonary embolism lead to NSTEMI because the increased oxygen demand cannot be
met.

The typical presentation of NSTEMI is pressure like substernal pain, occurring rest or with
minimal exertion. The pain generally lasts more than 10 minutes and may radiate to either
arm, the neck, or the jaw. The pain may be associated with dyspnea, nausea or vomiting,
syncope, fatigue or diaphoresis. Sudden onset of unexplained dyspnea with or without
associated symptoms also a common presentation.

Risk factor for ACS include male sex, older age, family history of coronary artery Disease,
diabetes, personal history of coronary artery disease and renal insufficiency. Atypical
symptoms may include a stabbing or pleuritic pain, epigastric or abdominal pain, indigestion
and isolated dyspnea..

While all patients presenting with ACS are more likely to present with typical symptoms than
atypical symptoms, the likelihood of atypical presentations increases with age over 75,
women and those with diabetes, renal insufficiency, and dementia. Physical Exam for ACS
and NSTEMI is often nonspecific.
NSTE-ACS

The invasive treatment strategy always starts with angiography to find the culprit lesion.
After the identification of the culprit stenosis and possible other non-culprit stenosis possible
treatments are Percutaneous coronary intervention (PCI), also known as stenting, or coronary
artery bypass grafting (CABG), also known as bypass surgery. The mode of revascularization
should be based on the severity and distribution of the coronary artery disease

Clues such as back pain with aortic dissection or pericardial friction rub with pericarditis may
point to an alternative diagnosis for a patient’s chest pain, but no such exam finding exists
that indicates ACS as the most likely diagnosis. Signs of heart failure should increase concern
for ACS but are, again, nonspecific findings.

Initial management strategies aim to reduce cardiac ischemia and prevent death. Treatment
for acute myocardial infarction (AMI), which includes STEMI and NSTEMI, is often started
in the emergency department (ED). About more than 90% of people with AMI receive
emergency care.
Although 60% of patients undergo same‐hospital admission, substantial portions are
transferred between hospitals via the ED. Clinical outcomes from NSTEMI may be enhanced
through the adherence to guideline-indicated treatments comprising of evidence-based
pharmacological therapies and invasive coronary processes. Several cohort studies have
revealed that improving compliance with evidence-based interventions decreased the hazard
of death after NSTEMI.

Though, between and within European country variation in the delivery and outcomes from
NSTEMI recommended that the possibility to diminish the prevalence and incidence of
cardiovascular disease (CVD) has not been understood. Measuring documented standards of
care is a procedure by which geographic differences in the use of guideline-indicated
treatments for NSTEMI may be addressed and, therefore, cardiovascular outcomes improved.

The treatment of these causes may reverse ischemic changes. Second, in most cases, no
complete thrombotic occlusion of a coronary artery is accountable for the infarction but only
a critical stenosis often involving multiple coronary vessels.

Accordingly, compared with STEMI, the need for urgent PCI is less compelling, especially if
the hemorrhagic risk is high, as in the peri-operative period. Finally, the incidence of adverse
events at 1-year follow-up is higher in NSTEMI than in STEMI. As a consequence, a
strategy of routine invasive therapy before hospital discharge has been shown to be generally
superior to medical therapy alone.

Oxygen, aspirin, and nitrates are administered based on initial concern for ACS and prior to a
definitive diagnosis. Subsequent treatment depends on confirmation of diagnosis or a high
index of suspicion with or without a 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 with ongoing symptoms should receive 0.4 mg sublingual nitroglycerin every 5
minutes for up to three doses or until the pain is relieved, unless otherwise contraindicated.
Contraindications include the recent use of phosphodiesterase inhibitors and hypotension.

Nitrates should be used with extreme caution in patients with concerns 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 a 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 a 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 the 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.
 1. MATERIALS

SOURCE OF DATA

This is a descriptive study observed in Mahatma Gandhi Medical and Research Institute
(MGMCRI) conducted in the period from march 2021 to february 2022. All patients
presented to MGMCRI from July 2021 with a confirmed diagnosis of NSTEMI according to
the ESC definition of NSTEMI and based on the universal definition of acute myocardial
infarction during the study period. Total coverage of all patients with NSTEMI fulfills the
inclusion criteria of the study. This study included 40 patients during the study period.

DURATION OF STUDY

March 2021-february 2022

INCLUSION CRITERIA

● All MI patients with non-ST elevation

● Patients also present with Q wave changes in ECG

EXCLUSION CRITERIA

● Those who with ST elevation myocardial infarction

STUDY DESCRIPTION

Total number of study subjects is about 40 patients

METHOLOGY

STUDY DESIGN

Coronary Angiogram (CAG) has been used to detect coronary artery disease in myocardial
infarction (both STEMI and NSTEMI) patients. While early (< 24 h) coronary angiography
via the radial access is the main strategy in the invasive management of NSTEMI patients, in
the presence of ongoing ischemia or hemodynamic instability, immediate (i.e., within 2 h)
coronary angiography is indicated

NSTEMI is diagnosed in patients determined to have symptoms consistent with ACS and
troponin elevation but without ECG changes consistent with STEMI.

SAMPLE - CARDIAC MARKERS

Troponin elevation is associated with increased mortality in patients with acute coronary
syndrome. Data about the predictors, characteristics and prognosis of patients admitted with
non–ST-elevation acute coronary syndrome, troponin elevation, and non-obstructive coronary
artery disease are lacking.

Diagnosis is then based on an elevation of cardiac troponin levels, as the marker is highly
sensitive and specific to detect cell necrosis; creatine kinase, MB fraction (CK-MB) has been
better validated with intervention-related MI and is usually based on a threefold elevation
above the normal values.

Blood tests play a central role in establishing a diagnosis and risk stratification for patients
suggestive of ACS. Troponin blood tests make it possible to distinguish between NSTEMI
and unstable angina pectoris.

Troponins are more specific and sensitive than the traditional cardiac enzymes such as
creatine kinase (CK), its isoenzyme MB (CK-MB), and myoglobin. Elevation of cardiac
troponins reflects myocardial cellular damage.2When an AMI occurs either with ST-
elevation or not, a rise in troponin occurs within ±4 hours after symptom onset.

A chest pain that lasted more than 20 to 30 minutes with ST-T changes is also strongly
positive. Other diagnostic helps are focal systolic or diastolic dysfunction on the
echocardiogram, a fixed flow-deficit on the nuclear scan, and late enhancement on NMR.

Unstable angina and NSTEMI differ primarily in the presence or absence of detectable
troponin leak. ECG, and cardiac biomarkers are the mainstays in the evaluation. An
ECG should be performed as soon as possible in patients presenting with chest pain or those
with a concern for ACS.

A normal ECG does not exclude ACS and NSTEMI. ST-elevation or anterior ST depression
should be considered a STEMI until proven otherwise and treated as such. Findings
suggestive of NSTEMI include transient ST elevation, ST depression, or new T wave
inversions.

ECG should be repeated at predetermined intervals or if symptoms return. Cardiac troponin is

the cardiac biomarker of choice. Troponin is more specific and more sensitive than other
biomarkers and becomes elevated relatively early in the disease process. While contemporary
cardiac troponin may not be elevated within the first 2 to 4 hours after symptom onset, newer
high sensitivity troponin assays have detectable elevations much earlier.

It is also true that the amount of troponin released, and therefore the time to elevation, is
proportional with infarct size, so it is unlikely to have a negative initial troponin with larger
infarcts.

Regardless of infarct size, most patients with true ischemia will have elevations in troponin
within 6 hours, and negative troponins at this point effectively rule out infarct in most
patients. Most assays use a cutoff value of greater than a 99th percentile as a positive test.

In older, contemporary troponin assays, no detectable troponin is reported in most healthy

individuals without the disease. Newer high sensitivity troponin assays often will report a
normal detectable range in healthy individuals without the disease.

Several tools and scores have been developed to assist in the workup of ACS. These tools
must be used with caution and in the appropriate context as none have been definitively
shown to be superior to clinician judgment.

Some common tools available are the TIMI (Thrombolysis In Myocardial Infarction) risk
score, the GRACE (Global Registry of Acute Coronary Events) risk score, the Sanchis score,
the Vancouver rule, HEART (History, ECG, Age, Risk Factors, and Troponin) score,
HEARTS3 score, and Hess prediction rule. The HEART score was specifically developed for
emergency department patients and has gained popularity in this setting.

N %

GENDER, M, F 2:1

MALE 27 67.5

FEMALE 13 32.5

AGE (YEARS)

41-55 10 25.0

56-70 24 60.0

>70 6 15.0
 2. RESULT

In total, this study enrolled 40 NSTEMI patients, 27(67%) were males and 13(32.5%) were
females, and most of the 24 (60%) were aged from 56 to 70 years . Diabetes (n=24; 60%) and
hypertension(n= 20; 50%) were the major CVD risk factors encountered.

Around 12 patients(30%) had prior MI, four (10%) had prior PCI, and three patients had a
history of heart failure Most of the patients had heart rate ranged from 60 to 100 bpm,
systolic blood pressure ranged from 90 to 140 mmHg (n=33; 82.5%) and diastolic blood
pressure ranged from 60 to 90 mmHg (n=34; 85%). Interestingly, 29 (72%) had late
symptoms onset (>6 hours) and 11 (28%) had early-onset (<6 hours). Two patients (5%)
presented with acute heart failure and one (2.5%) with arrhythmia or cardiac arrest.

All of the study population had been offered an echocardiogram, however, only 36 out of 40
patients had echocardiography done during the hospital stay. Among them, six patients had
LV systolic dysfunction (mild in two patients, moderate in three patients, and severe in one
patient) with the median ejection fraction was (ranged from 25% to 75%), and most of them
31 had EF levels >50%.

Diagnostic CAG was performed for 38 patients, 23 of them stented and 15 were not . The
major final management strategy among our study group was PCI in 23 patients followed by
medical therapy only without mechanical revascularization.

We conclude that NSTEMI predominantly affected male and older patients, with a delayed
presentation to Emergencies. Hypertension and DM were the major risk factors. All patients
were in sinus rhythm and the main ECG abnormality was a T-wave inversion. Most of the
patients received standard NSTEMI protocol with exception of risk stratification. PCI was the
major final management strategy used.

No in-hospital or 30-days mortality occurred. We recommend that the initial risk

stratification of all NSTEMI patients should be used and clearly documented. Sudan
needs ACS national registries (for both types STEMI and NSTEMI). Education of the general
population about ischemic heart disease and improving pre-hospital services would decrease
the time to presentation. Finally, more prospective studies with a larger sample sizes and
longer follow-up periods are needed.
 CARDIOVASCULAR RISK FACTORS

DM HTN (n=20) smoking(n=10) hypercholesterolemia n=6

(n=24)

CARDIOVASCULAR HISTORY

prior MI(n=12)
prior PCI(n=4) heart failure(n=3)
 SYMPTOMS OF ONSET
Column1,
early(<6Hrs)(n=1
1), 28%, 28%

early(<6Hrs)(n=11)
late(>6hrs)(n=29)

Column1,
late(>6hrs)(n=29)
, 72%, 72%

PRESENTATION

Sales,
arrhythmia/cardia c arrest(n=1), 2.50%, 33%

Sales, acute
HF(n=2), 5%, 67%
DISCUSSION

These observations were in accordance with a Spanish study in which hypertension, diabetes,
and dyslipidemia were the major risk factors found among NSTEMI patients. However,
Hall et al. reported smoking (ex or current) as the chief risk factor of NSTEMI. In general, as
reported in the, risk factors that increase the likelihood of NSTEMI includes, hypertension,
DM, family history of CAD, smoking, hyperlipidemia, renal insufficiency, and the previous
manifestation of CAD as well as peripheral or carotid artery disease.

On observations, most of the patients had normal heart rate , systolic blood pressure (82.5%),
and diastolic blood pressure (85%). Similar results were noticed. Most of the cases in this
study had a late presentation (>6 hours). This could be explained by a lack of community
awareness of the illness and insufficiency of the prehospital services.

Similarly, among the. reported 64% of patients had a late presentation. However, lowered
duration between chest pain onset and ED arrival (median= 4 hours) was reported. The
present study showed that 36 patients were Killip class I and the remaining 4 patients were
Killip class II. These findings were comparable to the study of Polonski et al. who reported
87% of NSTEMI patients had Killip classes I and II .

As recommended by ESC and AHA guidelines , initial risk stratification is important in

NSTE-ACS to predict outcomes and treatment selection by directly visualizing treatable
targets in higher-risk individuals, since the benefit of intensive therapies varies with risk.

In this study, no patient underwent risk score assessment during a hospital stay; this calls for
the emerging use of scoring tools such as GRACE and TIMI in our protocol. ECG changes
are one of the criteria in the diagnosis of NSTEMI; in the current study, all patients (i.e. 40)
had sinus rhythm.

The main ECG abnormality found among our study groups was T-wave inversion (70%). As
reported in the 2016 ESC guideline, T-wave flattening or inversion are major ECG changes
in NSTEMI. Also, in the study of Chung and Ying, T-wave abnormalities (65.6%) were the
commonest ECG changes among NSTEMI.

According to the recommendations of the 2017 ESC guideline, an echocardiogram should be

performed on all patients during their hospital stay. In our study, 90% of patients underwent
echocardiograms.

Among those, who had LV systolic dysfunction (mild in two patients, moderate in three
patients, and severe in one patient). The median ejection fraction was 52% and 31 of the
patients had EF levels >50%.

This study showed that diagnostic CAG was performed for 38 patients and a stent was
inserted for 23 of them. These variations might be due to differences in protocols between
studies. The major final management strategy among our study group was PCI in 23 patients.

PCI is the preferred reperfusion therapy if it can be performed by an experienced cardiologist

within 72 hours of the first medical contact .

In other revascularization methods, CABG was received by 10% of our subjects. A

comparable rate was reported by Saman and Arnoud who found 17% of NSTEMI patients
received CABG . All patients received aspirin, Clopidogrel, Parenteral anticoagulant outside
the cath lab, and ACE/ARBs. These findings were in agreement with the recommendation of
ESC and AHA guidelines
In respect to 30-days outcomes, all patients survived but 10 patients were readmitted due to
symptoms of angina. No in-hospital or 30-days mortality occurred, which is indicating there
has been improvement in NSTEMI mortality rates over time.

These findings were in agreement with the recommendation of ESC and AHA guidelines . In
respect to 30-days outcomes, all patients survived but 10 (25%) patients were readmitted due
to symptoms of angina. No in-hospital or 30-days mortality occurred, which is indicating
there has been improvement in NSTEMI mortality rates over time.

However, previous studies reported that, among patients with NSTEMI, in‐hospital and 30‐
day mortality rates of between 5.2% and 13.1% and between 7.6% and 17.0%, respectively,

have been reported. In registries of Yeh et al. and McManus et al. , the in‐hospital mortality
rate was 7.1% in 1994 and 5.2% in 2006, and from a 30‐day mortality rate was 10.0% in
1999 and 7.6% in 2008 .
SUMMARY

Non ST elevation myocardial infarction (NSTEMI) is a result of acute imbalance between

myocardial oxygen demand and supply most commonly due to a reduction in myocardial
perfusion.

Classically, it is thought that NSTEMI patients ultimately have a diagnosis of a non Q wave
MI; however 25% of patients with NSTEMI and elevated biomarker go on to develop Q
wave MI in the weeks to follow.

ACS can be divided into subgroups of:

● ST- segment elevation myocardial infarction(STEMI)

● Non-ST- segment elevation myocardial infarction (NSTEMI) and
● Unstable angina.

Unstable angina and NSTEMI differ primarily in the presence or absence of detectable
troponin leak. ECG, and cardiac biomarkers are the mainstays in the evaluation.

An ECG should be performed as soon as possible in patients presenting with chest pain or
those with a concern for ACS.

Coronary Angiogram (CAG) has been used to detect coronary artery disease in myocardial
infarction (both STEMI and NSTEMI) patients.

While early (< 24 h) coronary angiography via the radial access is the main strategy in the
invasive management of NSTEMI patients, in the presence of ongoing ischemia or
hemodynamic instability, immediate (i.e., within 2 h) coronary angiography is indicated.

Diagnostic CAG was performed for 38 patients, 23 of them stented and 15 were not . The
major final management strategy among our study group was PCI in 23 patients followed by
medical therapy only without mechanical revascularization.

We conclude that NSTEMI predominantly affected male and older patients, with a delayed
presentation to Emergencies. Hypertension and DM were the major risk factors.

All patients were in sinus rhythm and the main ECG abnormality was a T-wave inversion.
Most of the patients received standard NSTEMI protocol with exception of risk stratification.
PCI was the major final management strategy used.
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