Acute coronary syndrome (NSTEMI)MANAGEMENT

CARDIOVASCULAR PRESENTATIONS · 12 SECTIONS

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541 items

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01Approach to the Critical Patient/attcp31

Initial priorities

›NSTEMI time-critical pathway

›ABC stability

›If airway compromise, immediate airway management

›If SpO2 < 90%, initiate oxygen and titrate to SpO2 90-94%

›Monitoring and access

›Cardiac monitor

›Defibrillator pads for ongoing ischemia or dysrhythmia risk

›IV access x2

›If shock or vasoactive infusions, arterial line

›Early diagnostics

›12-lead ECG within 10 minutes

›Repeat ECG for recurrent pain or clinical change

›Early therapies

›Chewed aspirin unless true allergy

›Sublingual nitroglycerin if hypertensive ischemic pain and no contraindications

›High-risk triggers

›If hemodynamic instability, ICU level care and urgent cardiology

›SBP < 90 mmHg or requiring vasopressors

›Altered mental status

›If refractory ischemic pain, urgent cardiology and early invasive strategy

›Persistent symptoms despite nitrates and beta-blockade as tolerated

›Dynamic ST depression or transient ST elevation

›If malignant dysrhythmia, ACLS and cardiology

›VT or VF

›High-grade AV block with instability

›Alternate diagnosis red flags

›If tearing back pain or pulse deficit, aortic syndrome evaluation before anticoagulation

›CT aorta pathway

›If pleuritic pain with hypoxemia or high VTE risk, PE evaluation

›CT pulmonary angiography pathway

›If fever, pleuritic pain, diffuse ST elevation, myocarditis or pericarditis pathway

02History/hx64

Symptom characterization

›Ischemic symptom profile

›Chest pressure

›Retrosternal location

›Exertional onset

›Duration > 10-20 minutes

›Radiation

›Left arm

›Jaw

›Back

›Associated symptoms

›Dyspnea

›Diaphoresis

›Nausea or vomiting

›Presyncope or syncope

›Time course

›Onset time

›Symptom onset to first ECG interval

›Symptom onset to first troponin interval

›Pattern

›New

›Worsening

›Rest pain

›Response to therapies

›Relief with nitroglycerin

›Partial relief does not exclude non-cardiac causes

›Relief with rest

›Exertional threshold change

Risk and context

›Atherosclerotic risk factors

›Age and sex

›Male sex

›Postmenopausal status

›Diabetes

›Duration

›Insulin use

›Hypertension

›Control status

›Dyslipidemia

›Statin use

›Tobacco

›Current use

›Recent cessation

›Family history premature CAD

›First-degree relative

›Known cardiovascular disease

›Prior MI

›Prior PCI

›Prior CABG

›Heart failure

›Baseline functional class

›Stroke or PAD

›Antiplatelet therapy baseline

›Bleeding and anticoagulant context

›Prior intracranial hemorrhage

›Recent GI bleeding

›Current anticoagulant use

›DOAC

›Warfarin

›Substance and provoking factors

›Cocaine or stimulants

›Timing within 24 hours

›Recent surgery or trauma

›Anticoagulation implications

›Severe anemia symptoms

›Demand ischemia context

03Physical Exam/exam34

Cardiovascular and perfusion

›Hemodynamic profile

›Blood pressure

›Hypotension as high-risk marker

›Hypertension as ongoing ischemia marker

›Heart rate

›Tachycardia as demand marker

›Bradycardia with inferior ischemia or conduction disease

›Perfusion

›Cool extremities

›Capillary refill delay

›Cardiac exam

›New murmur

›Holosystolic murmur for papillary muscle dysfunction

›Harsh systolic murmur for VSD concern

›Gallop

›S3 for heart failure

›Volume and congestion

›JVP elevation

›Peripheral edema

Pulmonary and complications

›Lung exam

›Rales

›Pulmonary edema

›Wheeze

›Cardiac asthma differential

›Mechanical complication clues

›Acute pulmonary edema

›Severe MR concern

›Shock with clear lungs

›RV infarct or tamponade differential

›Alternate diagnosis exam

›Unilateral leg swelling

›DVT concern

›Focal neurologic deficit

›Aortic syndrome or stroke pathway

04Differential Diagnosis/ddx42

Life-threatening chest pain syndromes

›Critical differentials

›Acute coronary syndrome

›NSTEMI ICD-10 I21.4

›STEMI ICD-10 I21.3

›Unstable angina ICD-10 I20.0

›Aortic dissection ICD-10 I71.0

›Pulse deficit

›Neurologic deficit

›Pulmonary embolism ICD-10 I26.99

›Hypoxemia

›Pleuritic pain

›Tension pneumothorax ICD-10 J93.0

›Unilateral absent breath sounds

›Tracheal deviation

›Esophageal rupture ICD-10 K22.3

›Severe vomiting

›Subcutaneous emphysema

›Pericardial tamponade ICD-10 I31.4

›Hypotension

›JVP elevation

›Arrhythmic causes

›SVT with demand ischemia

›VT

›Bradyarrhythmia with hypoperfusion

Mimics and non-occlusive myocardial injury

›Non-atherothrombotic myocardial injury

›Myocarditis SNOMED 50920009

›Viral prodrome

›Troponin elevation with non-ischemic pattern

›Takotsubo cardiomyopathy

›Stress trigger

›Apical ballooning on echo

›Type 2 MI

›Sepsis

›Severe anemia

›Tachyarrhythmia

›Gastrointestinal

›GERD ICD-10 K21.9

›Peptic ulcer disease ICD-10 K27.9

›Musculoskeletal

›Costochondritis ICD-10 M94.0

›Pulmonary

›Pneumonia ICD-10 J18.9

05Laboratory Tests/lt31

Cardiac biomarkers and timing

›Troponin strategy

›High-sensitivity troponin preferred

›0 and 1 hour algorithm if validated locally

›0 and 2 hour algorithm if validated locally

›Conventional troponin if hs not available

›0 and 3-6 hour repeat for rule-out

›Dynamic change interpretation

›Rising or falling pattern supports acute injury

›Chronically elevated baseline in CKD context

›Ancillary biomarkers

›BNP or NT-proBNP for dyspnea and heart failure phenotype

›Prognostic enrichment

›Lactate for shock physiology

Baseline safety labs for ACS therapies

›Hematology and chemistry

›CBC for anemia and bleeding risk

›Hemoglobin threshold for transfusion decisions in ischemia context

›Electrolytes and renal function

›Potassium target 4.0-5.0 mmol/L

›Magnesium target 0.8-1.0 mmol/L

›eGFR for anticoagulant dosing

›Liver enzymes for statin baseline context

›Coagulation and pregnancy

›INR and aPTT for anticoagulation baseline

›Warfarin effect recognition

›Beta-hCG in pregnancy potential

›Medication and imaging modifications

Secondary prevention labs

›Risk modification labs

›Lipid panel

›Non-fasting acceptable for early statin initiation

›HbA1c

›Undiagnosed diabetes detection

06Diagnostic Tests/dt60

Scoring Systems

›Risk stratification tools

›HEART score

›History element

›ECG element

›Age element

›Risk factors element

›Troponin element

›TIMI risk score for UA/NSTEMI

›Age 65 years or older

›At least 3 CAD risk factors

›Known CAD with stenosis 50% or greater

›Aspirin use in prior 7 days

›Severe angina episodes within 24 hours

›ST deviation 0.5 mm or greater

›Positive cardiac biomarker

›GRACE risk score

›Age

›Heart rate

›Systolic blood pressure

›Creatinine

›Killip class

›Cardiac arrest at presentation

›ST deviation

›Troponin elevation

›Application thresholds

›Low risk chest pain pathways

›Low-risk score plus negative serial troponins plus non-ischemic ECG

›High-risk invasive strategy triggers

›GRACE > 140 for early invasive approach

›Recurrent ischemia or instability for immediate invasive approach

MRI

›Cardiac MRI roles

›Myocarditis confirmation

›Non-ischemic late gadolinium enhancement patterns

›Edema sequences support

›MINOCA evaluation

›Infarct pattern without obstructive coronary disease

›Contraindications and limitations

›Unstable patient not suitable

›Non-MRI compatible device or metal fragments

›CT use cases in ACS presentations

›CT aorta for dissection concern

›Prioritization before anticoagulation when suspicion high

›CT pulmonary angiography for PE concern

›Pleuritic pain with hypoxemia and VTE risk

›Coronary CT angiography for low-intermediate risk chest pain

›Consideration when serial troponins negative and ECG non-ischemic

›Contrast risk mitigation

›eGFR-based risk assessment

›Hydration strategy when appropriate

Ultrasound (or US)

›POCUS applications

›Cardiac POCUS

›LV systolic function estimate

›Regional wall motion abnormality support in expert hands

›Pericardial effusion and tamponade physiology

›Lung ultrasound

›B-lines for pulmonary edema

›Pleural sliding for pneumothorax exclusion support

›IVC assessment

›Volume status adjunct

›Limitation in ventilated patients

07Disposition/dispo31

Level of care and pathways

›Admission framework

›ICU indications

›Hemodynamic instability

›Refractory ischemia

›Malignant arrhythmia

›Acute pulmonary edema requiring noninvasive ventilation

›Stepdown or telemetry indications

›NSTEMI with stable vitals

›Ongoing troponin trend monitoring

›Early invasive strategy timeline

›Immediate invasive for very high risk

›Early invasive within 24 hours for high risk

›Delayed invasive within 72 hours for intermediate risk

›Discharge pathway for low-risk chest pain

›Eligibility elements

›Non-ischemic ECG

›Negative serial troponins per local algorithm

›Low risk score

›Follow-up timing

›Outpatient stress testing or cardiology within 72 hours to 1 week if indicated

›Primary care risk factor management within 1-2 weeks

Consultation and transfer

›Cardiology involvement

›NSTEMI diagnosis

›Antithrombotic plan alignment with angiography strategy

›Suspected mechanical complications

›Urgent echocardiography and surgical capability

›Transfer criteria

›No PCI capability with high-risk NSTEMI needing early angiography

›Transfer within 24 hours when feasible

›Ongoing instability

›Immediate transfer with critical care transport

08Treatment/t137

Antiplatelet therapy

›Platelet inhibition

›Aspirin

›Initial dosing

›160-325 mg chewed once

›If true allergy, consider P2Y12 monotherapy and allergy evaluation

›Maintenance

›75-100 mg daily

›P2Y12 inhibitor selection

›Ticagrelor

›Loading

›180 mg once

›Maintenance

›90 mg twice daily

›Key cautions

›Dyspnea common

›Avoid strong CYP3A inhibitors and inducers

›Clopidogrel

›Loading

›600 mg once for PCI strategy

›300 mg once for conservative strategy if chosen locally

›Maintenance

›75 mg daily

›Key cautions

›Reduced effect with some CYP2C19 variants

›Prasugrel

›Contraindications

›Prior stroke or TIA

›Age 75 years or older generally avoid

›Weight under 60 kg dose adjustment

›Loading

›60 mg once

›Maintenance

›10 mg daily

›5 mg daily if under 60 kg

›Dual antiplatelet duration

›Class I recommendation for DAPT up to 12 months after NSTEMI if bleeding risk acceptable

›Shorter duration consideration if high bleeding risk

Anticoagulation

›Parenteral anticoagulation for NSTEMI

›Unfractionated heparin

›Bolus

›60 units/kg IV

›Maximum 4000 units

›Infusion

›12 units/kg/hour IV

›Maximum 1000 units/hour initial

›Monitoring

›Titrate to aPTT per local anti-Xa or aPTT protocol

›Enoxaparin

›Standard dosing

›1 mg/kg SC every 12 hours

›Renal adjustment

›If eGFR < 30 mL/min, 1 mg/kg SC every 24 hours

›Age consideration

›If age 75 years or older and fibrinolysis context, different dosing

›Fondaparinux

›Dosing

›2.5 mg SC daily

›PCI caveat

›If PCI performed, add UFH in cath lab to prevent catheter thrombosis

›Renal contraindication

›Avoid if eGFR < 30 mL/min

›Bivalirudin

›PCI-focused option

›Dosing per cath lab protocol

›Bleeding reduction compared with heparin plus GP IIb/IIIa in selected patients

›Contraindications screen before anticoagulation

›Active major bleeding

›Suspected aortic dissection

›Recent intracranial hemorrhage

Anti-ischemic and supportive care

›Nitrates

›Sublingual nitroglycerin

›0.4 mg SL every 5 minutes

›Maximum 3 doses

›IV nitroglycerin for ongoing ischemia or pulmonary edema

›Initiate 5-10 mcg/min

›Titrate 5-10 mcg/min every 3-5 minutes

›Usual maximum 200 mcg/min

›Contraindications

›PDE5 inhibitor use within 24-48 hours

›RV infarct suspicion

›Hypotension

›Beta-blockade

›Early oral beta-blocker if no contraindications

›Metoprolol tartrate

›25-50 mg PO every 6-12 hours

›Transition to daily extended-release when stable

›IV beta-blocker for severe hypertension and ischemia in selected patients

›Metoprolol IV

›5 mg IV every 5 minutes

›Maximum 15 mg

›Contraindications

›Acute decompensated heart failure

›Cardiogenic shock risk

›Severe asthma with active bronchospasm

›High-grade AV block without pacing

›Analgesia

›Fentanyl for severe pain refractory to nitrates

›25-50 mcg IV every 5-10 minutes as needed

›Respiratory monitoring

›Morphine caution

›Potential association with worse outcomes in observational data

›Consider only for refractory pain and anxiety

›Oxygen

›Avoid routine oxygen if SpO2 90% or greater

›Hyperoxia vasoconstriction concern

›Statin

›High-intensity statin early

›Atorvastatin

›80 mg PO daily

›Rosuvastatin

›20-40 mg PO daily

Reperfusion and invasive strategy adjuncts

›Early invasive strategy

›Indications

›Recurrent ischemia

›Dynamic ECG changes

›Troponin rise with high-risk features

›Reduced LVEF or heart failure

›Coronary angiography timing

›Immediate for refractory ischemia or instability

›Within 24 hours for high-risk NSTEMI

›GP IIb/IIIa inhibitors

›Cath lab selective use

›Large thrombus burden

›No-reflow phenomenon

›Bleeding risk

›Avoid routine upstream use in many contemporary strategies

Secondary prevention initiation in hospital

›Neurohormonal therapy

›ACE inhibitor or ARB for LVEF 40% or lower, diabetes, or hypertension

›Class I recommendation if no contraindications

›Aldosterone antagonist for LVEF 40% or lower plus HF or diabetes after ACEi and beta-blocker

›Potassium and renal function prerequisites

›Lifestyle and risk

›Smoking cessation pharmacotherapy

›Nicotine replacement

›Varenicline consideration

›Cardiac rehabilitation referral

›Class I recommendation

09Special Populations/sp35

Pregnancy

›Pregnancy-specific considerations

›Diagnostic approach

›Troponin interpretation similar to nonpregnant

›ECG interpretation unchanged

›Medication safety

›Aspirin acceptable when indicated

›UFH preferred anticoagulant

›Enoxaparin acceptable with obstetric alignment

›Avoid ACE inhibitors and ARBs

›Avoid statins

›Multidisciplinary care

›Cardiology and obstetrics co-management

›Delivery planning if late gestation and high-risk ACS

Geriatric

›Older adult considerations

›Presentation differences

›Dyspnea predominant symptoms

›Delayed presentation

›Bleeding and frailty

›High bleeding risk scores

›Dose adjustments for renal impairment

›Antiplatelet selection

›Prasugrel avoidance in many patients age 75 years or older

›DAPT duration individualization for bleeding risk

›Goals of care

›Baseline function and patient priorities in invasive strategy decision

Pediatrics

›Pediatric considerations

›Rarity of atherosclerotic NSTEMI

›Congenital coronary anomalies

›Kawasaki disease sequelae

›Myocarditis more common than ACS

›Workup focus

›Echocardiography early

›Troponin for myocarditis and injury patterns

›Specialty involvement

›Pediatric cardiology early

10Background/b34

Epidemiology

›Population patterns

›NSTEMI more common than STEMI in many contemporary registries

›Older age distribution than STEMI

›Higher comorbidity burden

›Outcomes

›Significant short-term and long-term mortality risk without guideline-directed therapy

›Recurrent MI risk highest in first weeks after event

›Sex differences

›Higher atypical symptom frequency in women

›Under-recognition risk

Pathophysiology

›Mechanisms of NSTEMI

›Subtotal coronary occlusion

›Non-transmural ischemia pattern

›Plaque rupture or erosion

›Platelet-rich thrombus

›Demand ischemia and supply mismatch

›Tachyarrhythmia

›Hypotension

›Hypoxemia

›Severe anemia

›Microvascular dysfunction

›MINOCA spectrum

Therapeutic Considerations

›Treatment rationale

›Antiplatelet therapy reduces thrombotic propagation

›Aspirin Class I recommendation

›P2Y12 inhibitor as part of DAPT Class I recommendation in many patients

›Anticoagulation reduces ongoing thrombin generation

›Parenteral anticoagulation during hospitalization Class I recommendation

›Early invasive strategy reduces recurrent ischemia in high-risk NSTEMI

›GRACE-guided selection improves net benefit

›High-intensity statin stabilizes plaque and reduces recurrent events

›Early initiation Class I recommendation

›Oxygen avoidance when not hypoxemic

›Hyperoxia vasoconstriction and increased oxidative stress concern

11Patient Discharge Instructions/pdi23

copy discharge instructions

›NSTEMI discharge instructions

›Medications

›Take aspirin exactly as prescribed

›Take P2Y12 inhibitor exactly as prescribed

›Do not stop antiplatelets without cardiology advice

›Activity

›Gradual return to activity per cardiac rehab plan

›Avoid heavy exertion until cleared

›Follow-up

›Cardiology follow-up within 7 days or as directed

›Cardiac rehabilitation enrollment

›Risk reduction

›No tobacco or vaping

›Heart-healthy diet

›Diabetes and blood pressure control plan

›Return immediately to ED for

›Chest pain at rest

›Chest pain lasting more than 10 minutes

›Shortness of breath at rest

›Syncope or near-syncope

›New weakness, trouble speaking, or facial droop

›Black stools or vomiting blood

›Severe headache or new neurologic symptoms while on blood thinners

12References/r19

Clinical guidelines and evidence sources

›Core guideline sources

›ACC/AHA guideline for management of patients with acute coronary syndromes

›Class I recommendations for aspirin and anticoagulation in NSTEMI

›Risk-guided early invasive strategy recommendations

›ESC guidelines for non-ST-elevation acute coronary syndromes

›GRACE-guided invasive strategy timing

›Antithrombotic therapy recommendations

›Emergency medicine chest pain pathways

›ACEP clinical policy for evaluation and management of adult patients with suspected acute non-ST-elevation ACS

›Use of validated accelerated diagnostic pathways

›Shared decision-making for low-risk discharge

›Landmark trial and registry concepts

›DAPT trials supporting P2Y12 inhibitor use after ACS

›Ticagrelor and prasugrel efficacy versus clopidogrel in ACS populations

›Anticoagulation trials in UA/NSTEMI

›UFH and LMWH outcome and bleeding tradeoffs

›Risk score validation studies

›HEART score outcomes for low-risk chest pain

›GRACE risk prediction for mortality in ACS

Learn More: Acute coronary syndrome (NSTEMI)→

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.