Non Stemi Criteria

[7887firemedic]

Did a search without much luck.
What criteria do you use to determine a non stemi specifically? Whats the hallmark to look for?

St depressions, t wave inversions, hyperacute t waves, pathological q waves etc????

 

[Christopher]

Did a search without much luck.
What criteria do you use to determine a non stemi specifically? Whats the hallmark to look for?

St depressions, t wave inversions, hyperacute t waves, pathological q waves etc????

It depends, a lot of so called "NSTEMI" cases are actually true STEMI's that don't meet arbitrary criteria. Before covering NSTEMI, it is worth bringing up that most providers have unnecessarily narrow criteria for what is a STEMI!

I defer to Dr. Ivan Rokos' 2010 paper defining reasonable STEMI and STEMI-equivalents:

• Classic STEMI (Anterior, Inferior, Lateral)
• Pre-existing LBBB with Sgarbossa Concordance
• Isolated Posterior MI
• LMCA
• de Winter ST/T-wave Complexes

Once you have an appropriate definition for STEMI, which is far more important for prehospital providers, we can work on a good NSTEMI definition. We'll borrow from the Universal Definition of Myocardial Infarction (bold added by me):

Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit (URL) together with evidence of myocardial ischaemia with at least one of the following:

• Symptoms of ischaemia;
• ECG changes indicative of new ischaemia, but without STEMI or STEMI-equivalent present;
• Development of pathological Q waves in the ECG;
• Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.

 

[JPINFV]

Did a search without much luck.
What criteria do you use to determine a non stemi specifically? Whats the hallmark to look for?

St depressions, t wave inversions, hyperacute t waves, pathological q waves etc????

EKG + trops/CK q8 hours x 3.
Stress test.

 

[18G]

A question I have regarding NSTEMI is what criteria is used to determine which patient's get heparin and Integrilin and which ones don't? I transport many NSTEMI patients and some are on a heparin drip w/ Integrilin and some not.

 

[Christopher]

A question I have regarding NSTEMI is what criteria is used to determine which patient's get heparin and Integrilin and which ones don't? I transport many NSTEMI patients and some are on a heparin drip w/ Integrilin and some not.

From Modern Management of Acute Myocardial Infarction (NSTEACS, Non-ST-Segment Elevation Acute Coronary Syndrome, is UA+NSTEMI):

In light of this complex body of literature, Gp IIb/IIIa inhibition continues to be part of the recommended treatment strategy for many patients with NSTEACS. Use should be individualized based on level of risk for adverse outcomes and planned treatment strategy. Patients selected for an early invasive strategy should receive aspirin and an additional antiplatelet agent at the time of diagnosis. Guidelines allow for either clopidogrel or a Gp IIb/IIIa inhibitor, with eptifibatide or tirofiban being preferred if a Gp IIb/IIIa inhibitor is chosen.

 

[18G]

If I'm reading that right.... if an NSTEMI patient receives ASA and Plavix that is acceptable and as effective as Heparin and Integrilin? Heparin isn't an anti-platelet agent and isn't mentioned in that snippet.

 

[Christopher]

If I'm reading that right.... if an NSTEMI patient receives ASA and Plavix that is acceptable and as effective as Heparin and Integrilin? Heparin isn't an anti-platelet agent and isn't mentioned in that snippet.

Correct, as a whole the paper is somewhat equivocal on the literature support for Heparin usage in UA+NSTEMI:

There are no randomized trials of UFH in combination with modern medical therapies for NSTEACS. Aggregate results of early trials, however, did demonstrate a reduced composite rate of short-term death or MI when UFH was used with aspirin...

...Although statistical advantage was lost, enoxaparin also compared well with UFH in the setting of Gp IIb/IIIa inhibition, which was employed in all patients in the A to Z trial...

Regardless, they close the section out on Heparin and UA+NSTEMI:

Both UFH and enoxaparin are therefore considered suitable anticoagulant agents as part of an early invasive or conservative strategy in the treatment of NSTEACS and should be started as soon as possible after diagnosis.

 

[18G]

Thanks for posting the info. Appreciate it!

 

[Smash]

Some interesting reading here about heparin. There is also stuff about other treatment for ACS. And I can't get on board with NSTEACS I'm afraid. It's NSTEMI to me.

 

[Melclin]

Correct, as a whole the paper is somewhat equivocal on the literature support for Heparin usage in UA+NSTEMI:

Regardless, they close the section out on Heparin and UA+NSTEMI:

Thats because the literature on its use is equivocal. Worse than that, it straight up doesn't support its use in my obviously useless opinion.

 

[KellyBracket]

I love talking about the evidence for heparin in UA/ACS!

Anyway, there has been some recent chatter about this very topic. It was recently declared by the lead author of the Third Universal MI Definition (free PDF!) that "If high-sensitivity troponins are completely neutral in a patient with chest pain, it’s impossible that the patient has significant coronary disease."

You can see the press release here.

On the other hand, the aforementioned new guidelines also state that "Patients without elevated biomarker values can be diagnosed as having unstable angina." Ah. That clears it up.

Some more discussion of this topic can be found at MDAware. Good stuff.