In 2007, the American College of Cardiology/American Heart Association and the European Society of Cardiology updated their guidelines for the management of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Based on evidence from recent clinical studies, both 2007 guidelines recommend early risk stratification, administration of appropriate pharmacologic therapy, and selective use of percutaneous coronary intervention in order to reduce morbidity and mortality in these patients. In this article, we focus on management of patients with NSTEMI during the first 24 h of presentation and present a clinical scenario to illustrate the current guidelines-based management strategy.
Unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) form a continuum of acute ischemic heart disease resulting from subtotal occlusion of coronary arteries. The diagnosis of NSTEMI is established (most typically) by the triad of ischemic chest discomfort or other anginal equivalent symptoms, electrocardiographic changes of ST-segment depression and/or T-wave inversion, and most importantly, elevated markers of cardiac necrosis . Approximately 1.5 million cases of UA/NSTEMI occur in the United States per year . Among patients with high-risk non-ST-segment elevation acute coronary syndrome (NSTE ACS), approximately 12–15% will die or have a reinfarction within 30 days of the initial diagnosis . Evidence from clinical studies suggests that a management strategy based on early risk stratification, administration of appropriate pharmacologic therapy, and selective use of percutaneous coronary intervention (PCI) may reduce morbidity and mortality in these patients .
In this manuscript, we use the standard definitions for class of recommendation and level of evidence as described in the 2007 American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) guidelines for management of patients with NSTE ACS ( Table 1 ).