Spectrum of unstable angina, NSTEMI and STEMI from acute coronary plaque rupture or erosion.
Causes
- • Atherosclerotic plaque rupture
- • Coronary spasm
- • Embolism
- • Spontaneous dissection
Risk factors
- • Age, male, FHx
- • Smoking
- • Hypertension
- • Diabetes
- • Dyslipidaemia
- • Obesity
- • CKD
Clinical features
- • Central crushing chest pain >20 min
- • Radiation to arm/jaw
- • Diaphoresis, nausea
- • Dyspnoea (esp diabetics, elderly)
Examination
- • Pallor, sweating, anxious
- • S4 / new murmur
- • Pulmonary crackles if LV failure
- • Cool peripheries if shock
Investigations
- • 12-lead ECG within 10 min
- • High-sensitivity troponin 0 + 3 h
- • CXR, glucose, U&E, lipids
- • Echo for wall motion / EF
Diagnosis
- • STEMI: ST elevation or new LBBB + symptoms
- • NSTEMI: troponin rise + symptoms / ECG changes
- • UA: symptoms ± ECG changes, no troponin rise
Management
- • MONA-B: morphine, O₂ if SpO₂ <94, nitrate, aspirin 300, β-blocker if no CI
- • DAPT (ticagrelor/clopidogrel)
- • Anticoagulation (fondaparinux/LMWH)
- • STEMI: PPCI <90 min or fibrinolysis ≤12 h
- • NSTEMI: invasive angiography 24–72 h (risk-based)
- • Statin, ACEi, β-blocker on discharge
Complications
- • Arrhythmia (VF, AV block)
- • Cardiogenic shock
- • Mechanical: VSD, papillary muscle rupture
- • Pericarditis (Dressler)
Prevention
- • Lifestyle: smoking cessation, exercise, diet
- • BP, lipid, glucose control
- • Antiplatelet + statin in established disease
Follow-up
- • Cardiac rehab
- • 12-lead, lipids, HbA1c at 6 weeks
- • Echo at 6 weeks if LV impairment
Clinical pearls
- • Atypical presentation in elderly, diabetics, women
- • Posterior MI: tall R + ST↓ V1–V3 → reciprocal V7–V9
- • Right-sided leads for inferior MI (V4R)
References
- • ESC ACS 2023
- • AHA/ACC 2025
Related in WardRound
Educational — verify locally.
