NON-STEMI

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DEFINITION
See acute coronary syndromes.

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MANAGEMENT
Initial Management
Refer ACS.

Post-Stratification Management
Heparin LMW (weak evidence).
With aspirin for three days at least.
- need physician.
- ideally GP IIb IIIa inhibitors (PRISM, PRISM PLUS trials).
- nitrates when in pain

Evidence
These pts have 50% chance of an MI in 3 mo.
Aspirin alone -> 50% RRR (costs half a cent).
Heparin -> further 50% RRR (costs about $20).
GP IIb IIIa -> further 15-20% RRR (costs $900).
Hence the latter is too expensive for most practice.

Further Management
Early revascularisation (FRISC II).
Treadmill test +/- angiogram +/- revascularisation.

Secondary Prevention
Beta-blocker
Metoprolol is agent of choice.
20% reduction in sudden death (VF and cardiac rupture).
Also decreases myocardial O2 demand and decreased BP)
ACEi
(HOPE Trial).
Independent vessel protection and prevents remodelling.
Aspirin
Low dose.
Statin
Target <4.00 (AVERT trial).
Low 3s is ideal.
RRR 28% of death over 5 yrs (4S trial).
Blood Pressure
If needed further to the above agents.
Want target of 125/85 (be vigorous - WHOISH recommendations).
Benefit down to 120/80.
Beware J-shaped curve of increasing mortality below this.
NB - Thiazides are losing favour as they leach K+, and have no independent advantage, unlike ACEi, Beta-blockers.
Diet
Accounts 10-15% of cholesterol levels.
Increase fruit and vegetable intake - NHF recommends 7+ a day in those with cardiac disease.
Antioxidants (anthracidins in grapes, strawberries, cruesetin in tomatoes).
Vegetables bind to fat in the gut decreasing absorption.
Decrease saturated fats.
Exercise
30-40 minutes 3-4 times per week - bare minimum.
Slight further benefit 1 hr.
Excessive exercise beyond this, especially vigorous sports should be avoided because of the risk of intimal tears.
Sex ok if pt can get heart rate above 115bpm/ walk 20mins and then swiftly climb a decent flight of stairs.
Other
Modify other risk factors.
Eg don't smoke or you're a death waiting to happen.

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