Non ST-elevation myocardial infarction - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

Non-ST-elevation myocardial infarction (NSTEMI) is part of the acute coronary syndrome (ACS) spectrum.
Symptoms are indistinguishable from those of unstable angina. Most patients present with chest pain. However, NSTEMI is differentiated from unstable angina by a rise in level of cardiac troponin above the 99th percentile. A patient with NSTEMI may also be clinically unstable (e.g., low blood pressure, shock, left ventricular failure) which is not a feature of unstable angina.
ECG is the first-line investigation in all patients and should not be delayed for history, exam, or other tests.
Risk assessment soon after presentation is used to guide diagnostic and therapeutic decision making in patients presenting with ACS, including decisions about timing of invasive coronary angiography and subsequent management.
Complications are progression or worsening of myocardial infarction, heart failure, cardiogenic shock, arrhythmias, and death.

From the personal collection of Dr Syed W. Yusuf and Dr Iyad N. Daher, Department of Cardiology, University of Texas, Houston; used with permission

Quick Reference

History & Exam
- Key Factors
- Other Factors
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Diagnostics Tests
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Treatment Options
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Definition

Epidemiology

Etiology

Pathophysiology

Images

ECG showing ST depression
ECG showing ST depression
64-slice CT angiography (A) and conventional angiography (B) showing a high-grade lesion in the mid-right coronary artery, indicated by the arrows. The arrowheads show artifacts that may be mistaken for lesions
64-slice CT angiography of a patient with stable angina showing 3D reconstruction (A), curved reformatted images (B) and confirmation of a high-grade lesion on conventional angiography (C). The arrowheads show calcified plaques. Dx= diagnosis

Citations

Key Articles

Rao SV, O'Donoghue ML, Ruel M, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2025 Apr;151(13):e771-862.[Abstract][Full Text]
Thygesen K, Alpert JS, Jaffe AS, et al; Executive Group on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth universal definition of myocardial infarction (2018). J Am Coll Cardiol. 2018 Oct 30;72(18):2231-64.[Abstract][Full Text]
Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC guidelines for the management of acute coronary syndromes. Eur Heart J. 2023 Oct 12;44(38):3720-826.[Full Text]
Writing Committee Members; Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee On Clinical Practice Guidelines. J Am Coll Cardiol. 2021 Nov 30;78(22):e187-285.[Abstract][Full Text]
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-228.[Abstract][Full Text]
Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee On Clinical Practice Guidelines. Circulation. 2022 Jan 18;145(3):e18-114.[Abstract][Full Text]

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