Non-ST Elevation MI
NSTEMI (Non ST elevation myocardial infarction) is a myocardial infarction that does not have ST elevation on the ECG.
Most NSTEMIs will show ischaemic changes on the ECG such as ST depression and/or inverted T waves, however, some will show unremarkable ECGs.
IF YOUR PATIENT HAS ST DEPRESSION IN THE ANTERIOR LEADS:
CHECK THE POSTERIOR V7, V8, V9 BEFORE QUERYING NSTEMI.
SUSPECT NSTEMI IF:
The patient has ST depression of more than 1mm in at least two ECG leads and/or T wave inversion
AND
On-going ischaemic chest pain on presentation of less than 12 hours duration. The patient must also appear unwell i.e. they have cardiac symptoms.
Management is dependent on trust policy:
Pre-alert closest A+E stating ‘?NSTEMI’ or
Pre-alert closest heart attack centre stating ‘?High Risk ACS.’
NOTE: IF THE PAIN SUBSIDES AFTER GTN/ANALGESIA THEN YOU CAN STILL SUSPECT NSTEMI.
STEMI with Atypical Presentation
Patients who have ST elevation that meets criteria for PCI but they do not have chest pain, transmit the ECG to PCI or convey to the heart attack centre if they have any of the following symptoms:
Ache/pain/heaviness in either arm and/or either shoulder
Ache/pain in jaw and/or neck
Sweaty/Clammy
Fatigue and/or weakness and/or dizziness
Breathlessness (if this is unusual for the patient)
If the patient does not have classic cardiac chest pain, be suspicious of MI in unwell diabetics, the unwell elderly and unwell female patients.
IT IS IMPORTANT TO LOOK AT THE PATIENT, NOT THE ECG. CONSIDER THE CLINICAL PRESENTATION, SIGNS AND SYMPTOMS, THE HISTORY, AND THEN THE ECG.
There is always assistance available by calling clinical supervisors in control who can help you ascertain the best management plan for these patients.