NSTEMI / Unstable Angina

NSTEMI is ACS with troponin rise but no persistent ST elevation. Risk stratify with GRACE score. High-risk (GRACE >140 or very-high-risk features) needs urgent angiography within 24 hours. Very high-risk (cardiogenic shock, refractory ischaemia)…

NSTEACS Risk Stratification

The pathway

1 · ECG & troponin

ECG at 0h — look for ST depression, T-wave changes, or new LBBB
hs-Troponin at 0h and 1–3h
Serial troponin rise confirms NSTEMI

2 · GRACE score

Calculate GRACE 2.0 score (age, HR, SBP, Cr, Killip class, troponin, ST deviation, cardiac arrest). >140 = high risk, <109 = low risk. Drives angiography timing.

3 · Dual antiplatelet therapy

Aspirin 300mg loading dose
Ticagrelor 180mg loading dose (preferred over clopidogrel)
Assess bleeding risk before prescribing P2Y12 inhibitor

4 · Anticoagulation

Fondaparinux 2.5mg SC OD (preferred in NSTEMI)
Or LMWH (enoxaparin 1mg/kg SC BD)
Continue until angiography

5 · Angiography timing

Very high-risk (cardiogenic shock, refractory ischaemia): within 2 hours
High-risk (GRACE >140, troponin rise, ST depression): within 24 hours
Intermediate: within 72 hours
Low risk: non-invasive testing first

6 · Secondary prevention

High-intensity statin (atorvastatin 80mg)
Beta-blocker
ACEi
Dual antiplatelet 12 months
Cardiac rehab
Driving advice (DVLA 1 week for NSTEMI)

Drugs

Drug	Dose	Route	Notes
Aspirin	300mg stat, then 75mg OD	PO	Loading dose immediately.
Ticagrelor	180mg stat, then 90mg BD	PO	Preferred P2Y12 inhibitor. Avoid if high bleeding risk.
Fondaparinux	2.5mg OD	SC	Preferred anticoagulant in NSTEMI. Avoid if CrCl <20ml/min.
Atorvastatin	80mg OD	PO	High-intensity statin. Start immediately.
GTN spray	400mcg	SL	Avoid if SBP <90 or on PDE5i. IV GTN for refractory ischaemia.

When to escalate

Cardiogenic shock — immediate angiography (<2h), ITU, vasopressors,Refractory ischaemia on medical therapy — immediate angiography,Haemodynamic instability — HDU/ITU,Post-NSTEMI pericarditis (Dressler's) — NSAIDs + colchicine

Reference: ESC NSTEACS Guidelines 2023 / NICE NG185

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