Internal Diseases and Therapy · MU Sofia

27. Acute coronary artery syndromes without ST segment – elevation: unstable angina

Explains non-ST-elevation acute coronary syndromes, separating unstable angina from NSTEMI by troponin, and sets out the Braunwald classification table alongside the clinical forms and causes such as non-occlusive thrombus, spasm and MINOCA. It then covers ECG findings including the Wellens pattern, the high-sensitivity troponin 0 h/1 h algorithm, GRACE and TIMI risk scores, timing of angiography, antithrombotic drug doses and dual antiplatelet duration, and prognosis.

Inside: 8 sections · 2 labelled pictures · 4 tables · 15 flashcards · 12 min

Topic 27 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 8 sections, about 1,388 words (12 min of reading), with 15 flashcards.

In this note

  1. Definition
  2. Etiology and pathogenesis
  3. Classification
  4. Clinical features
  5. Diagnosis
  6. Risk stratification
  7. Treatment
  8. Complications and prognosis

Definition

  • Non-ST-elevation acute coronary syndrome (NSTE-ACS): an acute coronary syndrome (ACS) without persistent ST elevation on the electrocardiogram (ECG). It includes two conditions, told apart by troponin (European Society of Cardiology, ESC 2023 ACS guideline):
  • Non-ST-elevation myocardial infarction (NSTEMI): acute ischaemia with a rise and/or fall of cardiac troponin above the 99th percentile (a myocardial infarction (MI) by the Fourth Universal Definition, topic 26); necrosis is usually subendocardial.
  • Unstable angina (UA): ischaemia at rest or on minimal effort without myocyte necrosis (troponin not raised). With high-sensitivity troponin assays it has become less common and carries a lower risk.

Image: “ACS scheme” by User:Stevenfruitsmaak, CC BY-SA 3.0, via Wikimedia Commons.

  • Clinical forms of UA: rest angina (usually over 20 minutes); new-onset angina of Canadian Cardiovascular Society (CCS) class II–III; crescendo angina (previously stable angina becoming more frequent, longer or provoked by less effort, by at least one CCS class to class III); post-infarction angina.
  • NSTE-ACS is more frequent than ST-elevation MI (STEMI); patients are older with more comorbidity (diabetes, chronic kidney disease (CKD), previous MI).

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