Non-ST-elevation myocardial infarction

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Last reviewed: 23 Jun 2024
Last updated: 14 May 2024

Summary

Definition

History and exam

Key diagnostic factors

  • chest pain
  • risk factors for cardiovascular disease
  • marked sweating
  • cardiogenic shock
  • acute heart failure
Full details

Other diagnostic factors

  • nausea and vomiting
  • arrhythmias
  • heart murmur
  • epigastric pain
  • dyspnoea
  • syncope
  • back pain
Full details

Risk factors

  • smoking
  • hypertension
  • diabetes
  • obesity and metabolic syndrome phenotype
  • sedentary behaviour and physical inactivity
  • dyslipidaemia
  • chronic kidney disease
  • atherosclerosis (history of angina, myocardial infarction, stroke, transient ischaemic attack, peripheral vascular disease)
  • family history of premature coronary artery disease
  • age >60 years
  • cocaine use
  • depression
  • stent thrombosis or restenosis
  • sleep apnoea
  • surgical procedures (including intra-operative and postoperative periods)
Full details

Diagnostic investigations

1st investigations to order

  • ECG
  • high-sensitivity troponin
  • chest x-ray
  • full blood count
  • urea, electrolytes, and creatinine
  • liver function tests
  • blood glucose
  • C-reactive protein
Full details

Investigations to consider

  • echocardiography
  • invasive coronary angiography (ICA)
Full details

Treatment algorithm

ACUTE

very high-risk or high-risk features (suspected or confirmed NSTEMI)

no high-risk features (suspected or confirmed NSTEMI)

ONGOING

post-NSTEMI

Contributors

Expert advisers

Shrilla Banerjee, MD, FRCP

Consultant Interventional Cardiologist

East Surrey Hospital

Surrey and Sussex Healthcare NHS Trust

UK

Disclosures

SB has received speaker fees for educational lectures (presentation content was her own) and meeting participation from Menarini, Edwards Lifesciences, Abbott Vascular, and Shockwave IVL. She has also participated in an Advisory Board for Sahajanand Medical Technologies Limited. SB has received travel sponsorship from Biosensors International to attend the PCR meeting in Paris in 2022. She has prepared a manuscript on coronary microvascular dysfunction for Abbott for Cardiovascular News (no royalties).

Adam Hartley, MBBS, BSc, MRCP

Wellcome Trust Clinical Research Fellow

Imperial College London

Specialist Registrar in Cardiology

Imperial College Healthcare NHS Trust

London

UK

Disclosures

AH declares that he has no competing interests.

Acknowledgements

BMJ Best Practice would like to gratefully acknowledge the previous expert contributors, whose work has been retained in parts of the content:

Resham Baruah MBBS, BSc MRCP, PhD

Consultant Cardiologist

Chelsea and Westminster Hospital NHS Foundation Trust

Royal Brompton & Harefield NHS Foundation Trust

London

UK

Cody S Deen, MD

Assistant Professor of Medicine

Director of Cardiology

Hillsborough Hospital

University of North Carolina

Hillsborough

NC

Disclosures

RB has received honoraria/speakers’ fees from Novartis and Boehringer Ingelheim. CSD was previously the Director of Cardiac Rehab for Chatham Hospital, which was financially set up as a consultancy relationship, until 2017. CSD has spoken (unpaid) at the Update in Cardiology and Update in Internal Medicine Conferences at UNC for the last 5 years. CSD has served as the PI for the Dal-GeneE (site now closed) and the ACCELERATE Trials at the University of North Carolina (trial now completed). Each trial required paid travel to an investigator meeting.

Peer reviewers

Gavin Galasko, BM, BCh, MA, DM (Oxon), FRCP

Consultant Interventional Cardiologist

Director of Research, Development and Innovation

Blackpool Teaching Hospitals NHS Foundation Trust

Blackpool

UK

Disclosures

GG declares that he has no competing interests.

Editors

Annabel Sidwell

Section Editor, BMJ Best Practice

Disclosures

AS declares that she has no competing interests.

Susan Mayor

Lead Section Editor, BMJ Best Practice

Disclosures

SM works as a freelance medical journalist and editor, video editorial director and presenter, and communications trainer. In this capacity, she has been paid, and continues to be paid, by a wide range of organisations for providing these skills on a professional basis. These include: NHS organisations, including the National Institute for Health and Care Excellence, NHS Choices, NHS Kidney Care, and others; publishers and medical education companies, including the BMJ Group, the Lancet group, Medscape, and others; professional organisations, including the British Thoracic Oncology Group, the European Society for Medical Oncology, the National Confidential Enquiry into Patient Outcome and Death, and others; charities and patients’ organisations, including the Roy Castle Lung Cancer Foundation and others; pharmaceutical companies, including Bayer, Boehringer Ingelheim, Novartis, and others; and communications agencies, including Publicis, Red Healthcare and others. She has no stock options or shares in any pharmaceutical or healthcare companies; however, she invests in a personal pension, which may invest in these types of companies. She is managing director of Susan Mayor Limited, the company name under which she provides medical writing and communications services.

Rachel Wheeler

Lead Section Editor, BMJ Best Practice

Disclosures

RW declares that she has no competing interests.

Julie Costello

Comorbidities Editor, BMJ Best Practice

Disclosures

JC declares that she has no competing interests.

Adam Mitchell

Drug Editor, BMJ Best Practice

Disclosures

AM declares that he has no competing interests.

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