Non-ST-elevation myocardial infarction

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Última revisão das evidências: 12 Feb 2026

Última atualização do tópico: 23 Dec 2025

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.

Definição

NSTEMI is an acute ischemic event causing irreversible necrosis of heart muscle.[1] The initial ECG may show ischemic changes such as ST depressions, T-wave inversions, or transient ST elevations; however, it may also be normal or show nonspecific changes. If persistent ST elevation, evidence of posterior myocardial infarction, or a new left bundle-branch block is present, then the patient should be evaluated as an ST-elevation myocardial infarction. NSTEMI, therefore, encompasses a broad spectrum of ischemic injury to the myocardium, which is detected by elevation of troponin.[2] It can be distinguished from unstable angina pectoris, a condition in which troponin is not elevated.

História e exame físico

Principais fatores diagnósticos

chest pain
diaphoresis
cardiogenic shock
acute heart failure

Detalhes completos

Outros fatores diagnósticos

nausea and vomiting
epigastric pain
arrhythmias
abnormal heart sounds
shortness of breath
syncope
early morning onset

Detalhes completos

Fatores de risco

smoking
hypertension
diabetes
obesity and metabolic syndrome phenotype
sedentary behavior and physical inactivity
dyslipidemia
chronic kidney disease (CKD)
atherosclerosis (history of angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease)
family history of premature coronary artery disease (CAD)
age >60 years
cocaine use
depression
stent thrombosis or restenosis
sleep apnea
surgical procedures (including intraoperative and postoperative periods)
migraine
adverse pregnancy outcomes
anticholinergic burden

Detalhes completos

Investigações diagnósticas

Primeiras investigações a serem solicitadas

ECG
cardiac biomarkers
echocardiography
CXR
CBC
BUN and serum creatinine
electrolytes
LFTs
blood glucose
CRP

Detalhes completos

Tests to avoid

coronary artery calcium (CAC)

Detalhes completos

Investigações a serem consideradas

angiography/cardiac catheterization
lipids
brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
stress testing
coronary CT angiography (CCTA)

Detalhes completos

Algoritmo de tratamento

AGUDA

acute presentation

CONTÍNUA

post-stabilization

Colaboradores

Consultores especialistas

Mahi L. Ashwath, MD, MBA, FACC, FASE, FSCMR

Professor of Medicine and Radiology

Multimodality Imaging Director

Inaugural Reuben Jacobs Chair in Internal Medicine

UHS/UT Heart and Vascular Institute

San Antonio

Declarações

MLA declares that she is a consultant for Tersera.

Agradecimentos

Dr Mahi L. Ashwath would like to gratefully acknowledge Dr Sanjay Gandhi, Dr Cody Deen, Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic.

Declarações

SG declares that he is Senior Director of Medical Strategy and Innovation for the US market at Philips. SG is a senior advisor at Emeritus. SG is a voluntary board member of the American College of Cardiology (ACC) National Cardiovascular Data Registry oversight committee, the Chest Pain Myocardial Infarction registry steering committee, and the ACC finance committee. 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. SB, MO, TV, and DK declare that they have no competing interests.

Revisores

Syed Wamique Yusuf, MBBS, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center

Houston

Declarações

SWY declares that he has no competing interests.

Créditos aos pareceristas

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Declarações

As afiliações e declarações dos pareceristas referem--se ao momento da revisão.

Referências

Nossas equipes internas de editoria e de evidências trabalham em conjunto com colaboradores internacionais especializados e pares revisores para garantir que forneçamos acesso às informações o mais clinicamente relevantes possível.

Principais artigos

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo

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.Texto completo Resumo

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.Texto completo Resumo

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.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais
- ST-elevation myocardial infarction (STEMI)
- Unstable angina
- Aortic dissection
Mais Diagnósticos diferenciais
Diretrizes
- 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
- 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes
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Calculadoras
ASCVD Risk Estimator Plus
ASCVD Risk Estimator Plus
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Non-ST-elevation myocardial infarction

Resumo

Definição

História e exame físico

Principais fatores diagnósticos

Outros fatores diagnósticos

Fatores de risco

Investigações diagnósticas

Primeiras investigações a serem solicitadas

Tests to avoid

Investigações a serem consideradas

Algoritmo de tratamento

acute presentation

post-stabilization

Colaboradores

Consultores especialistas

Mahi L. Ashwath, MD, MBA, FACC, FASE, FSCMR

Declarações

Agradecimentos

Declarações

Revisores

Syed Wamique Yusuf, MBBS, FRCPI

Declarações

Créditos aos pareceristas

Declarações

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Diagnósticos diferenciais

Diretrizes

Calculadoras

Folhetos informativos para os pacientes

Conectar-se ou assinar para acessar todo o BMJ Best Practice

Conectar-se ou assinar para acessar todo o BMJ Best Practice

Conectar-se para acessar todo o BMJ Best Practice