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NSTEMI — EECC MCQ

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ModerateCoronary Artery DiseaseNSTEMIEECC

A 55-year-old woman presents with a 3-hour history of crushing chest pain at rest. Her ECG shows 2 mm ST-segment depression in leads V3-V6 and T-wave inversion in I and aVL. Initial high-sensitivity cardiac troponin I is 85 ng/L (99th centile URL 16 ng/L) and at 1 hour is 210 ng/L. She has ongoing pain despite sublingual glyceryl trinitrate. Blood pressure is 145/90 mmHg, heart rate 95 bpm. She has no signs of heart failure. Using the ESC 0h/1h algorithm, what is the most appropriate next step?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Arrange immediate invasive coronary angiography (within 2 hours)

Explanation lettering: E = shown as A · D = shown as C · A = shown as D · C = shown as E

This patient has confirmed NSTEMI with ongoing ischaemic symptoms refractory to medical therapy, which constitutes a very high-risk feature. Per the 2023 ESC ACS Guidelines, immediate invasive strategy (within 2 hours) is recommended for patients with very high-risk features including recurrent or ongoing chest pain refractory to medical treatment. Option C (within 24 hours) would be appropriate for high-risk NSTE-ACS without very high-risk features. Discharge (A) is inappropriate. Further observation (B) is unnecessary as diagnosis is established. Routine GPIIb/IIIa therapy (E) is not recommended upstream in NSTE-ACS.

Reference: ESC (2023): Guidelines for the Management of Acute Coronary Syndromes