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High-Risk NSTEMI — RACP Adult Medicine MCQ

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ModerateCardiologyHigh-Risk NSTEMIRACP Adult Medicine

A 60-year-old woman presents with 6 hours of chest pain. ECG shows ST depression in V3-V6 and T-wave inversion in I and aVL. Troponin at 0 hours is 45 ng/L, 3-hour troponin is 380 ng/L (significant rise). She has ongoing chest pain. GRACE score is 145 (high risk). What is the most appropriate management?

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Correct answer: E — Medical management with anticoagulation

NSTEMI (troponin rise/fall with ischaemic symptoms/ECG changes without ST elevation) with high GRACE score (>140) and ongoing pain is high-risk NSTEMI warranting early invasive strategy (coronary angiography ± PCI within 24 hours). Medical management includes: DAPT (aspirin + ticagrelor/prasugrel), anticoagulation (fondaparinux preferred unless invasive within 24h — then UFH), beta-blocker, statin, GTN. Thrombolysis is CONTRAINDICATED in NSTEMI.

Reference: CSANZ – 2025 – ACS; ESC 2023 NSTEMI