Immediate Medical Treatment for Non-Specific ST Segment Elevation

Initial Assessment and Risk Stratification

The European Society of Cardiology recommends immediate coronary angiography with a view to revascularization for patients presenting with non-specific ST segment elevation and ongoing chest pain or ischemic symptoms, as these patients may have acute coronary occlusion that would otherwise be missed 1
Obtain a 12-lead ECG within 10 minutes of patient arrival and compare with prior ECGs if available, as recommended by the American Heart Association 2
Assess for high-risk features indicating immediate invasive strategy: ongoing chest pain, hemodynamic instability, cardiogenic shock, heart failure, or electrical instability, according to the European Heart Journal 3, 4
Draw high-sensitivity cardiac troponin immediately, with repeat testing at 1-2 hours using validated algorithms, as suggested by the European Heart Journal 5, 6

The American College of Cardiology recommends aspirin 75-150 mg immediately (can give 300 mg loading dose) for patients with non-specific ST segment elevation 2
The European Society of Cardiology suggests P2Y12 inhibitor loading: Clopidogrel 600 mg, prasugrel, or ticagrelor (clopidogrel preferred if bradycardia risk or bleeding concerns) 7, 2
Beta-blockers orally or intravenously are recommended in absence of contraindications (heart failure, hypotension, bradycardia, heart block) by the American Heart Association 2
Nitroglycerin (sublingual or IV) is recommended for ongoing chest pain by the American College of Cardiology 2
Morphine 5 mg IV is suggested for pain relief if needed by the American Heart Association 7
Unfractionated heparin (5000 IU bolus) or low molecular weight heparin is recommended by the American College of Cardiology 7

The European Society of Cardiology recommends immediate angiography (<2 hours) for hemodynamic instability or cardiogenic shock 3, 4, 2
Recurrent or ongoing chest pain despite medical therapy is an indication for immediate angiography, according to the European Heart Journal 1, 4
Marked ST-segment depression suggesting ongoing ischemia is an indication for immediate angiography, as recommended by the European Heart Journal 4
Heart failure or electrical instability is an indication for immediate angiography, according to the European Heart Journal 4
Transient ST-segment elevation (even if resolved) is an indication for immediate angiography, as suggested by the European Heart Journal 3, 5
Elevated troponin with dynamic changes compatible with NSTEMI is an indication for early invasive strategy (<24 hours), according to the European Society of Cardiology 3, 2
GRACE risk score >140 is an indication for early invasive strategy (<24 hours), as recommended by the European Heart Journal 3
Dynamic or new contiguous ST/T-segment changes is an indication for early invasive strategy (<24 hours), according to the European Heart Journal 3

Continuous cardiac monitoring for at least 24 hours is recommended by the American Heart Association 2
Oxygen is recommended only if hypoxemic (SpO2 <90%) by the European Heart Journal 4
Emergency echocardiography is recommended to assess LV function and exclude mechanical complications by the European Heart Journal 3
Assess renal function for contrast and medication dosing, as suggested by the European Heart Journal 3

The European Society of Cardiology recommends same diagnostic and therapeutic strategies for elderly patients, but adjust antithrombotic dosing based on renal function 3
For patients with chronic kidney disease, use low/iso-osmolar contrast at lowest volume and adjust anticoagulant doses, as recommended by the European Heart Journal 3
For patients with diabetes, screen glucose and monitor frequently, and avoid hypoglycemia, according to the European Heart Journal 3