1. Prehospital NSTEMI Patient Assessment and Treatment
Paul A. Berlin, MS, NRP

2. Presenter Disclosure Information
Paul A. Berlin
Prehospital Non-STEMI Assessment and Treatment
FINANCIAL DISCLOSURE:
None
UNLABELED/UNAPPROVED USES DISCLOSURE:

3. 82 YOM, Hx HTN, complain of chest pressure
ECG: High Risk ACS?
82 YOM, Hx HTN, complain of chest pressure

4. 68 YOF, Weakness, 132/88, 83, 24 Inversion of T’s in V1, V2 & V3 avl
Ischemic T’s in Anterior & Septal

5. Acute Coronary Syndrome Myocardial Infarction
Presentation
Working Dx
ECG
No ST Elevation
ST Elevation
Non-ST ACS
Cardiac
Biomarker UA
NSTEMI
Unstable
Angina
Myocardial Infarction
Final Dx
NQMI
Qw MI
Libby P. Circulation 2001;104:365, Hamm CW, Bertrand M, Braunwald E, Lancet 2001; 358: ; Davies MJ. Heart 2000; 83: Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157,

6. Myocardial Infarction
Non-ST – Segment Elevation (NSTEMI) (30% - 45%)
ST – Segment Elevation (STEMI) (55% - 70%)
How do we find the 30% - 45% of MI patients we are missing?

7. Prognosis of NSTEMI vs STEMI
GUSTO IIb
Cumulative mortality (%) 2 4 6 8 10 30 60 90
120
150
180
Days from randomization
T-wave inversion
ST  ACS
STEMI with fibrinolytics
Short-term (in-hospital or one month) mortality:
NSTEMI (3-5%) compared to STEMI (10-15%).
Re-infarction rate after hospital discharge
NSTEMI (15-25%) to STEMI (5-8%).
Long-term mortality is similar or higher in NSTEMI compared to STEMI (two year mortality is approximately 30% in both cases
References
Savonitto S, Ardissino D, Granger CB, et al. Prognostic value of the admission electrocardiogram in acute coronary syndromes. JAMA. 1999;281:

8. NSTEMI ECG Features Can Be:
ST depression (70-80%)
T wave inversion(10-20%)
Symmetrical
Both ST depression and T wave inversion
Normal ECG

9. Assess Applicability for ACS Triage WA State EMS
≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease:
Chest discomfort, pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation, usually in the center of the chest lasting more than a few minutes, or that goes away and comes back.
Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain.
Shortness of breath with or without chest discomfort.
Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.
Other symptoms may include sweating, nausea, vomiting.
Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

10. Assess High Risk Criteria Based on TIMI (Three or more checked, High risk for NSTEMI)
Age ≥ 55*
3 or more CAD risk factors:
Family history of CAD
High BP
High cholesterol
Diabetes
Current smoker
Aspirin use in last 7 days
Angina in last 24 hours
ST-segment deviation on ECG
Known coronary disease
Elevated cardiac biomarkers

11. Reporting Times for Cardiac Markers for the ED
Bedside Test (mean=15 mins)
Laboratory Test (mean=128 mins) 20 40 60 80
100
120
140
160
180
Test Type
Reporting Times (mins)
POC
Point-of-care testing reduces ED length of stay (Annals of EM, June 2005)

12. High-sensitivity cardiac troponin I at presentation in patients with suspected ACS
Low plasma troponin concentrations identify two–thirds of patients at very low risk of cardiac events who could be discharged from hospital.
Implementation of this approach could substantially reduce hospital admissions and have major benefits for both patients and health–care providers.
The Lancet, 10/27/2015 Shah ASV, et al.

13. NSTEMI MORTALITY RATES: EARLY vs LATER CATH
Bhatt, D. L. et al. JAMA 2004;292:

14. Treatment Options Limit scene time
Transport patient to the right facility
Follow AHA or local protocols
Communicate with receiving facility
Transmit ECG if available
Fibrinolytic check sheet PRN

15. Challenges ECG quality Acceptance of POC Risk Assessment Training
Establishing POC
Risk Assessment Training
Acceptance by Receiving Centers

16. Questions?
NSTEMI recognition programs are the next step in ACS care following the implementation of strong Prehospital STEMI care programs.
Early recognition of NSTEMI using ECG findings, risk stratification and early biomarkers by prehospital care providers can direct patients to appropriate receiving facilities and reduce morbidity and mortality.

17. Paul A. Berlin Irondoc.paul@gmail.com
Contact Info:
Paul A. Berlin

18. Reference Cannon CP. J Thromb Thrombolysis. 1995;2:205-218.
Journal of the American College of Cardiology, 2007; 50:1-157, doi: /j.jacc
Anderson JL, et al. J Am Coll Cardiol 2007;50:e1–e157,
Bhatt, D. L. et al. JAMA 2004;292:
European Heart Journal. 2007;28(12):
Christenson R: Md Med 2001 Spring:Suppl:98-103
Galvani M, et al. Circulation 2004;110:128–34.
Antman EM. N Engl J Med 1996; 335:
Antman et al, JAMA, 284:835
de Lemos JA, et al. N Engl J Med. 2001;345:
Savonitto S, et al. JAMA. 1999;281:
Shah ASV, et al. The Lancet, 10/27/2015
The Lancet, 10/27/2015 Shah ASV, et al.
Abdul Wadud NSTEMI.ORG, NSTEMI vs STEMI, September 12, 2013 update 5/25/14