A 58-year-old man from Delhi presents with acute chest pain at rest for 2 hours, radiating to the left arm. His ECG shows ST-segment depression in leads II, III, aVF, and V4–V6 with T-wave inversion. Troponin I is elevated at 0.8 ng/mL (normal <0.04). Regarding the management of this NSTEMI, all of the following are appropriate EXCEPT:

Explanation

## Management of NSTEMI: Reperfusion Strategy **Key Point:** NSTEMI management centers on **antiplatelet therapy, anticoagulation, and coronary angiography with percutaneous coronary intervention (PCI)** — NOT thrombolytic therapy. ### Reperfusion Strategy in NSTEMI vs. STEMI | Condition | Reperfusion Strategy | Rationale | |-----------|----------------------|-----------| | **STEMI** | **Immediate PCI or thrombolysis** | Complete coronary occlusion; time-critical to restore flow | | **NSTEMI** | **Coronary angiography + PCI (not thrombolysis)** | Partial occlusion; angiography identifies culprit lesion; PCI is superior to thrombolysis | | **Unstable Angina** | **Coronary angiography ± PCI** | No myocardial necrosis; angiography guides intervention | **High-Yield:** Thrombolytic therapy is **NOT indicated** in NSTEMI. Thrombolytics are reserved for STEMI when PCI is not available within 120 minutes. ### Why Thrombolysis Is Inappropriate in NSTEMI 1. **Partial occlusion** — NSTEMI results from partial coronary occlusion; the vessel is already partially patent. Thrombolytics risk distal embolization without achieving optimal reperfusion. 2. **Evidence-based practice** — Multiple trials (e.g., TIMI IIIB, FRISC II) demonstrate that **early invasive strategy (angiography + PCI) is superior to thrombolysis** in NSTEMI. 3. **Increased bleeding risk** — Thrombolytics in NSTEMI increase major bleeding without mortality benefit. 4. **Angiography is diagnostic** — Coronary angiography identifies the culprit lesion, assesses collaterals, and guides PCI or medical therapy. **Clinical Pearl:** The management paradigm for NSTEMI is **"diagnose and revascularize,"** not "lyse and hope." Early invasive strategy (angiography within 24–72 hours, or earlier in high-risk patients) is the standard of care. ### Appropriate NSTEMI Management (Options 0, 1, 3) #### 1. Dual Antiplatelet Therapy (Option 0) — **CORRECT** - **Aspirin** 300 mg loading dose (then 75 mg daily) - **P2Y12 inhibitor** (ticagrelor 180 mg, prasugrel 60 mg, or clopidogrel 600 mg loading dose) - Reduces recurrent ischemia and death #### 2. Anticoagulation (Option 1) — **CORRECT** - **Unfractionated heparin (UFH)** 60–70 U/kg IV bolus, then infusion - **OR Low-molecular-weight heparin (LMWH)** e.g., enoxaparin 1 mg/kg SC BD - Prevents thrombotic extension and recurrent events #### 3. Beta-Blockers & ACE Inhibitors (Option 3) — **CORRECT** - **Beta-blockers** (e.g., metoprolol, atenolol) — reduce myocardial oxygen demand, lower heart rate and BP, reduce anginal episodes - **ACE inhibitors** (e.g., lisinopril, enalapril) — reduce afterload, prevent LV remodeling, improve survival - Both are cardioprotective and reduce reinfarction risk **Mnemonic: DAPT + AC + BB + ACE-I** — **D**ual antiplatelet, **A**nticoagulation, **B**eta-blockers, **A**CE inhibitors — the "quadruple therapy" of NSTEMI. ### Risk Stratification & Timing of Angiography **High-risk features in this patient:** - Elevated troponin (0.8 ng/mL) - ST-segment depression (extensive ischemia) - Inferior + anterior wall involvement (suggests large territory at risk) **Recommendation:** Early invasive strategy with coronary angiography **within 24 hours** (or sooner if hemodynamically unstable or ongoing ischemia). [cite:Harrison 21e Ch 297]