Cardiology · USMLE Step 1 and Step 2

NSTEMI song

NSTEMI - Diagnosis & Management, as a song. Hear the short teaser here. The full song is on YouTube and Spotify.

NSTEMI

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Key points in this song10

NSTEMI is defined by elevated cardiac troponin without ST elevation on ECG, distinguishing it from STEMI, which requires emergent reperfusion.
Pathophysiology involves partial occlusion of a coronary artery by a non-occlusive thrombus, preserving some antegrade flow and sparing the epicardium from full-thickness necrosis.
ECG findings in NSTEMI include ST depression, T-wave inversions, or a normal tracing — ST elevation is absent by definition.
Troponin I and T are the preferred biomarkers; levels rise within 3–6 hours of injury, peak at 24 hours, and remain elevated for up to 10–14 days.
Initial management follows the MONA framework: Morphine (selectively), Oxygen (if SpO₂ < 90%), Nitrates, and Aspirin 325 mg chewed immediately.
Dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) is a cornerstone of NSTEMI treatment to prevent further thrombosis.
Anticoagulation with unfractionated heparin, enoxaparin, fondaparinux, or bivalirudin is added to antiplatelet therapy to reduce thrombus propagation.
TIMI or GRACE risk scores stratify patients for early invasive strategy (cardiac catheterization within 24–48 hours) versus conservative management.
High-risk features mandating urgent catheterization include refractory chest pain, hemodynamic instability, new heart failure, or sustained ventricular arrhythmias.
Beta-blockers reduce myocardial oxygen demand and should be initiated within 24 hours unless contraindicated by cardiogenic shock, severe bradycardia, or decompensated heart failure.