NSTEMI in an older woman with diabetes and CKD — case discussion

Objectives

1. Recognise NSTE-ACS when the presenting symptoms are chest pain-equivalents.^[1]
2. Assign the ESC 2023 risk tier and invasive timing, and contrast ACC/AHA 2025.^[1][2]
3. Prescribe antithrombotic therapy adjusted for age and kidney function.^[1]

Candidate brief

Practice case discussion; this is not a real patient. You are the cardiologist taking the call from the regional doctor. In 15 minutes, give your diagnosis, risk assessment, timing of angiography and drug plan, and explain how her age and kidney function change it.

Expected actions

• Name the presentation. Dyspnoea and epigastric pain are chest pain-equivalent symptoms, and ESC 2023 says the descriptor "atypical" should be avoided.^[1] Patients with diabetes may more often present with non-specific symptoms, which can delay diagnosis.^[1]
• Make the working and final diagnosis. No persistent ST elevation means a working diagnosis of NSTE-ACS.^[1] ESC 2023 says a troponin rise and/or fall above the 99th percentile with ischaemic symptoms points to MI under the Fourth UDMI (2018), a framing now dated, and she is ruled in as NSTEMI by the ESC 0 h/1 h algorithm.^[1] Under the current Fifth UDMI (2026), spontaneous acute myocardial injury with ischaemic symptoms, new or presumed new ischaemic ECG changes or pathological Q waves, and no alternative acute condition or cardiac procedure as the trigger makes primary MI likely.^[29] Her breathlessness, epigastric discomfort and ST depression fit; an acute coronary pathology at angiography, or a new ischaemic-pattern wall motion abnormality or loss of viable myocardium on imaging, would confirm it.^[29]
• Assign risk (ESC 2023). She is stable with no very high-risk feature.^[1] Confirmed NSTEMI by the ESC hs-cTn algorithm is a high-risk criterion: early angiography within 24 h should be considered (Class IIa, Level A) and an inpatient invasive strategy is recommended (Class I, Level A).^[1]
• Contrast ACC/AHA 2025. At intermediate or high ischaemic risk, an invasive approach with intent to revascularise is recommended during hospitalisation. A meta-analysis found no mortality benefit with earlier angiography, although GRACE over 140, diabetes, age over 75 and elevated biomarkers favoured it, without significant interaction tests.^[2]
• Do not let age or CKD block angiography. ESC 2023: older adults should, in general, have the same strategies, including invasive angiography (Class I, Level B); CKD patients should have the same strategies, although dose adjustment may be necessary (Class I, Level C).^[1] Observational data suggest a better prognosis with early revascularisation than medical therapy alone in moderate to severe CKD.^[1]
• Aspirin and P2Y12. Aspirin loading 150–300 mg orally, or 75–250 mg IV if oral ingestion is not possible, then 75–100 mg once daily, with no specific CKD adjustment.^[1] No routine P2Y12 pretreatment, because angiography is planned within 24 h (Class III, Level A); give the loading dose at PCI.^[1] At age 75 or older prasugrel should be used with caution (5 mg daily if deemed necessary); ESC 2023 says clopidogrel may be considered in older patients, and in POPular AGE (age 70 or older) PLATO major or minor bleeding over 12 months was 18% with clopidogrel vs 24% with ticagrelor.^[1][15]
• Anticoagulant for her kidney function. For early angiography UFH is recommended, with enoxaparin to be considered as an alternative (Class IIa, Level B).^[1] If enoxaparin is used with creatinine clearance under 30 mL/min, reduce it to 1 mg/kg SC once daily (ESC 2023).^[1]
• Protect the kidneys at angiography. The antithrombotic type and dose and the contrast volume should be considered based on kidney function, and low- or iso-osmolar contrast at the lowest possible volume is recommended (ESC 2023; Class I, Level A). Hydration during and after angiography should be considered in patients at risk of contrast-induced nephropathy (Class IIa, Level B).^[1] Use radial access, which ESC 2023 recommends as the standard approach unless there are overriding procedural considerations (Class I, Level A).^[1]
• Check glucose. ESC 2023 recommends assessing glycaemic status at initial evaluation in all patients with ACS (Class I, Level B).^[1]

Marking

Pass:

• Names dyspnoea and epigastric pain as chest pain-equivalents and reaches NSTEMI.^[1]
• Places her in the ESC 2023 high-risk tier and arranges inpatient angiography, considered within 24 h.^[1]
• Avoids routine P2Y12 pretreatment and adjusts enoxaparin, if used, for creatinine clearance under 30 mL/min.^[1]
• Addresses contrast volume and hydration for CKD.^[1]

Fail:

• Withholds angiography because of age or CKD alone.^[1]
• Gives full-dose twice-daily enoxaparin despite creatinine clearance under 30 mL/min.^[1]
• Pretreats with prasugrel before the anatomy is known.^[1][13]