NSTEMI (non-ST-elevation heart attack): symptoms, tests and treatment

The NHS describes a heart attack as blood flow to your heart being blocked. Doctors use several terms to describe different patterns of heart attack, and NSTEMI, which stands for non-ST-segment elevation myocardial infarction, is one of them. NICE’s guideline on acute coronary syndromes deals with unstable angina and NSTEMI together in its section on early management.

This guide is written for patients and families. The detailed drug and procedure information comes from NICE guideline NG185, which is written for clinicians, and the symptoms and emergency advice come from the NHS. It does not cover every patient situation, and your cardiology team will tailor decisions to your own history.

The NHS lists the symptoms of a heart attack, which apply to NSTEMI as to other heart attacks. Not everyone has all of them, and some people have mild or unusual symptoms.

• Chest pain that may feel like crushing or squeezing, and may spread to the arm, neck and jaw.

• Feeling short of breath.

• Feeling sick or being sick.

• Feeling like you have indigestion, with a burning feeling in the chest and feeling full or bloated.

• Sweating.

• Pale, blue or grey skin, which on black or brown skin may be easier to see on the palms of the hands.

The NHS says to call 999 if you have chest pain that feels tight or like squeezing, chest pain that is spreading to your arms, neck or jaw, severe difficulty breathing, pale, blue or grey lips or skin, or if someone has passed out and is not responding normally. It says not to drive yourself to A&E; the person on the 999 call will give you advice about what to do.

While waiting for help, the NHS suggests sitting and resting in a comfortable position with your knees bent and back supported, taking a 300mg aspirin if you have one and are not allergic, and using your GTN spray if you have angina. If someone stops responding and stops breathing, start CPR. Call NHS 111 if you are suddenly more short of breath than usual, or have chest pain with feeling sick or a racing, slow, skipping or fluttering heartbeat, and you are unsure.

NICE says that in people with suspected unstable angina or NSTEMI the initial assessment includes a physical examination, including blood pressure and heart rate, a resting 12-lead ECG looking for patterns that indicate ischaemia, and blood tests such as troponin I or T, creatinine, glucose and haemoglobin. The NHS adds that if tests show you are having a heart attack you may have an echocardiogram, to see whether the heart has been damaged, and a coronary angiogram to find exactly where blood flow is blocked.

Once the diagnosis is made and aspirin and antithrombin therapy have been offered, NICE recommends a formal risk assessment using an established scoring system that predicts 6-month mortality, with the GRACE score given as an example. This estimate helps decide how soon angiography should be done.

Treatment depends on how severe the heart attack is. The NHS says it may include medicines to treat the blockage and improve blood flow, coronary angioplasty with a stent, or coronary artery bypass surgery. NICE guidance on NSTEMI sets out early drug treatment and the timing of angiography, summarised below.

The NHS says you will be given medicines to take long term after a heart attack to treat the causes and reduce the risk of another one. They may include antiplatelets, statins, and medicines to lower blood pressure such as ACE inhibitors and beta-blockers. Recovery varies: for some people it takes several weeks with little effect on life, and for others it can take months or years.

You will usually need to rest, including time off work, and be referred to cardiac rehabilitation, which may be in person or remote using video calls or apps. The NHS says most people can continue normal activities once recovered, and advises talking to your GP if you feel anxious or have low mood after a heart attack.

A suspected heart attack is an emergency, and the route is 999 and an NHS emergency department, where tests and treatment such as angiography are delivered free at the point of use. There is no choice between providers at this stage because speed matters most.

Private care may become relevant afterwards, for example for outpatient cardiology review, further imaging or second opinions about long-term medication. Cardiac rehabilitation is typically offered on the NHS. Whichever route you use, make sure that the team looking after you has your full discharge information and medicine list.