Associate Director, Cardiology, Max Hospital, Gurugram
Part 8 of 10 in Diagnosis and Management of Ischemic Heart Disease
Managing Non-STEMI and Unstable Angina
September 4, 2026
Non-STEMI and unstable angina share a treatment protocol that looks similar to STEMI's at first glance, but Dr. Rohit Goel drew one bright line between them: thrombolysis has no place in either condition.
The initial workup
The ECG in non-STEMI or unstable angina can show ischemic changes or appear entirely normal, so the diagnosis relies mainly on clinical history, examination, and cardiac biomarkers: an elevated troponin or CK-MB means non-STEMI, and a normal result with a matching clinical picture means unstable angina.
Medical management, not thrombolysis
At admission, Dr. Goel starts the same sequence used across acute coronary syndrome: IV access, oxygen, aspirin, clopidogrel, a statin, a beta blocker, nitrates and low molecular weight heparin. GP2b3a inhibitors are added for patients at very high risk. What never happens, in contrast to STEMI, is thrombolysis; these patients are managed on blood thinners and standard anti-ischemic therapy instead.
Escalating to angiography
The same medications continue after any intervention: aspirin, clopidogrel, statins, beta blockers, and an ACE inhibitor if the patient is hypertensive, diabetic, or has poor ejection fraction, plus nitrates. Once a high-risk non-STEMI or unstable angina patient is not improving on medical therapy, Dr. Goel's practice is to proceed to coronary angiography for further treatment.
This article is based on a Jivo Masterclass session conducted by Dr. Rohit Goel, Principal Consultant, Cardiology, Max Hospital, Gurgaon. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
Looking for a cardiology consultation or a second opinion on ischemic heart disease? Get in touch with the Jivo team
This guide is based on a live Jivo Masterclass — Dr. Rohit Goel taught doctors across Africa on June 1, 2025.
FROM THE LIVE Q&A
Doctor on the call (name unclear from transcript)
Can myocardial bridging cause acute coronary syndrome, or can it be a risk factor?
Dr. Rohit Goel
Myocardial bridging can cause chest pain and can act as a risk factor. The initial approach is medical management with beta blockers, calcium channel blockers or nitrates. If the patient's chest pain continues despite medication, the next step is bypass surgery rather than angioplasty, since angioplasty is not successful in a bridged segment of artery.
Frequently Asked Questions
What is the safety of these ACS drugs in pregnancy?▼
Aspirin, clopidogrel, statins and beta blockers are all safe in pregnancy and can be used without hesitation. Low molecular weight heparin is also safe. ACE inhibitors should not be given, and thrombolysis is contraindicated outright in pregnant patients; these patients should instead be referred for primary angioplasty. The mother's life takes priority, though the fetal risk should be explained to the family before proceeding.
Can you elaborate more on glycoprotein 2b3a inhibitors and low molecular weight heparin?▼
There are three glycoprotein 2b3a inhibitors: abciximab, tirofiban and eptifibatide. These were used far more commonly a decade ago, before stents and catheterization labs were as standardized and widely available as they are now. Today their use has decreased and they are reserved for high-risk patients, such as those with a high thrombotic burden or delayed presentation, because of the increased risk of bleeding in the brain, stomach and at the local puncture site.
What is the prognosis of patients with ST-elevation MI if thrombolysis is not done, especially when there are contraindications?▼
The prognosis is poor when a patient with ST-elevation MI cannot be thrombolyzed because of a contraindication. Ideally these patients should be sent for primary angioplasty; if that is also unavailable, they should be managed medically in an ICU with aspirin, clopidogrel or ticagrelor, statins, beta blockers, ACE inhibitors, nitrates and heparin or low molecular weight heparin, using whatever resources are available. Outcomes can be described as roughly 50/50: some patients respond well to this treatment, while others deteriorate and need referral to a higher-level facility.
What is the approach for aortic dissection presenting like acute coronary syndrome?▼
Management of aortic dissection depends on which part of the aorta is involved. If the dissection involves the ascending aorta or the arch, it needs surgical management. If it involves the descending thoracic aorta or the descending abdominal aorta, percutaneous repair of the aneurysm is possible instead.
What is the lag time between the onset of symptoms and ST elevation on ECG?▼
Once symptoms begin, the earliest ST elevation can appear on ECG within 15 to 30 minutes. This ST elevation persists if there is complete occlusion of the artery, and can still be present up to 48 hours later. If blood flow is restored spontaneously, whether from medicines or other reasons, the ST elevation resolves; otherwise it persists until the artery is reopened.
Why is thrombolysis not used in non-STEMI or unstable angina?▼
Thrombolysis is reserved specifically for ST-elevation MI. Non-STEMI and unstable angina are managed instead with aspirin, a P2Y12 inhibitor, a statin, a beta blocker, nitrates and low molecular weight heparin.
When does a non-STEMI or unstable angina patient need coronary angiography?▼
When they are high-risk and not improving on medical management, or when the initial presentation already carries a high-risk profile.
In This Series: Diagnosis and Management of Ischemic Heart Disease
- 1.Diagnosis and Management of Ischemic Heart Disease
- 2.Recognizing a Heart Attack: Classical and Atypical Symptoms of Acute Coronary Syndrome
- 3.ECG and Cardiac Biomarkers: The Two Investigations That Diagnose a Heart Attack
- 4.STEMI, Non-STEMI and Unstable Angina: How to Tell Them Apart
- 5.Emergency Drug Protocol for ST-Elevation Myocardial Infarction
- 6.Primary Angioplasty or Thrombolysis: Choosing the Right Reperfusion Strategy
- 7.Thrombolytic Drugs and When Thrombolysis Should Not Be Used
- 8.Managing Non-STEMI and Unstable Angina
- 9.Cardiac Rehabilitation, Follow-Up and Preventing the Next Heart Attack
- 10.Heart Attack Drugs in Pregnancy and Distinguishing Aortic Dissection from ACS