Ischaemic Heart Disease for NEET PG Medicine: Angina, Unstable Angina, NSTEMI, STEMI ECG, Reperfusion, Complications of MI

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🎯 Exam priority: High. Expect: ECG localisation of an infarct, STEMI criteria, why NSTEMI is not thrombolysed, right ventricular infarction management, troponin timing, the ICMR loading doses and PCI window, and post-MI complications by clue.

CBME mapping: GM 2.1–2.24. Atherosclerosis and infarct histology are in Pathology article 20; the full ECG and arrhythmias are in Medicine article 3.

ACS spectrum, infarct territories, complications and the ICMR STEMI pathway. Drawn by TrackNation.

Angina

• Angina pectoris: precordial discomfort from transient ischaemia without infarction. Stable angina is brought on by exertion or stress and relieved by rest or sublingual nitroglycerin. Tests: ECG, stress testing (ECG or imaging), CT angiography.

• Vasospastic angina: coronary spasm; angina at rest, ST elevation during an attack; provocation with ergonovine or acetylcholine; treat with calcium channel blockers and nitroglycerin.

• ICMR stable angina STW: aspirin 75 mg daily (clopidogrel if intolerant), anti-ischaemic drugs, revascularise if anatomy suits; prefer CABG over PCI in diabetics with multivessel disease.

Acute Coronary Syndromes

• Unstable angina: ischaemia without necrosis (troponin below the 99th centile). NSTEMI: troponin rise without ST elevation. STEMI: ST elevation ≥ 1 mm in two contiguous leads (1.5–2.5 mm in V2–V3 by age and sex). A new LBBB alone is not a STEMI equivalent.

• ECG within 10 minutes of presentation; high-sensitivity troponin at presentation and 1–2 hours later (0 and 3–6 hours with standard assays). Pathological Q waves mark established infarction.

• Territories: inferior (II, III, aVF — right coronary or dominant circumflex), lateral (I, aVL, V4, V6), anterior (LAD; larger infarcts, worse prognosis). Extra leads: V4R for the right ventricle, V7–V9 for the posterior wall.

• Right ventricular infarction usually accompanies an inferior infarct (proximal right coronary). Hypotension: give IV saline (1–2 L); avoid nitrates and diuretics, which drop preload and cause severe hypotension.

Treatment

• Prehospital: oxygen (if hypoxic), aspirin, nitrates and transfer to the right centre. In hospital: aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor), anticoagulation (heparin), nitroglycerin, beta-blocker, statin, ACE inhibitor or ARB.

• Nitroglycerin is preferred to morphine or fentanyl, which can blunt some P2Y12 inhibitors.

• Reperfusion: STEMI → primary PCI, or fibrinolysis (tenecteplase, alteplase, reteplase, streptokinase) when timely PCI is not available. Fibrinolytics worsen outcome in unstable angina and NSTEMI.

Complications

• Electrical: VT/VF (often within 24 hours), atrial arrhythmias, sinus node and conduction disturbances.

• Mechanical: hypotension, cardiogenic shock, heart failure; papillary muscle dysfunction (acute MR); septal rupture — sudden loud systolic murmur and thrill at the left sternal border; free-wall rupture (1% of MIs, 15% of in-hospital deaths) — sudden collapse; ventricular aneurysm — persistent ST elevation and a bulging cardiac shadow, with mural thrombus and emboli.

• Inflammatory: early peri-infarction pericarditis; Dressler (post-MI) syndrome days to months later — autoimmune; fever, pericarditis, effusions, pleuritis, joint pain. Anticoagulants are contraindicated in Dressler syndrome but not in early pericarditis.

Traps the Examiner Sets

• Inferior STEMI + hypotension → right-sided leads, fluids; no nitrates.

• NSTEMI is never thrombolysed.

• New LBBB alone is not automatically STEMI.

• Persistent ST elevation weeks after MI = ventricular aneurysm.

• ICMR: PCI if within 120 minutes, else lyse within 12 hours.

Memory Hooks & Shortcuts

Shortcuts to lock in this article's numbers and lists. Each one only re-packages facts proven above.

• 🧠 Inferior = II, III, aVF — 'two, three, and a Very Fat RCA' — inferior MI

• 🧠 RV infarct: Fill it, don't Nitrate it — RV infarction

• 🧠 NSTEMI: No STEMI, No Streptokinase — fibrinolysis

• 🧠 120 to PCI, 12 to lyse — ICMR reperfusion

• 🧠 Persistent ST = Pouch (aneurysm) — LV aneurysm

• 🧠 Dressler = Delayed, Defensive (autoimmune), Don't anticoagulate — Dressler

Rapid-Revision Cards

• Stable angina

  Exertion; relieved by rest/GTN; no infarction.

• Vasospastic angina

  Rest pain, ST ↑ in attack; CCB + GTN.

• Unstable angina

  Troponin < 99th centile.

• NSTEMI

  Troponin ↑, no ST ↑; no fibrinolysis.

• STEMI criterion

  ST ↑ ≥ 1 mm in 2 contiguous leads (V2–V3: 1.5–2.5 mm).

• ECG timing

  Within 10 min of presentation.

• hs-troponin timing

  0 and 1–2 h.

• Inferior MI

  II, III, aVF; RCA or dominant LCx.

• Lateral MI

  I, aVL, V4, V6.

• Anterior MI

  LAD; larger, worse prognosis.

• RV infarct

  With inferior MI; V4R; fluids, no nitrates.

• Posterior MI

  V7–V9.

• New LBBB

  Not a STEMI equivalent alone.

• ICMR STEMI loading

  Aspirin 325, clopidogrel 300, atorvastatin 80.

• ICMR PCI window

  Within 120 min, else lyse within 12 h.

• ICMR NSTEMI revasc

  High risk < 24 h; intermediate < 72 h.

• DAPT after PCI (NSTEMI)

  ≥ 12 months.

• Morphine in ACS

  Blunts some P2Y12 inhibitors; GTN preferred.

• Septal rupture

  New loud murmur + thrill, left sternal border.

• Free-wall rupture

  Sudden collapse; 1% of MIs.

• LV aneurysm

  Persistent ST ↑; mural thrombus.

• Dressler syndrome

  Autoimmune; weeks later; no anticoagulants.

Sources

Facts in this article were checked against these documents.

• MSD Manual Professional: Angina Pectoris; Vasospastic Angina; Overview of Acute Coronary Syndromes; Acute Myocardial Infarction; Medications for Acute Coronary Syndromes; Complications of Acute Coronary Syndromes — Merck & Co. (MSD Manuals), reviewed 2025–26 (link)

• Standard Treatment Workflows: STEMI; Unstable Angina/NSTEMI; Stable Angina — ICMR / Department of Health Research, MoHFW, January 2026

• Competency Based Undergraduate Curriculum, General Medicine (GM 2) — National Medical Commission, 2024

Test Yourself: Practice Questions

Thirty questions in NEET PG style, most of them clinical vignettes.

Practice Questions (NEET PG pattern)

Original questions written in the style of the exam: +4 for a correct answer, −1 for a wrong one. Every answer was checked against the sources listed above. NEET PG papers are not published by NBEMS, so these are not past-paper questions.

Q1. A man gets chest pressure when climbing stairs that settles within minutes of rest or sublingual nitroglycerin. This is

• (a) pericarditis

• (b) NSTEMI

• (c) stable angina

• (d) unstable angina

Q2. A patient has recurrent chest pain at rest; ECG during pain shows ST elevation that resolves afterwards. Treatment of choice is

• (a) urgent CABG

• (b) fibrinolysis

• (c) a beta-blocker alone

• (d) a calcium channel blocker with nitroglycerin

Q3. A patient with prolonged rest chest pain has no ST elevation and troponin below the 99th percentile on repeat testing. The diagnosis is

• (a) STEMI

• (b) stable angina

• (c) unstable angina

• (d) NSTEMI

Q4. STEMI on ECG (outside V2–V3) requires ST elevation of at least

• (a) 0.5 mm in one lead

• (b) 1 mm in two or more contiguous leads

• (c) 3 mm in all leads

• (d) 1 mm in any single lead

Q5. How soon should an ECG be recorded in a patient with suspected ACS?

• (a) within 1 hour

• (b) within 10 minutes of presentation

• (c) after troponin returns

• (d) within 24 hours

Q6. ECG shows ST elevation in II, III and aVF with reciprocal depression elsewhere. The usual culprit artery is

• (a) first diagonal

• (b) left main

• (c) left anterior descending

• (d) right coronary (or dominant circumflex)

Q7. Which infarcts tend to be largest with the worst prognosis?

• (a) posterior infarcts

• (b) anterior infarcts from LAD occlusion

• (c) inferior infarcts

• (d) isolated right ventricular infarcts

Q8. Hyperacute ST elevation in I, aVL, V4 and V6 indicates infarction of the

• (a) inferior wall

• (b) lateral wall

• (c) septum only

• (d) right ventricle

Q9. A patient with inferior STEMI becomes hypotensive with high right-sided filling pressure. After right-sided leads confirm the cause, the first treatment is

• (a) morphine

• (b) IV normal saline 1–2 L

• (c) IV furosemide

• (d) IV nitroglycerin

Q10. Extra ECG leads V7–V9 are recorded to detect

• (a) posterior infarction

• (b) pericarditis

• (c) LBBB

• (d) right ventricular infarction

Q11. With a high-sensitivity troponin assay, a suspected ACS patient should be tested

• (a) after 12 hours only

• (b) on presentation and again 1–2 hours later

• (c) only once at 24 hours

• (d) only if ECG is normal

Q12. A patient with NSTEMI is in a hospital without a catheter lab. Fibrinolysis should

• (a) be given with half dose

• (b) be given within 12 hours

• (c) be given if troponin is high

• (d) not be given — it worsens outcome in NSTEMI

Q13. For chest pain in ACS, nitroglycerin is preferred to morphine because opioids

• (a) cause hypertension

• (b) dissolve clots

• (c) can reduce the activity of some P2Y12 inhibitors

• (d) raise troponin

Q14. The ICMR STEMI workflow loading doses are

• (a) heparin only

• (b) clopidogrel 75 mg, simvastatin 10 mg

• (c) aspirin 75 mg alone

• (d) aspirin 325 mg, clopidogrel 300 mg, atorvastatin 80 mg

Q15. Per the ICMR STEMI workflow, a patient at a non-PCI centre should be transferred for primary PCI if it can be done within

• (a) 120 minutes

• (b) 30 minutes only

• (c) 6 hours

• (d) 24 hours

Q16. Oxygen in STEMI (ICMR) is indicated when

• (a) always at 15 L/min

• (b) only during PCI

• (c) never

• (d) oxygen saturation is below 90%

Q17. A fibrinolytic preferred by the ICMR STEMI workflow is

• (a) heparin

• (b) urokinase only

• (c) aspirin

• (d) a fibrin-specific agent such as tenecteplase

Q18. Per ICMR, a high-risk NSTEMI patient should be revascularised within

• (a) 1 month

• (b) 72 hours

• (c) 7 days

• (d) 24 hours

Q19. After PCI for NSTEMI, the ICMR workflow advises dual antiplatelet therapy for at least

• (a) 1 month

• (b) 12 months

• (c) lifelong double therapy always

• (d) 1 week

Q20. A diabetic with stable angina has multivessel coronary disease suitable for revascularisation. The ICMR workflow prefers

• (a) PCI over CABG

• (b) medical therapy only

• (c) CABG over PCI

• (d) fibrinolysis

Q21. After an MI, a patient suddenly develops a new loud systolic murmur with a thrill at the left sternal border. The likely complication is

• (a) free-wall rupture

• (b) Dressler syndrome

• (c) ventricular septal rupture

• (d) pericarditis

Q22. A patient recovering from MI suddenly collapses with loss of blood pressure while the ECG still shows rhythm. The likely cause is

• (a) Dressler syndrome

• (b) septal rupture

• (c) mural thrombus

• (d) free-wall rupture

Q23. After a large MI, the ECG still shows persistent ST elevation and the chest X-ray shows a bulge of the cardiac border. This suggests

• (a) re-infarction

• (b) pericarditis

• (c) left ventricular aneurysm

• (d) Dressler syndrome

Q24. Three weeks after an MI, a patient has fever, pericardial rub, pleural effusion and joint pains. The mechanism is

• (a) bacterial pericarditis

• (b) drug allergy to aspirin

• (c) re-infarction

• (d) an autoimmune reaction to necrotic myocyte material

Q25. In Dressler syndrome, anticoagulation is

• (a) contraindicated

• (b) the first-line treatment

• (c) irrelevant

• (d) mandatory

Q26. Ventricular tachycardia or fibrillation after PCI for STEMI most often occurs

• (a) only with LBBB

• (b) after 1 month

• (c) after 6 months

• (d) within 24 hours

Q27. In isolation, a new left bundle branch block on ECG

• (a) is always STEMI

• (b) is not considered a STEMI equivalent

• (c) means posterior MI

• (d) excludes MI

Q28. Which pair of drugs is used as dual antiplatelet therapy in ACS?

• (a) aspirin and a P2Y12 inhibitor such as ticagrelor

• (b) aspirin and digoxin

• (c) clopidogrel and statin

• (d) heparin and warfarin

Q29. Fibrinolytics such as tenecteplase and streptokinase work by

• (a) blocking GP IIb/IIIa

• (b) blocking P2Y12

• (c) activating plasminogen

• (d) inhibiting thrombin directly

Q30. Right ventricular infarction usually occurs together with

• (a) an inferior left ventricular infarction

• (b) aortic dissection

• (c) a lateral infarction

• (d) an anterior infarction

Active Recall

From memory: define stable, vasospastic and unstable angina, NSTEMI and STEMI; give the STEMI ECG criterion and lead territories; explain right ventricular infarction management; outline ACS drugs, the ICMR loading doses and the PCI-or-lysis rule; and list MI complications with their clues.