What is the treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI)?

From the Guidelines

NSTEMI treatment should prioritize dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor, along with anticoagulation and an early invasive strategy, as recommended by the most recent guidelines 1.

Key Components of NSTEMI Treatment

• Dual antiplatelet therapy: aspirin (325mg loading dose, then 81mg daily indefinitely) and a P2Y12 inhibitor such as ticagrelor (180mg loading dose, then 90mg twice daily) or clopidogrel (600mg loading dose, then 75mg daily) 1
• Anticoagulation: options include enoxaparin, bivalirudin, fondaparinux, or unfractionated heparin, with the choice depending on the patient's renal function and the selected management strategy 1
• Early invasive strategy: cardiac catheterization within 24-72 hours to determine if revascularization (PCI or CABG) is needed, as supported by studies such as FRISC II and TACTICS 1

Additional Considerations

• High-intensity statins: atorvastatin 40-80mg or rosuvastatin 20-40mg daily, to reduce cholesterol levels and improve outcomes 1
• Beta-blockers: metoprolol 25-100mg twice daily, to reduce myocardial oxygen demand and improve survival 1
• ACE inhibitors or ARBs: for patients with reduced ejection fraction or diabetes, to reduce mortality and morbidity 1
• Pain management: nitroglycerin and morphine may be necessary to control chest pain and reduce ischemia 1

Importance of Early Invasive Strategy

• The FRISC II trial demonstrated a 22% reduction in the incidence of death or MI at 6 months with an early invasive strategy compared to a conservative approach 1
• The TACTICS trial showed a significant reduction in the primary end point of death, MI, and rehospitalization for worsening chest pain by 6 months with an early invasive strategy 1
• The 2015 ESC guidelines recommend an early invasive strategy for patients with NSTEMI, as it improves outcomes and reduces morbidity and mortality 1

From the FDA Drug Label

Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization Clopidogrel tablets should be administered in conjunction with aspirin.

NSTEMI Treatment:

• Indication: Clopidogrel is indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]).
• Administration: Clopidogrel should be administered in conjunction with aspirin.
• Dosage: Initiate clopidogrel with a single 300 mg oral loading dose and then continue at 75 mg once daily 2.

From the Research

NSTEMI Treatment Overview

• NSTEMI patients are at high risk for atherothrombotic recurrences, and dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay of treatment 3.
• The current treatment regimens include novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, or adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar or rivaroxaban 3.

Antiplatelet Therapy

• Clopidogrel pretreatment and double-loading pretreatment with P2Y12 inhibitors have been shown to reduce the incidence of major adverse cardiac and cerebrovascular events (MACCEs) in patients with NSTEMI 4.
• Potent P2Y12-receptor inhibition with prasugrel or ticagrelor provides additional benefit over clopidogrel regarding cardiovascular mortality and myocardial infarction, but no advantage in stroke 5.

Aspirin Dosage

• The optimal dose of aspirin for NSTEMI treatment is unclear, but daily doses of 75 to 325 mg are sufficient for long-term treatment and prevention of cardiovascular disease 6.
• An initial dose of 162 mg aspirin may be as effective as and perhaps safer than 325 mg for the acute treatment of ST-elevation myocardial infarction 7.

Treatment Considerations

• Prolonging intensified antiplatelet therapy beyond 1 year has been investigated, but it reduces ischemic events at the expense of an increased risk of bleeding complications 3.
• The choice of P2Y12 inhibitor and the duration of treatment should be individualized based on the patient's risk profile and clinical presentation 4, 5.