From the Guidelines
Guideline-directed medical therapy (GDMT) for non-ST-elevation myocardial infarction (NSTEMI) should include aspirin and a P2Y12 inhibitor, with ticagrelor preferred over clopidogrel, as well as parenteral anticoagulation, taking into account patient age and renal function. The management of NSTEMI involves a comprehensive approach, including antithrombotic treatment, with the choice of regimen based on the selected management strategy and revascularization modality 1.
Key Components of GDMT for NSTEMI
- Aspirin is recommended as part of the antithrombotic regimen
- Ticagrelor is preferred over clopidogrel for patients not at high bleeding risk, especially in those intended for conservative treatment 1
- Parenteral anticoagulation is also recommended, with dosing considerations for patient age and renal function 1
- The optimal timing of ticagrelor administration in patients intended for an invasive strategy has not been fully investigated, but prasugrel is recommended only after coronary angiography prior to PCI 1
Considerations for GDMT
- Patient age and renal function should be considered when dosing antithrombotic agents 1
- The choice of antithrombotic regimen should be based on the selected management strategy (conservative vs. invasive) and revascularization modality (PCI vs. CABG) 1
- High bleeding risk should be assessed when selecting the antithrombotic regimen, with ticagrelor preferred in patients not at high bleeding risk 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
In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily.
Patients taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily
The Guideline-Directed Medical Therapy (GDMT) for NSTEMI includes:
- Antiplatelet therapy:
From the Research
Guideline-Directed Medical Therapy (GDMT) for Non-ST-Elevation Myocardial Infarction (NSTEMI)
- The management of NSTEMI involves the use of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor 4.
- Novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, have been shown to be more effective than clopidogrel in reducing ischemic events in NSTEMI patients 5.
- The use of GDMT, including β-blockers, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), and statins, is recommended for the secondary prevention of atherothrombotic events in patients with NSTEMI 6, 7.
Comparison of P2Y12 Receptor Inhibitors
- A network meta-analysis comparing oral P2Y12 inhibitors in patients with NSTEMI found that prasugrel was associated with a reduction in the composite cardiovascular endpoint compared to clopidogrel and ticagrelor 5.
- A propensity score analysis of five contemporary European registries found that prasugrel and ticagrelor were associated with lower all-cause in-hospital death rates compared to clopidogrel in patients with STEMI, but not NSTEMI specifically 8.
- However, another study found that prasugrel and ticagrelor were not significantly different in terms of ischemic and bleeding outcomes in patients with NSTEMI 5.
Bleeding Risk
- The use of intensified and prolonged antithrombotic treatment regimens in NSTEMI patients has been shown to reduce ischemic events, but at the expense of an increased risk of bleeding complications 4.
- Early initiation of GDMT has been associated with a reduced risk of in-hospital major bleeds in STEMI patients treated with percutaneous coronary intervention (PCI) 6.