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

From the Guidelines

NSTEMI patients should be managed with dual antiplatelet therapy, including aspirin and a P2Y12 inhibitor such as ticagrelor, along with anticoagulation and high-intensity statins, and should undergo cardiac catheterization within 24-72 hours to determine if revascularization is needed. The initial evaluation of NSTEMI patients should include a rapid assessment by a qualified physician, with a delay between first medical contact and ECG of ≤10 min, and monitoring of the cardiac rhythm 1. The working diagnosis of NSTEMI should be based on parameters such as chest pain characteristics, age, gender, CV risk factors, and 12-lead ECG findings 1.

The choice of antithrombotic regimen in NSTEMI should be based on the selected management strategy and revascularization modality, with dosing taking into account patient age and renal function 1. Aspirin and parenteral anticoagulation are recommended, along with a P2Y12 inhibitor such as ticagrelor, which is preferred over clopidogrel in patients not at high bleeding risk 1. Other medications that should be considered include beta-blockers, ACE inhibitors or ARBs, and high-intensity statins.

Some key points to consider in the management of NSTEMI include:

• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor
• Anticoagulation with heparin or low molecular weight heparin
• High-intensity statins, such as atorvastatin or rosuvastatin
• Beta-blockers, such as metoprolol, for patients with reduced ejection fraction or diabetes
• Cardiac catheterization within 24-72 hours to determine if revascularization is needed
• Lifelong aspirin and at least 12 months of P2Y12 inhibitor therapy after discharge, along with statins and cardiac rehabilitation.

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

• Indication: Clopidogrel is indicated for patients with NSTEMI to reduce the rate of myocardial infarction and stroke.
• Usage: Clopidogrel should be administered in conjunction with aspirin.
• Key points:
  • Reduce the rate of myocardial infarction and stroke in patients with NSTEMI
  • Can be used in patients who are to be managed medically or with coronary revascularization
  • Should be administered with aspirin 2, 2, 2

From the Research

NSTEMI Treatment

• The treatment of Non-ST-Elevation Myocardial Infarction (NSTEMI) typically involves antithrombotic therapy, including antiplatelet and anticoagulant agents 3, 4, 5.
• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor, is commonly used to reduce ischemic events in NSTEMI patients 4, 5.
• Anticoagulation therapy, including unfractionated heparin (UFH), low molecular weight heparin (enoxaparin), and fondaparinux, may also be used to prevent thrombus formation 3, 5.
• The combination of aspirin, clopidogrel, and low-dose rivaroxaban has been shown to reduce cardiovascular mortality in NSTEMI patients, but its use is not yet established in daily clinical practice 5.

Antithrombotic Therapy

• Optimized antithrombotic therapy with enoxaparin, clopidogrel, and aspirin has been shown to reduce the combined endpoint of death and non-fatal reinfarctions in NSTEMI patients compared to standard therapy with UFH and aspirin 6.
• P2Y12 receptor inhibitors, such as ticagrelor and clopidogrel, have been shown to reduce the risk of recurrent stroke in patients with acute noncardioembolic ischemic stroke or transient ischemic attack (TIA) when used in combination with aspirin 7.
• However, the use of P2Y12 receptor inhibitors in combination with aspirin may increase the risk of severe bleeding, including intracranial hemorrhage 7.

Treatment Strategies

• The choice of antithrombotic therapy in NSTEMI patients depends on various factors, including the patient's risk of bleeding and the presence of other medical conditions 3, 4, 5.
• Strategies to balance the potential benefit of antithrombotic therapy against the risk of bleeding complications are being developed, including the use of radial access in coronary angiography and restricted use of combination therapy 5.