What medications should be given in the Emergency Room (ER) to a patient who presents with Non-ST-Elevation Myocardial Infarction (NSTEMI)?

From the Guidelines

For a patient presenting with NSTEMI in the emergency room, immediate medication management should include dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as ticagrelor or clopidogrel, as well as anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux, as recommended by the 2014 AHA/ACC guideline 1. The dual antiplatelet therapy should consist of aspirin (325 mg loading dose, then 81 mg daily) and a P2Y12 inhibitor such as ticagrelor (180 mg loading dose, then 90 mg twice daily) or clopidogrel (600 mg loading dose, then 75 mg daily) 1. Anticoagulation should be initiated with:

• Unfractionated heparin (60-70 units/kg IV bolus, then 12-15 units/kg/hr infusion) 1
• Enoxaparin (1 mg/kg subcutaneously every 12 hours) 1
• Fondaparinux (2.5 mg subcutaneously daily) 1 Pain and ischemia should be managed with:
• Sublingual nitroglycerin (0.4 mg every 5 minutes as needed) 1
• IV morphine (2-4 mg) if pain persists 1 A beta-blocker such as metoprolol (5 mg IV every 5 minutes for 3 doses, then 25-50 mg orally twice daily) should be given if there are no contraindications like heart failure or hypotension 1. High-intensity statin therapy with atorvastatin (80 mg daily) should be started immediately 1. An ACE inhibitor like lisinopril (5-10 mg daily) should be considered, especially in patients with left ventricular dysfunction or diabetes. These medications work together to reduce platelet aggregation, prevent further clot formation, decrease myocardial oxygen demand, stabilize plaque, and limit infarct size, ultimately improving outcomes and reducing mortality in NSTEMI patients. Key considerations include:
• Patient weight <60 kg may require a lower maintenance dose of prasugrel (5 mg) 1
• Patients age ≥75 years should not receive prasugrel due to increased risk of bleeding 1
• Ticagrelor should be discontinued at least 5 days before any surgery 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. The primary endpoint of the study was a composite of refractory ischemia, new MI and death within 7 days. There was a 32% risk reduction in the overall composite primary endpoint.

The medications that should be given in the ER to a patient who presents with NSTEMI are:

• Aspirin
• Clopidogrel (PO) 2
• Tirofiban (IV) 3

Key points:

• Clopidogrel should be administered in conjunction with aspirin.
• Tirofiban has been shown to reduce the risk of refractory ischemia, new MI, and death in patients with NSTEMI.

From the Research

Medications for NSTEMI in the ER

The following medications are recommended for patients presenting with NSTEMI in the ER:

• Antiplatelet agents:
  • Aspirin 4, 5, 6
  • P2Y12 receptor inhibitors (e.g. clopidogrel, prasugrel, ticagrelor) 4, 6
• Anticoagulants:
  • Heparin (unfractionated or low molecular weight) 4, 5, 7
  • Direct oral anticoagulants (DOACs) (e.g. rivaroxaban) 4, 6
• Other medications:
  • Beta-blockers 5
  • Nitrates 5
  • Morphine 5

Initial Management

Patients presenting with NSTEMI should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period, or until percutaneous coronary intervention 4. Aspirin and a P2Y12 receptor inhibitor should be started as soon as possible, and continued for at least 1 year 4, 6.

Special Considerations

Patients with an existing indication for long-term anticoagulation (e.g. atrial fibrillation) may require triple antithrombotic therapy with an anticoagulant, aspirin, and a P2Y12 receptor inhibitor 4, 6. The choice of anticoagulant and antiplatelet agents may depend on the individual patient's risk factors and medical history 4, 6.