What home medications can be given to a patient with Non-ST-Elevation Myocardial Infarction (NSTEMI) who refuses hospital admission?

From the Guidelines

I strongly recommend against managing NSTEMI at home as this is a medical emergency requiring hospital admission for proper monitoring and treatment. However, if a patient absolutely refuses hospitalization despite understanding the serious risks, an emergency medication regimen could include:

• Aspirin 325mg immediately followed by 81mg daily
• Clopidogrel 300-600mg loading dose followed by 75mg daily
• A high-intensity statin like atorvastatin 40-80mg daily
• A beta-blocker such as metoprolol 25-50mg twice daily if blood pressure and heart rate permit
• Sublingual nitroglycerin 0.4mg to use for chest pain as needed, as recommended by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. This regimen addresses platelet aggregation, cholesterol levels, and cardiac workload, but cannot replace proper hospital care including anticoagulation, cardiac monitoring, and interventional procedures if needed. The patient must understand that home management significantly increases their risk of complications including death, and they should be strongly encouraged to seek immediate medical attention if symptoms worsen, including any chest pain, shortness of breath, dizziness, or palpitations. It is crucial to note that the management of NSTEMI should be guided by the most recent and highest-quality evidence, and the patient's treatment plan should be individualized based on their specific needs and risk factors, as outlined in the guidelines 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.

For a patient with NSTEMI who refused admission, the recommended home medication is:

• Clopidogrel 75 mg once daily orally, in conjunction with aspirin, as it is indicated to reduce the rate of myocardial infarction and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]) 2.
• A single 300 mg oral loading dose of clopidogrel may also be considered if an antiplatelet effect is needed within hours 2.

From the Research

Home Medication for NSTEMI Patients Who Refused Admission

When a patient with non-ST segment elevation myocardial infarction (NSTEMI) refuses admission, it is crucial to provide them with appropriate home medication to reduce the risk of further ischemic events. The following medications can be considered:

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor, as evidenced by studies 3, 4, 5, 6
• Novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, or adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar or rivaroxaban, respectively, as mentioned in 3

Considerations for P2Y12 Inhibitors

P2Y12 inhibitors have been shown to reduce the incidence of major adverse cardiac and cerebrovascular events (MACCEs) in patients with NSTEMI, as demonstrated in 4. However, the choice of P2Y12 inhibitor and the duration of treatment should be individualized based on the patient's clinical characteristics and risk factors, as discussed in 5 and 6.

Safety and Efficacy of P2Y12 Inhibitors

The safety and efficacy of P2Y12 inhibitors in elderly patients with acute coronary syndrome have been evaluated in 6, which found that potent P2Y12 inhibitors reduce cardiovascular death but increase bleeding with no difference in major adverse cardiovascular events (MACE) or all-cause death when compared with clopidogrel. Additionally, 7 found that dual antiplatelet therapy with P2Y12 inhibitors and aspirin reduces the risk of stroke recurrence but is associated with an increased risk of severe or moderate bleeding.

Key Points to Consider

• The patient's clinical characteristics, such as age, comorbidities, and risk factors, should be taken into account when selecting a P2Y12 inhibitor and determining the duration of treatment.
• The benefits and risks of P2Y12 inhibitors, including the risk of bleeding, should be carefully weighed and discussed with the patient.
• Regular follow-up and monitoring are essential to ensure the patient's safety and adjust the treatment plan as needed.