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 it requires hospital monitoring and treatment. However, if a patient absolutely refuses admission despite understanding the risks, an emergency medication regimen could include:

• Aspirin 325mg immediately followed by 81mg daily, as recommended by 1 and 1
• Clopidogrel 300mg loading dose followed by 75mg daily, as suggested by 1 and 1
• A high-intensity statin like atorvastatin 40-80mg daily, as recommended by 1 and 1
• A beta-blocker such as metoprolol 25-50mg twice daily if blood pressure allows, as recommended by 1 and 1
• Sublingual nitroglycerin 0.4mg can be used as needed for chest pain, as recommended by 1 and 1

The patient should be instructed to call emergency services immediately if they experience worsening chest pain, shortness of breath, dizziness, or other concerning symptoms. This regimen addresses platelet aggregation, inflammation, and cardiac workload but is significantly inferior to hospital care where IV anticoagulation, continuous cardiac monitoring, and immediate intervention for complications would be available. The patient should understand they are accepting substantial risk of death, heart failure, or other serious complications by refusing hospital admission for NSTEMI.

It is essential to note that the management of NSTEMI at home is not a standard practice and should be avoided whenever possible, as hospital care provides more comprehensive and timely treatment, which can significantly improve outcomes, as highlighted by 1, 1, 1, 1, and 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

• The following medications can be considered for home medication:
  • Aspirin: as part of dual antiplatelet therapy (DAPT) 3, 4, 5
  • P2Y12 receptor inhibitors: such as clopidogrel, prasugrel, or ticagrelor, which can be used in combination with aspirin for DAPT 3, 4, 6, 5
• The choice of P2Y12 receptor inhibitor may depend on the patient's specific condition and medical history:
  • Clopidogrel: may be considered for patients who are not at high risk of bleeding 4, 5
  • Prasugrel or ticagrelor: may be considered for patients who are at high risk of ischemic events and not at high risk of bleeding 3, 6, 5
• It is essential to weigh the benefits and risks of each medication, including the risk of bleeding, and to monitor the patient's condition closely 3, 4, 5, 7
• The patient should be educated on the importance of adhering to the medication regimen and attending follow-up appointments to monitor their condition 3, 4, 5