From the Guidelines
Management of a Non-ST-Elevation Myocardial Infarction (NSTEMI) typically involves immediate medical therapy followed by risk stratification for potential invasive intervention, with a preference for an early invasive strategy with coronary angiography within 24-72 hours, as recommended by the 2015 ESC guidelines 1. The initial treatment includes dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as ticagrelor, which is preferred over clopidogrel, as stated in the 2015 ESC guidelines 1.
- Anticoagulation with unfractionated heparin, low molecular weight heparin, or fondaparinux should be initiated promptly.
- Additional medications include high-intensity statins, beta-blockers, and ACE inhibitors or ARBs for patients with left ventricular dysfunction or hypertension.
- Pain management with nitroglycerin and morphine may be necessary. The choice of antithrombotic regimen should be based on the selected management strategy and the chosen revascularization modality, as outlined in the 2015 ESC guidelines 1.
- The dosing of antithrombotic agents should take into account patient age and renal function. Most moderate to high-risk NSTEMI patients benefit from an early invasive strategy, as shown in the FRISC-II trial 1 and the TACTICS-TIMI 18 trial 1, which demonstrated a significant reduction in death or nonfatal MI with an early invasive approach. This comprehensive approach aims to limit myocardial damage, prevent recurrent ischemia, and reduce mortality by addressing the underlying coronary artery disease and optimizing cardiac function, as recommended by the 2015 ESC guidelines 1 and supported by the 2014 AHA/ACC guideline 1.
From the FDA Drug Label
- 1 Acute Coronary Syndrome Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
The typical management for an NSTEMI includes the use of prasugrel to reduce the rate of thrombotic cardiovascular events, in conjunction with aspirin and PCI. The recommended dosing regimen is a single 60 mg oral loading dose, followed by 10 mg orally once daily 2.
- Key components of NSTEMI management:
- Antiplatelet therapy: prasugrel and aspirin
- PCI: percutaneous coronary intervention
- Important considerations:
- Bleeding risk: increased with prasugrel, especially in patients with certain risk factors (e.g., body weight <60 kg, propensity to bleed)
- Timing of loading dose: administer at the time of PCI, unless coronary anatomy has not been established, in which case it may be administered after diagnostic coronary angiography 2.
From the Research
Typical Management for NSTEMI
The typical management for Non-ST-Elevation Myocardial Infarction (NSTEMI) involves the use of antiplatelet and anticoagulant therapies to reduce the risk of ischemic events and bleeding complications.
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, is commonly used 3.
- Novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, may also be used as part of DAPT 3.
- The use of adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar or rivaroxaban, may also be considered 3.
- Pretreatment with a P2Y12 inhibitor before percutaneous coronary intervention (PCI) has been shown to reduce the incidence of major adverse cardiac and cerebrovascular events (MACCEs) in patients with NSTEMI 4.
Antiplatelet Therapy
Antiplatelet therapy is a crucial component of NSTEMI management, with the goal of reducing the risk of ischemic events.
- Aspirin is commonly used as part of DAPT, with a dose of 162 mg being as effective as 325 mg in reducing ischemic events, but with a lower risk of bleeding complications 5.
- P2Y12 inhibitors, such as clopidogrel, prasugrel, and ticagrelor, are also used as part of DAPT to reduce the risk of ischemic events 3, 4.
- The use of DAPT with aspirin and a P2Y12 inhibitor has been shown to reduce the risk of stroke recurrence in patients with minor stroke or high-risk transient ischemic attack 6.
Bleeding Complications
Bleeding complications are a significant concern in NSTEMI management, particularly with the use of antiplatelet and anticoagulant therapies.
- The use of DAPT with aspirin and a P2Y12 inhibitor has been shown to increase the risk of bleeding complications, particularly severe or moderate bleeding 6.
- The risk of bleeding complications may be higher with certain P2Y12 inhibitors, such as ticagrelor, and with longer durations of DAPT therapy 6.