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

From the Guidelines

The recommended treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) includes immediate dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor, such as ticagrelor or prasugrel, in addition to anticoagulation with heparin, preferably unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) like enoxaparin. According to the most recent guidelines 1, aspirin is recommended for all patients without contraindications at an initial oral loading dose of 150-300 mg, and at a maintenance dose of 75-100 mg once daily for long-term treatment. A P2Y12 receptor inhibitor is also recommended in addition to aspirin, with options including prasugrel, ticagrelor, or clopidogrel, depending on the patient's specific situation and the planned treatment strategy.

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

• The use of anticoagulation, in addition to antiplatelet therapy, is recommended for all patients, with options including UFH, LMWH, fondaparinux, or bivalirudin 1.
• The choice of P2Y12 receptor inhibitor should be based on the patient's individual risk factors and the planned treatment strategy, with prasugrel preferred over ticagrelor for patients proceeding to percutaneous coronary intervention (PCI) 1.
• Beta-blockers and high-intensity statins should be started early in the treatment of NSTEMI, as they have been shown to improve outcomes in these patients 1.
• Pain management is also an important aspect of NSTEMI treatment, and typically includes the use of nitroglycerin and morphine as needed.

In terms of specific treatment regimens, the following are recommended:

• Aspirin: 150-300 mg loading dose, then 75-100 mg once daily 1.
• Ticagrelor: 180 mg loading dose, then 90 mg twice daily 1.
• Prasugrel: 60 mg loading dose, then 10 mg once daily 1.
• Clopidogrel: 300-600 mg loading dose, then 75 mg once daily 1.
• UFH: weight-adjusted intravenous bolus during PCI, with an activated clotting time target range of 250-350 seconds 1.
• Enoxaparin: 1 mg/kg subcutaneously twice daily, with dose adjustment for renal impairment 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. In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily.

The recommended treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) includes:

• Clopidogrel tablets, initiated with a single 300 mg oral loading dose, then continued at 75 mg once daily
• Aspirin, to be administered in conjunction with clopidogrel tablets 2 Key points:
• Clopidogrel tablets reduce the rate of myocardial infarction and stroke in patients with NSTEMI
• Aspirin should be used in conjunction with clopidogrel tablets
• A loading dose of clopidogrel is necessary to achieve an antiplatelet effect within hours 2

From the Research

NSTEMI Treatment Overview

• The recommended treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) involves a combination of antithrombotic agents, including antiplatelet drugs and anticoagulants, as well as early revascularization 3.
• Aspirin is the foundation antiplatelet agent, and new P2Y12 receptor inhibitors such as prasugrel and ticagrelor have clear benefits compared to clopidogrel for dual antiplatelet therapy 3.

Antithrombotic Therapy

• The current status of antithrombotic therapy in acute coronary syndromes, including NSTEMI, involves the use of antiplatelet agents such as aspirin, clopidogrel, prasugrel, and ticagrelor, as well as anticoagulants such as bivalirudin, unfractionated heparin, enoxaparin, and fondaparinux 3.
• The combination of aspirin, clopidogrel, and low-dose rivaroxaban has been approved by the European Medicines Agency for secondary prevention after acute coronary syndromes 3.

Upstream Loading of P2Y12 Inhibitors

• Upstream loading of P2Y12 inhibitors, such as ticagrelor, at least 4 hours before diagnostic angiography has been associated with very low rates of bleeding and short length of stay in patients with NSTEMI managed invasively 4.
• The use of P2Y12 inhibitors, such as clopidogrel, prasugrel, and ticagrelor, has been shown to reduce ischemic events in patients with NSTEMI 5.

Secondary Prevention

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay of treatment for secondary prevention in patients with NSTEMI 5.
• Novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, or adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar or rivaroxaban, may be used for long-term prevention of atherothrombotic events in patients with NSTEMI 5.

Aspirin Dosage

• The optimal dose of aspirin for patients with acute coronary syndromes, including NSTEMI, is unclear, but an initial dose of 162 mg may be as effective as and perhaps safer than 325 mg 6.