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

From the Guidelines

NSTEMI treatment should begin with dual antiplatelet therapy using aspirin and a P2Y12 inhibitor, such as ticagrelor, as the cornerstone of treatment, as recommended by the most recent guidelines 1. The treatment approach for Non-ST-Elevation Myocardial Infarction (NSTEMI) involves a multi-faceted strategy to stabilize the patient, prevent further ischemia, and reduce the risk of complications and recurrent events.

Key Components of NSTEMI Treatment

• Dual antiplatelet therapy with aspirin (75-100 mg once daily) and a P2Y12 receptor inhibitor, such as ticagrelor (180 mg loading dose, then 90 mg twice daily) or prasugrel, is the recommended standard treatment for NSTEMI patients, as supported by recent trials 1.
• Anticoagulation with unfractionated heparin or low molecular weight heparin should be administered.
• A high-intensity statin, such as atorvastatin 80 mg daily, should be started.
• A beta-blocker, such as metoprolol (25-50 mg orally twice daily), should be initiated if there are no contraindications.
• Consideration of an ACE inhibitor or ARB, especially in patients with left ventricular dysfunction, is crucial.
• Pain management with nitrates and morphine may be necessary.

Invasive Strategy

An early invasive strategy with cardiac catheterization within 24-72 hours is recommended for most patients, with timing based on risk stratification 1. Revascularization via percutaneous coronary intervention or coronary artery bypass grafting may be required based on coronary anatomy. The choice of antithrombotic regimen should be based on the selected management strategy and revascularization modality, with ticagrelor preferred over clopidogrel in patients not at high bleeding risk 1. It is essential to consider the patient's age, renal function, and potential bleeding risks when selecting the antithrombotic regimen. By following this aggressive treatment approach, healthcare providers can effectively manage NSTEMI patients and reduce the risk of morbidity, mortality, and improve quality of life.

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 treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) is clopidogrel in conjunction with aspirin. The recommended dosage is a single 300 mg oral loading dose, followed by 75 mg once daily. 2

From the Research

Treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI)

• Aspirin should be given as soon as possible and continued indefinitely 3, 4, 5, 6
• Clopidogrel should be given for up to 9 months in patients in whom an early noninterventional approach is planned or in whom a percutaneous coronary intervention (PCI) is planned 6
• A platelet glycoprotein IIb/IIIa inhibitor should also be given in addition to aspirin, clopidogrel, and heparin in patients in whom cardiac catheterization and PCI are planned 3, 6
• Beta blockers and angiotensin-converting enzyme (ACE) inhibitors should be given and continued indefinitely 6
• Statins should be used if the serum low-density lipoprotein (LDL) cholesterol is >or=100 mg/dl and continued indefinitely 6
• Enoxaparin is preferable to intravenous unfractionated heparin in the absence of renal failure and unless CABGS is planned within 24 hours 6
• High-risk patients should have an early invasive strategy with CABGS or PCI performed depending on the coronary artery anatomy, left ventricular function, presence or absence of diabetes, and findings on noninvasive testing 6

Medical Management

• Aspirin in a dose of 160 to 325 mg should be administered on day 1 of an acute MI and continued indefinitely on a daily basis 3
• Intravenous heparin should be given in persons with acute MI undergoing primary coronary angioplasty or surgical coronary revascularization and in persons with acute MI at high risk for systemic embolization 3
• Long-term oral warfarin should be given after MI for the secondary prevention of MI in post-MI persons unable to tolerate daily aspirin, in post-MI persons with persistent atrial fibrillation, and in post-MI persons with left ventricular thrombus 3, 4, 5

Invasive Management

• Primary coronary angioplasty when available should be used rather than thrombolytic therapy in the treatment of older persons with acute MI who are poor candidates for thrombolytic therapy 3
• Coronary artery bypass graft surgery (CABGS) should be performed depending on the coronary artery anatomy, left ventricular function, presence or absence of diabetes, and findings on noninvasive testing 6