From the Guidelines
The management of Non-ST-Elevation Myocardial Infarction (NSTEMI) involves several key medications, with antiplatelet therapy forming the cornerstone of treatment, typically beginning with aspirin and a P2Y12 inhibitor such as ticagrelor or prasugrel, as recommended by the most recent guidelines 1.
Key Medications for NSTEMI Management
- Aspirin: 75-100 mg once daily, as it is the cornerstone of treatment for inhibition of thromboxane A2 generation 1.
- P2Y12 inhibitors:
- Anticoagulation therapy: essential in NSTE-ACS patients, especially those undergoing myocardial revascularization by PCI, with options including unfractionated heparin, low molecular weight heparin like enoxaparin, or fondaparinux.
- Beta-blockers: reduce heart rate and contractility, decreasing myocardial oxygen demand, with metoprolol being a common choice.
- High-intensity statins: should be initiated regardless of baseline cholesterol levels to reduce the risk of recurrent ischemic events.
- ACE inhibitors or ARBs: indicated for patients with left ventricular dysfunction, hypertension, or diabetes.
- Nitroglycerin: provides symptomatic relief for ongoing chest pain.
Considerations for Medication Use
- The choice of P2Y12 inhibitor should be based on the patient's clinical profile and the presence of any contraindications 1.
- Anticoagulation therapy should be managed carefully to balance the risk of bleeding and thrombosis 1.
- Beta-blockers and ACE inhibitors should be used cautiously in patients with certain comorbidities, such as heart failure or renal impairment.
Recent Guideline Recommendations
- The 2020 ESC guidelines recommend the use of ticagrelor or prasugrel as the preferred P2Y12 inhibitors in NSTE-ACS patients 1.
- The guidelines also emphasize the importance of anticoagulation therapy and the use of beta-blockers and ACE inhibitors in patients with certain clinical characteristics.
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.
The medications used in the management of Non-ST-Elevation Myocardial Infarction (NSTEMI) include:
- Clopidogrel: an antiplatelet medication that should be administered in conjunction with aspirin 2.
- Aspirin: should be used in conjunction with clopidogrel.
From the Research
Medications Used in NSTEMI
The management of Non-ST-Elevation Myocardial Infarction (NSTEMI) involves the use of various medications to reduce the risk of ischemic events and improve patient outcomes. Some of the key medications used in NSTEMI include:
- Antiplatelet agents:
- Anticoagulants:
- Glycoprotein IIb/IIIa inhibitors:
- Eptifibatide 6
- Other medications:
- Vorapaxar, a protease-activated receptors (PAR)-1 receptor inhibitor 3
Dual Antiplatelet Therapy (DAPT)
DAPT with aspirin and a P2Y12 receptor inhibitor is a cornerstone of NSTEMI management, significantly reducing the risk of ischemic events 3, 4, 5. The choice of P2Y12 receptor inhibitor depends on the clinical circumstances, with ticagrelor, prasugrel, and clopidogrel being commonly used options 4.
Upstream Loading of P2Y12 Inhibitors
Upstream loading of P2Y12 inhibitors, such as ticagrelor or clopidogrel, at least 4 hours before diagnostic angiography, has been shown to be safe and effective in reducing ischemic events in NSTEMI patients 5.
Bleeding Risks
While intensified antiplatelet therapy reduces ischemic events, it also increases the risk of bleeding complications 3, 4, 6, 7. The choice of medication and dosing strategy should be carefully considered to minimize this risk.