Do you use Dual Antiplatelet Therapy (DAPT) in Non-ST-Elevation Myocardial Infarction (NSTEMI) Type 1 with no intervention?

From the Guidelines

Dual Antiplatelet Therapy (DAPT) is not explicitly recommended for patients with Type 1 NSTEMI without intervention, as the guidelines primarily focus on post-interventional treatment. However, considering the importance of preventing further platelet aggregation and thrombus formation, DAPT may still be beneficial in these patients.

Key Considerations

• The 2021 ESC guidelines for the management of acute coronary syndromes recommend DAPT with a P2Y12 receptor inhibitor on top of aspirin for 12 months in patients with NSTE-ACS treated with coronary stent implantation 1.
• The guidelines also suggest that adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered in patients with a high risk of ischemic events and without increased risk of major or life-threatening bleeding 1.
• In patients with no prior stroke/transient ischemic attack who are at high ischemic risk and low bleeding risk, low-dose rivaroxaban (2.5 mg b.i.d. for approximately 1 year) may be considered after discontinuation of parenteral anticoagulation 1.

Treatment Approach

• The standard regimen for DAPT consists of aspirin 325 mg loading dose followed by 81 mg daily indefinitely, plus a P2Y12 inhibitor such as clopidogrel 300-600 mg loading dose followed by 75 mg daily for 12 months.
• Ticagrelor (180 mg loading, 90 mg twice daily) may be preferred over clopidogrel in higher-risk patients without contraindications.
• Regular monitoring for bleeding complications is essential, and proton pump inhibitors should be considered for patients at high risk of gastrointestinal bleeding.

Important Notes

• The 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes suggests that targeting oral anticoagulant therapy to a lower international normalized ratio (INR) may be reasonable in patients with NSTE-ACS managed with aspirin and a P2Y12 inhibitor 1.
• However, the combination of oral antiplatelet therapy and oral anticoagulant therapy significantly increases the risk of bleeding, and the benefit of such therapy must be weighed against the risk of bleeding complications.

From the FDA Drug Label

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 taking prasugrel tablets should also take aspirin (75 mg to 325 mg) daily

The use of Dual Antiplatelet Therapy (DAPT), which includes prasugrel and aspirin, is indicated in patients with NSTEMI Type 1 who are to be managed with PCI. However, the provided drug labels do not explicitly address the use of DAPT in NSTEMI Type 1 patients with no intervention.

• The labels discuss the administration of prasugrel in the context of PCI.
• They do not provide guidance on the use of DAPT in the absence of intervention. Therefore, based on the provided information, no conclusion can be drawn regarding the use of DAPT in NSTEMI Type 1 patients with no intervention 2, 2, 2.

From the Research

Dual Antiplatelet Therapy (DAPT) in NSTEMI Type 1

• In patients with Non-ST-Elevation Myocardial Infarction (NSTEMI) Type 1, Dual Antiplatelet Therapy (DAPT) is a recommended treatment approach 3, 4.
• DAPT typically consists of aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor 3, 5, 4.
• The use of DAPT in NSTEMI Type 1 patients without intervention is supported by evidence, as it reduces the risk of ischemic events 3, 6.

Bleeding Risk Considerations

• While DAPT is effective in reducing ischemic events, it also increases the risk of bleeding complications 3, 6.
• Predicting the risk of bleeding during DAPT treatment is crucial, and several baseline predictors have been identified, including age, sex, weight, and renal function 6.
• The TRILOGY ACS bleeding models can inform risk-benefit considerations regarding the duration of DAPT following acute coronary syndromes 6.

Management of NSTEMI Type 1

• The management of NSTEMI Type 1 patients involves a comprehensive approach, including risk stratification, anti-anginal, anticoagulant, and antiplatelet therapies 7.
• Hospitalists play a critical role in managing or coordinating the care of NSTEMI patients, and following published guidelines can result in better short- and long-term clinical outcomes 7.