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

From the Guidelines

The treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) should involve immediate medical intervention with antiplatelet therapy, anticoagulation, and risk stratification for invasive management, with a preference for ticagrelor over clopidogrel in patients not at high bleeding risk, as recommended by the 2015 ESC guidelines 1. The choice of antithrombotic regimen should be based on the selected management strategy and revascularization modality.

• Aspirin and parenteral anticoagulation are recommended for all patients.
• In patients intended for a conservative treatment and not at high bleeding risk, ticagrelor is preferred over clopidogrel once the NSTEMI diagnosis is established.
• In patients intended for an invasive strategy, the optimal timing of the administration of ticagrelor has not been adequately investigated, while prasugrel is recommended only after coronary angiography prior to PCI. Additional medications include high-intensity statins, beta-blockers, and ACE inhibitors or ARBs for patients with left ventricular dysfunction.
• Early risk stratification determines whether an early invasive approach (cardiac catheterization within 24-72 hours) or a conservative strategy is appropriate.
• High-risk patients benefit from early coronary angiography and revascularization if indicated, as shown in studies such as TACTICS-TIMI 18 1 and ISAR-COOL 1. The 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non-ST-elevation myocardial infarction also support a routine invasive therapy strategy over an ischemia-guided strategy or a selectively invasive approach 1. However, the optimal timing of cardiac catheterization and coronary revascularization remains a topic of debate, with some studies suggesting that very early intervention may be beneficial in high-risk patients 1. Overall, the goal of treatment is to prevent further clot formation, reduce myocardial oxygen demand, stabilize atherosclerotic plaques, and potentially restore blood flow to the affected heart muscle, thereby limiting infarct size and improving outcomes.

From the FDA Drug Label

For 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, USP have been shown to decrease the rate of a combined endpoint of cardiovascular death, myocardial infarction (MI), or stroke as well as the rate of a combined endpoint of cardiovascular death, MI, stroke, or refractory ischemia. For patients with non-ST-elevation ACS (UA/NSTEMI), initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily. Initiate aspirin (75 to 325 mg once daily) and continue in combination with clopidogrel tablets

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

• Clopidogrel: a single 300 mg oral loading dose, then 75 mg once daily
• Aspirin: 75 to 325 mg once daily, in combination with clopidogrel 2, 2, 2

From the Research

NSTEMI Treatment Overview

• The treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI) involves a combination of medications and procedures to reduce the risk of further heart damage and improve outcomes 3, 4, 5, 6, 7.
• The goal of treatment is to restore blood flow to the heart, reduce pain and discomfort, and prevent complications such as heart failure and arrhythmias.

Medications

• Anti-ischemic medications, such as nitrates, beta-blockers, and calcium channel blockers, are used to reduce myocardial oxygen consumption and improve blood flow to the heart 3.
• Antithrombotic medications, such as aspirin, clopidogrel, and prasugrel, are used to prevent blood clots from forming and causing further heart damage 5, 7.
• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is commonly used in NSTEMI patients to reduce the risk of ischemic events 5.

Procedures

• Percutaneous coronary intervention (PCI) is a procedure used to open blocked coronary arteries and restore blood flow to the heart 4, 6, 7.
• Coronary angiography is used to visualize the coronary arteries and identify blockages 4, 6, 7.
• Revascularization procedures, such as PCI or coronary artery bypass grafting (CABG), are used to restore blood flow to the heart and improve outcomes 3, 4, 6, 7.

Treatment Strategies

• An immediate invasive strategy, including PCI and revascularization, is often used in high-risk NSTEMI patients to reduce the risk of death and ischemic events 4, 6, 7.
• Antithrombotic strategies, such as the use of heparin, bivalirudin, and glycoprotein IIb/IIIa inhibitors, are used to prevent blood clots and improve outcomes in NSTEMI patients undergoing PCI 7.
• The choice of treatment strategy depends on the individual patient's risk factors, medical history, and clinical presentation 3, 4, 5, 6, 7.