What is the management of Non-ST-Elevation Myocardial Infarction (NSTEMI)?

From the Guidelines

Management of NSTEMI requires prompt intervention with dual antiplatelet therapy, anticoagulation, and risk stratification for invasive management, as outlined in the 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. The initial treatment strategy should include aspirin and a P2Y12 inhibitor, such as ticagrelor or clopidogrel, to reduce further thrombosis and limit infarct size.

• Aspirin should be given as a 325mg loading dose followed by 81mg daily indefinitely
• A P2Y12 inhibitor such as ticagrelor 180mg loading dose then 90mg twice daily or clopidogrel 600mg loading then 75mg daily should be added Anticoagulation should be started with unfractionated heparin or enoxaparin to prevent further thrombosis.
• Unfractionated heparin can be given as a 60 units/kg bolus, maximum 4000 units, followed by 12 units/kg/hour infusion
• Enoxaparin can be given as 1mg/kg subcutaneously twice daily High-risk patients should undergo coronary angiography within 24 hours, while intermediate-risk patients can be evaluated within 72 hours, as determined by the patient’s history, clinical presentation, and findings obtained during the initial assessment 1. Additional medications, such as beta-blockers, high-intensity statins, and ACE inhibitors, should be considered based on the patient’s individual risk factors and clinical presentation.
• Beta-blockers, such as metoprolol 25-50mg twice daily, can be used to reduce myocardial oxygen demand
• High-intensity statins, such as atorvastatin 40-80mg daily, can be used to reduce cholesterol levels
• ACE inhibitors, such as ramipril 2.5-10mg daily, can be used for patients with reduced ejection fraction, diabetes, or hypertension Nitroglycerin can be used for ongoing chest pain to reduce myocardial oxygen demand. After discharge, cardiac rehabilitation, smoking cessation, and lifestyle modifications are essential components of secondary prevention, and regular follow-up should be scheduled to monitor medication adherence and adjust therapy as needed.

From the FDA Drug Label

1.1 Acute Coronary Syndrome 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 management of Non-ST-Elevation Myocardial Infarction (NSTEMI) includes the use of:

• Aspirin: in conjunction with clopidogrel
• Clopidogrel: to reduce the rate of myocardial infarction and stroke
• Coronary revascularization: as part of the management plan for some patients 2 Additionally, prasugrel may be used to reduce the rate of thrombotic CV events in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI), including those with NSTEMI 3 Key considerations:
• The use of antiplatelet therapy, such as clopidogrel or prasugrel, in conjunction with aspirin
• The management of patients with NSTEMI may involve coronary revascularization
• The risk of bleeding associated with the use of antiplatelet therapy should be carefully considered 3, 2

From the Research

Management of Non-ST-Elevation Myocardial Infarction (NSTEMI)

The management of NSTEMI involves the use of antithrombotic therapy, including antiplatelet and anticoagulant agents.

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor, is a well-established treatment regimen for NSTEMI patients 4, 5, 6.
• The choice of P2Y12 inhibitor depends on the patient's risk of bleeding and other factors, with prasugrel and ticagrelor being more potent than clopidogrel 5, 7.
• Anticoagulant therapy, such as unfractionated heparin (UFH), low molecular weight heparin (enoxaparin), or fondaparinux, may also be used in patients with NSTEMI, particularly those undergoing percutaneous coronary intervention (PCI) 4.
• The use of novel anticoagulant agents, such as rivaroxaban, has also been investigated in the management of NSTEMI, with some studies suggesting a reduction in cardiovascular mortality 4, 5.

Antiplatelet Therapy

• Aspirin is a cornerstone of antiplatelet therapy in NSTEMI, with a dose of 162 mg or 325 mg commonly used 8.
• The addition of a P2Y12 receptor inhibitor to aspirin has been shown to reduce ischemic events in NSTEMI patients, with prasugrel and ticagrelor being more effective than clopidogrel in some studies 5, 7.
• The duration of DAPT therapy is also an important consideration, with some studies suggesting that prolonged therapy beyond 1 year may be beneficial in reducing ischemic events, but at an increased risk of bleeding 5.

Anticoagulant Therapy

• UFH has been the traditional anticoagulant of choice in NSTEMI, but newer agents such as enoxaparin and fondaparinux have been shown to be effective alternatives 4.
• The use of anticoagulant therapy in NSTEMI is generally reserved for patients undergoing PCI or those at high risk of thrombotic complications 4.
• The choice of anticoagulant agent depends on the patient's individual risk factors and the specific clinical scenario 4.