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 1. The initial evaluation and pathway for NSTEMI involve rapid assessment by a qualified physician, with a delay between first medical contact and ECG of ≤10 min, and monitoring of the cardiac rhythm 1. The working diagnosis of NSTEMI and initial management should be based on parameters such as chest pain characteristics, probability of CAD, and 12-lead ECG findings 1.

• Initial treatment measures include nitrates (sublingual or i.v.) for persisting chest pain, and assignment to one of four working diagnoses: STEMI, NSTE-ACS with ongoing ischaemia or haemodynamic instability, NSTE-ACS without ongoing ischaemia or haemodynamic instability, or NSTE-ACS unlikely 1.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor or clopidogrel, should be started immediately, along with anticoagulation with unfractionated heparin or enoxaparin 1.
• High-risk patients should undergo coronary angiography within 24 hours, while intermediate-risk patients can be evaluated within 72 hours, as supported by the optimal timing of intervention in non-ST-segment elevation acute coronary syndromes study 1.
• Additional medications include beta-blockers, high-intensity statins, and ACE inhibitors for patients with left ventricular dysfunction or diabetes, and nitroglycerin can be used for ongoing chest pain, with oxygen administered only if saturation is below 90% 1.
• Risk factor modification, including smoking cessation, blood pressure and diabetes control, and cardiac rehabilitation, are essential components of long-term management, and should be prioritized to improve outcomes and reduce morbidity and mortality.

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

• Key points:
  • Administer clopidogrel with aspirin
  • Initiate with a 300 mg loading dose
  • Continue with 75 mg once daily
• Important consideration: Patients who are CYP2C19 poor metabolizers may have a reduced response to clopidogrel, and alternative treatments should be considered. 2

From the Research

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

The management of NSTEMI involves a combination of antiplatelet and anticoagulant therapy, early coronary angiography, and revascularization along with anti-ischemic medical therapy 3. The main goals of treatment are to improve outcomes and reduce the risk of cardiovascular events.

Treatment Strategies

• Antiplatelet therapy: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, is commonly used to reduce ischemic events in NSTEMI patients 4.
• Anticoagulant therapy: Anticoagulants, such as heparin or low molecular weight heparin, are used to prevent clot formation during the acute phase of NSTEMI, and may be continued long-term in patients with other indications for anticoagulation 5.
• Invasive strategy: Early coronary angiography and revascularization, such as percutaneous coronary intervention (PCI), can improve outcomes in NSTEMI patients, especially those with high-risk features 6, 7.
• Anti-ischemic medical therapy: Medications such as beta blockers, nitrates, and calcium channel blockers may be used to reduce ischemic symptoms and improve outcomes in NSTEMI patients 3.

Risk Assessment and Treatment

• Risk assessment: Patients with NSTEMI should undergo risk assessment to identify those at high risk for adverse outcomes, and to guide treatment decisions 7.
• Treatment-risk paradox: Despite having a higher long-term mortality risk, patients with NSTEMI are often treated less aggressively than those with ST-segment elevation myocardial infarction (STEMI), highlighting the need for more aggressive treatment strategies in high-risk patients 7.

Long-term Management

• Secondary prevention: Long-term management of NSTEMI involves secondary prevention strategies, such as lifestyle modification, risk factor control, and antiplatelet therapy, to reduce the risk of recurrent cardiovascular events 3, 4.
• Antithrombotic therapy: Antithrombotic therapy, including DAPT and anticoagulant therapy, may be continued long-term in patients with NSTEMI, depending on individual risk factors and indications 5, 4.