What medications do I start after Non-ST-Elevation Myocardial Infarction (NSTEMI) confirmation?

Medication Management After NSTEMI Confirmation

After NSTEMI confirmation, you should immediately start dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel), along with anticoagulation, beta-blockers, and statins. 1

Initial Antiplatelet Therapy

Aspirin

• Administer aspirin as soon as possible after hospital presentation and continue indefinitely in patients who tolerate it 1
• Recommended dose: 81 mg daily (preferred maintenance dose) 1

P2Y12 Inhibitor (add one of the following to aspirin)

• For invasive strategy patients:

  • Before PCI: Clopidogrel (loading dose 600 mg) or Ticagrelor (loading dose 180 mg) 1
  • At time of PCI: Clopidogrel, Prasugrel (60 mg loading dose), or Ticagrelor 1
  • Maintenance therapy: Clopidogrel 75 mg daily, Prasugrel 10 mg daily, or Ticagrelor 90 mg twice daily for at least 12 months 1

• For conservative strategy patients:

  • Clopidogrel (loading dose followed by 75 mg daily) or Ticagrelor (loading dose followed by 90 mg twice daily) 1
  • Continue for up to 12 months 1

Important considerations:

• Prasugrel is contraindicated in patients with history of stroke/TIA or active bleeding 1
• Prasugrel generally not recommended for patients ≥75 years 1
• For patients <60 kg on prasugrel, consider reducing maintenance dose to 5 mg daily 1
• When using ticagrelor, the recommended aspirin dose is 81 mg daily 1

Anticoagulation

• Initiate anticoagulant therapy along with antiplatelet therapy 1
• Options include unfractionated heparin, low molecular weight heparin, fondaparinux, or bivalirudin (particularly if PCI is planned) 1

Beta-Blockers

• Start beta-blockers within a few days of the event if not initiated acutely 1, 2
• Continue indefinitely unless contraindicated 1
• For patients with severe intolerance, discontinue beta-blockers 2

Angiotensin-Converting Enzyme (ACE) Inhibitors

• Indicated for patients with heart failure, LV dysfunction (LVEF <0.40), hypertension, or diabetes mellitus 1
• Continue indefinitely unless contraindicated 1

Statins

• High-intensity statin therapy should be initiated or continued in all patients without contraindications 3

Special Considerations

• For patients unable to take aspirin: Use clopidogrel, prasugrel (in PCI-treated patients), or ticagrelor as monotherapy 1
• For patients with recurrent symptoms on initial conservative therapy: Add GP IIb/IIIa inhibitor (eptifibatide or tirofiban) before diagnostic angiography 1
• For patients with indication for anticoagulation: Consider adding warfarin to maintain INR 2.0-3.0 1

Common Pitfalls to Avoid

• Delaying P2Y12 inhibitor administration in NSTEMI patients 4, 5
• Inappropriate use of prasugrel in contraindicated populations (prior stroke/TIA, elderly ≥75 years, low body weight <60 kg) 1, 5
• Using prasugrel before cardiac catheterization in NSTEMI patients 5
• Using two concurrent P2Y12 receptor inhibitors (not recommended) 1
• Failing to risk-stratify patients to determine optimal timing of invasive strategy 6, 7

Remember that early identification and appropriate treatment of high-risk NSTEMI patients improves outcomes. The medication regimen should be tailored based on the planned management strategy (invasive vs. conservative) and individual patient risk factors for bleeding and ischemic events.