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

From the Guidelines

Management of NSTEMI (Non-ST Elevation Myocardial Infarction) requires prompt intervention with dual antiplatelet therapy, anticoagulation, and risk stratification for invasive management, as recommended by the 2020 ESC guidelines 1. The initial treatment includes aspirin 325mg loading dose followed by 81mg daily indefinitely, plus a P2Y12 inhibitor such as ticagrelor 180mg loading dose followed by 90mg twice daily, which is preferred over clopidogrel, as stated in the 2015 ESC guidelines 1. Anticoagulation with unfractionated heparin or enoxaparin should be initiated, with dosing taking into account patient age and renal function, as recommended in the 2015 ESC guidelines 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 TACTICS-TIMI 18 trial and the RITA 3 trial 1. Additional medications include beta-blockers, high-intensity statins, and ACE inhibitors for patients with reduced ejection fraction, diabetes, or hypertension. Some key points to consider in the management of NSTEMI include:

• Continuous rhythm monitoring is recommended until the diagnosis of NSTEMI has been established or ruled out, as stated in the 2020 ESC guidelines 1.
• Rhythm monitoring up to 24 h or to PCI (whichever comes first) is recommended in NSTEMI patients at low risk for cardiac arrhythmias, as recommended in the 2020 ESC guidelines 1.
• The choice of antithrombotic regimen should be based on the selected management strategy and the chosen revascularization modality, as stated in the 2015 ESC guidelines 1.
• Nitroglycerin can be used for ongoing chest pain, and oxygen should be administered only if saturation is below 90%, as part of a comprehensive approach to reduce myocardial oxygen demand. The 2020 ESC guidelines 1 provide the most recent and highest quality evidence for the management of NSTEMI, and should be prioritized in clinical decision-making.

From the FDA Drug Label

1.1 Acute Coronary Syndrome (ACS) 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 clopidogrel in conjunction with aspirin to reduce the rate of myocardial infarction and stroke, and this can be done in patients who are to be managed medically or with coronary revascularization 2.

• Key points:
  • Clopidogrel is indicated for NSTEMI
  • Should be administered with aspirin
  • Can be used in patients managed medically or with coronary revascularization
• Dosage:
  • A single 300 mg oral loading dose, then 75 mg once daily 2
  • In patients ≥75 years of age, consider alternative treatments due to increased risk of bleeding, except in high-risk situations 3
  • For patients <60 kg, consider lowering the maintenance dose to 5 mg 3

From the Research

Management of Non-ST Elevation Myocardial Infarction (NSTEMI)

The management of NSTEMI involves several key components, including:

• Anticoagulation therapy: Patients presenting with NSTEMI should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period for those medically managed or until percutaneous coronary intervention 4.
• Antiplatelet therapy: Dual antiplatelet therapy (DAPT) with aspirin and the P2Y12 receptor inhibitor clopidogrel significantly reduces the ischemic events in NSTEMI patients 5, 6.
• Invasive strategy: Clinical guidelines recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization 7.

Antithrombotic Regimens

The following antithrombotic regimens are recommended for patients with NSTEMI:

• Triple antithrombotic therapy of anticoagulant (preferably DOAC) with aspirin and clopidogrel for up to 1 month (typically 1 week or until hospital discharge) 4.
• DOAC plus clopidogrel for up to 1 year, and then DOAC monotherapy thereafter 4.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is recommended for patients with NSTE-ACS 6.

Safety and Efficacy

The safety and efficacy of reduced-dose enoxaparin combined with dual-antiplatelet therapy followed by triple-antiplatelet therapy alone (without additional anticoagulation) during subsequent PCI appears safe and may prove efficacious 8.

• The overall technical success rate was 99.8% 8.
• Major adverse clinical events occurred in 0.1% of patients within 24 hours after PCI, and 0.4% within 30 days after PCI 8.