From the Guidelines
Management of Non-ST-Elevation Myocardial Infarction (NSTEMI) involves an early invasive approach with coronary angiography and potential revascularization, especially in high-risk patients.
Key Recommendations
- High-risk patients and those with recurrent ischemia should undergo an immediate or early invasive approach (within 24 hours) with potential revascularization 1.
- The management of acute heart failure should follow current guideline recommendations, and emergency echocardiography should be performed to gather information about the LVEF, regional wall motion abnormalities, right ventricular function, presence of valvular heart disease, and volume loading 1.
- Emergency coronary angiography is recommended in patients with cardiogenic shock complicating ACS, and emergency PCI of the culprit lesion is recommended for patients with CS due to NSTE-ACS, independent of the time delay from symptom onset, if the coronary anatomy is amenable to PCI 1.
- Antiplatelet and anticoagulant therapy is crucial in the management of NSTEMI, with aspirin and a thienopyridine (such as clopidogrel) indicated in most patients, except those who are potential candidates for urgent coronary artery bypass grafting (CABG) 1.
- Platelet glycoprotein (GP) IIb/IIIa antagonists are indicated in high-risk patients likely to undergo percutaneous coronary intervention (PCI) but are not indicated in the management of lower-risk patients who do not undergo PCI 1.
Important Considerations
- Risk stratification is essential in the management of NSTEMI, with high-risk patients requiring more aggressive treatment, including early invasive strategies 1.
- Revascularization should be performed as soon as possible in patients with cardiogenic shock or hemodynamic instability, with a preference for PCI over CABG if the coronary anatomy is amenable to PCI 1.
- Mechanical circulatory support devices, such as intra-aortic balloon pumps (IABP), may be considered in selected patients with cardiogenic shock, but their use should be individualized based on patient characteristics and clinical judgment 1.
From the Research
Management of Non-ST-Elevation Myocardial Infarction (NSTEMI)
The management of NSTEMI involves a combination of antiplatelet and anticoagulant therapy, as well as consideration of early coronary angiography and revascularization along with anti-ischemic medical therapy 2. The American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations should be applied in practice to improve outcomes 2.
Risk Stratification and Treatment
Risk stratification is crucial in managing NSTEMI patients, and treatment should be based on individualized patient risk assessment 3. The use of evidence-based treatment, including combination of antiplatelet and anticoagulant therapy, can result in better short- and long-term clinical outcomes, including near-term readmission and recurrent events 3.
Invasive Strategy and Dual Antiplatelet Therapy (DAPT)
An invasive strategy is associated with lower mortality among patients without non-coronary precipitating events (NCPE), but this benefit is reduced in patients with NCPE 4. DAPT is associated with lower mortality in patients without NCPE, but not in those with NCPE 4.
Total Coronary Occlusion and Ischemic Mitral Regurgitation
Patients with NSTEMI and total coronary occlusion represent a high-risk subgroup that may benefit from immediate invasive strategy 5. Ischemic mitral regurgitation (IMR) is a significant predictor of poor outcomes in NSTEMI patients, and revascularization strategies such as percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or CABG+ mitral valve (MV) surgery can improve outcomes in patients with significant IMR 6.
Key Considerations
- NSTEMI patients with NCPE have poor survival and modified effect of management strategies 4
- Total coronary occlusion in NSTEMI patients is associated with high-risk and may require immediate invasive strategy 5
- Significant IMR in NSTEMI patients is associated with higher mortality and admission rates, and revascularization strategies can improve outcomes 6
- Application of ACC/AHA guideline recommendations can result in improved outcomes 2
- Individualized patient risk assessment is crucial in managing NSTEMI patients 3