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, with ticagrelor preferred over clopidogrel in patients not at high bleeding risk. The initial treatment should include aspirin and a P2Y12 inhibitor such as ticagrelor, with dosing adjusted based on patient age and renal function 1. Anticoagulation should be started with unfractionated heparin or enoxaparin. High-risk patients should undergo coronary angiography within 24 hours, while intermediate-risk patients can be evaluated within 72 hours.

Key considerations in NSTEMI management include:

• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor
• Anticoagulation with unfractionated heparin or enoxaparin
• Risk stratification for invasive management
• Use of beta-blockers, high-intensity statins, and ACE inhibitors as indicated
• Nitroglycerin for ongoing chest pain

The choice of antithrombotic regimen should be based on the selected management strategy and revascularization modality, with ticagrelor preferred over clopidogrel in patients not at high bleeding risk 1. The TACTICS-TIMI 18 trial showed a significant reduction in death or infarction at 6 months with an invasive strategy, particularly in high- or intermediate-risk patients 1.

Overall, a comprehensive approach to NSTEMI management, including dual antiplatelet therapy, anticoagulation, and risk stratification for invasive management, can improve both short- and long-term outcomes. The use of ticagrelor as the preferred P2Y12 inhibitor, along with aspirin and anticoagulation, is a key component of this approach.

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.

1. 1 Acute Coronary Syndrome Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.

NSTEMI Management:

• Clopidogrel is indicated to reduce the rate of myocardial infarction and stroke in patients with NSTEMI, and should be administered in conjunction with aspirin.
• Prasugrel is indicated to reduce the rate of thrombotic CV events in patients with NSTEMI who are to be managed with PCI.
• The choice between clopidogrel and prasugrel should be based on individual patient factors, such as the risk of bleeding and the potential benefits of each medication 2 3.
• Patients with NSTEMI should be managed with a combination of antiplatelet therapy, including aspirin and either clopidogrel or prasugrel, and other evidence-based treatments, such as beta blockers and statins.
• It is essential to carefully weigh the benefits and risks of each medication and to monitor patients closely for signs of bleeding or other adverse effects.

From the Research

NSTEMI Management Overview

• NSTEMI (Non-ST-Elevation Myocardial Infarction) management involves the use of antiplatelet and anticoagulant therapy to reduce the risk of thrombotic events 4.
• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor, is a common treatment approach 5, 4.

Antiplatelet Therapy

• Potent P2Y12 inhibition with prasugrel or ticagrelor is the mainstay of treatment after an acute coronary syndrome (ACS) 6.
• Prasugrel has been shown to be more efficient than ticagrelor in reducing the composite cardiovascular end point in patients with NSTEMI intended to receive invasive management 6.
• Clopidogrel, a second-generation P2Y12 inhibitor, may be used as an alternative in patients with contraindications for third-generation P2Y12 inhibitors and/or a high risk of bleeding 4.

Anticoagulant Therapy

• Unfractionated heparin (UFH) has been the traditional anticoagulant of choice for ACS, but novel alternative parenteral anticoagulant strategies, such as low molecular weight heparin enoxaparin and the synthetic pentasaccharide fondaparinux, are also available 4.
• The direct parenteral factor IIa (thrombin) inhibitor bivalirudin has been shown to be as effective as UFH plus GPIIb/IIIa inhibitor in NSTEMI patients undergoing PCI 4.

Clinical Outcomes

• The use of P2Y12 receptor antagonists, such as clopidogrel, prasugrel, and ticagrelor, has been shown to reduce the risk of cardiovascular death, myocardial infarction, and stroke in patients with ACS or undergoing PCI 7.
• Potent P2Y12 inhibitors, such as prasugrel and ticagrelor, have been shown to provide additional benefit over clopidogrel in reducing cardiovascular mortality and myocardial infarction, but not stroke 7.