What is the management plan for Non-ST-Elevation Myocardial Infarction (NSTEMI) in the context of Acute Coronary Vascular Disease (ACVD) infarct?

NSTEMI Management

Administer aspirin 162-325 mg immediately, initiate dual antiplatelet therapy with ticagrelor (preferred) or clopidogrel plus parenteral anticoagulation, perform risk stratification using GRACE score, and proceed with early invasive strategy (angiography within 24 hours) for high-risk patients including those with elevated troponins, hemodynamic instability, or GRACE score >140. 1

Immediate Management (First 10 Minutes)

• Perform 12-lead ECG within 10 minutes of presentation to distinguish NSTEMI from STEMI 2
• Administer aspirin 162-325 mg immediately as a loading dose, then continue 75-100 mg daily indefinitely 1, 3
• Admit to monitored unit with continuous cardiac rhythm monitoring for at least 24 hours 3, 4
• Provide supplemental oxygen only if arterial oxygen saturation is <90% or respiratory distress is present 1, 3
• Administer sublingual or intravenous nitroglycerin for ongoing chest pain unless contraindicated (systolic BP <90 mmHg, severe bradycardia, right ventricular infarction, or recent phosphodiesterase inhibitor use within 24-48 hours) 3, 4
• Consider morphine sulfate 2-4 mg IV for severe, uncontrolled chest pain despite nitroglycerin, though use cautiously as it may be associated with adverse outcomes 3

Antiplatelet Therapy

Dual antiplatelet therapy (DAPT) is the cornerstone of NSTEMI treatment and should be initiated immediately. 1

P2Y12 Inhibitor Selection

• Ticagrelor is the preferred P2Y12 inhibitor over clopidogrel: loading dose 180 mg, then 90 mg twice daily 1, 3, 4
• Prasugrel (60 mg loading dose, then 10 mg daily) is an alternative for patients undergoing PCI who were not pretreated with another P2Y12 inhibitor and have no history of stroke/TIA 1
• Clopidogrel (300-600 mg loading dose, then 75 mg daily) should only be used when ticagrelor or prasugrel are contraindicated, unavailable, or not tolerated 1, 5
• Continue P2Y12 inhibitor for at least 12 months after NSTEMI, regardless of whether stenting was performed 1, 3

Important Caveats

• The recommended aspirin maintenance dose with ticagrelor is specifically 81 mg daily (not higher doses) 1
• Clopidogrel effectiveness is reduced in CYP2C19 poor metabolizers; consider genetic testing and alternative P2Y12 inhibitors in these patients 5
• Avoid concomitant use of clopidogrel with omeprazole or esomeprazole as they significantly reduce antiplatelet activity 5

Anticoagulation Therapy

All NSTEMI patients require parenteral anticoagulation in addition to antiplatelet therapy, regardless of management strategy. 1, 3

Anticoagulant Options (Choose One)

• Enoxaparin: 1 mg/kg subcutaneous every 12 hours (reduce to 1 mg/kg once daily if creatinine clearance <30 mL/min), continued for duration of hospitalization or until PCI 1, 3
• Fondaparinux: 2.5 mg subcutaneous daily, continued for duration of hospitalization or until PCI 1, 3
  • Critical: If PCI is performed on fondaparinux, administer additional anticoagulant with anti-IIa activity (UFH or bivalirudin) due to catheter thrombosis risk 1
• Bivalirudin: 0.10 mg/kg loading dose followed by 0.25 mg/kg/hour infusion (only for early invasive strategy), continued until angiography or PCI 1
• Unfractionated heparin (UFH): 60 IU/kg IV bolus (maximum 4000 IU) with 12 IU/kg/hour infusion (maximum 1000 IU/hour), adjusted to aPTT, continued for 48 hours or until PCI 1, 3

Contraindications

• Fibrinolytic therapy is contraindicated in NSTEMI and causes harm 1

Risk Stratification and Management Strategy

Risk stratification using the GRACE score determines the urgency and type of management approach. 1

Early Invasive Strategy (Angiography Within 24 Hours)

Indicated for patients with ANY of the following high-risk features: 1, 3

• Elevated cardiac troponins (diagnosis of NSTEMI) 1
• GRACE risk score >140 1
• Hemodynamic instability or cardiogenic shock 1
• Recurrent or refractory angina despite medical therapy 3, 4
• Life-threatening ventricular arrhythmias or cardiac arrest 1
• Dynamic ST-segment or T-wave changes suggesting ongoing ischemia 1
• Transient ST-segment elevation 1
• Heart failure or left ventricular dysfunction 6

Ischemia-Guided (Conservative) Strategy

• Appropriate for low-risk patients (GRACE score <140) without ongoing ischemia or high-risk features 1, 3
• Perform stress testing or coronary CT angiography to detect inducible ischemia or obstructive CAD 1

Revascularization Approach

Technical Considerations

• Radial artery access is the standard approach for coronary angiography unless procedural considerations dictate otherwise 1
• Drug-eluting stents (DES) are recommended over bare-metal stents for any PCI, regardless of clinical presentation, lesion type, or planned duration of DAPT 1
• Base revascularization strategy (culprit lesion PCI vs. multivessel PCI vs. CABG) on clinical status, comorbidities, and disease severity using SYNTAX score principles 1

Special Situations

• Emergency PCI of culprit lesion is recommended for cardiogenic shock due to NSTEMI if anatomy is amenable 1
• Emergency CABG is recommended for cardiogenic shock if anatomy is not amenable to PCI 1
• Routine immediate revascularization of non-culprit lesions is not recommended in NSTEMI patients with multivessel disease presenting with cardiogenic shock 1

Perioperative Management for CABG

If CABG is planned after angiography: 1

• Continue aspirin perioperatively (reduces operative morbidity and mortality) 1
• Discontinue clopidogrel at least 5 days before elective CABG 1
• Discontinue ticagrelor at least 5 days before elective CABG 1
• Discontinue prasugrel at least 7 days before elective CABG 1

However, balance the bleeding risk against delaying surgery in acute settings—CABG performed 1-4 days after clopidogrel discontinuation increases transfusion requirements but may not significantly increase life-threatening bleeding 1

Long-Term Medical Management

Cardioprotective Medications

• ACE inhibitors are mandatory for patients with heart failure, LVEF <40%, hypertension, or diabetes 1, 3, 6
• Angiotensin receptor blockers (ARBs) provide an alternative if ACE inhibitors are not tolerated 1, 3
• Beta-blockers are recommended for patients with LVEF ≤40% or heart failure 1, 6
• Mineralocorticoid receptor antagonists (preferably eplerenone) are recommended for patients with LVEF ≤35% and either heart failure or diabetes, without significant renal dysfunction or hyperkalemia 1
• High-intensity statin therapy should be started as early as possible and maintained long-term, regardless of baseline LDL levels 1, 3

Follow-Up Assessment

• Measure left ventricular ejection fraction (LVEF) before discharge 3, 6
• Consider diagnostic angiography if LVEF ≤0.40 and not already performed 3, 6
• Perform stress testing if LVEF >0.40 in patients managed conservatively 3

Special Populations

Diabetes Mellitus

• Screen all NSTEMI patients for diabetes and monitor blood glucose frequently 1
• Target blood glucose <180 mg/dL while avoiding hypoglycemia (both hyperglycemia and hypoglycemia increase mortality) 1
• Apply the same diagnostic and therapeutic strategies as for non-diabetic patients 1

Chronic Kidney Disease

• Assess kidney function by eGFR in all patients 1
• Apply the same diagnostic and therapeutic strategies with appropriate dose adjustments 1
• Use low- or iso-osmolar contrast media at the lowest possible volume during invasive procedures 1

Older Patients

• Apply the same diagnostic and interventional strategies as for younger patients 1
• Adapt antithrombotic agent dosing and secondary prevention based on renal function and specific contraindications 1

Critical Pitfalls to Avoid

• Never administer fibrinolytic therapy in NSTEMI—it causes harm 1
• Avoid NSAIDs (except aspirin) during hospitalization as they increase mortality, reinfarction, hypertension, heart failure, and myocardial rupture risk 3, 4
• Do not use immediate-release dihydropyridine calcium channel blockers without adequate beta-blockade 3, 4
• Avoid intravenous ACE inhibitors within the first 24 hours due to hypotension risk 3
• Do not routinely use intra-aortic balloon pump (IABP) in cardiogenic shock without mechanical complications—it does not reduce mortality 1
• Remember to administer additional anticoagulant with anti-IIa activity if performing PCI on a patient receiving fondaparinux 1

Performance Monitoring

Continuous monitoring of these quality indicators improves outcomes: 1

• Use of aspirin and P2Y12 inhibitor (ticagrelor/prasugrel/clopidogrel) 1
• Use of parenteral anticoagulation (fondaparinux/bivalirudin/UFH/enoxaparin) 1
• Use of early invasive procedures in intermediate- to high-risk patients 1
• Use of beta-blockers at discharge in patients with LV dysfunction 1
• Use of statins and ACE inhibitors/ARBs in appropriate patients 1
• Smoking cessation counseling and enrollment in cardiac rehabilitation 1