What are the discharge criteria and medication regimen for a patient with non-ST elevation myocardial infarction (NSTEMI)?

NSTEMI Discharge Criteria and Medication Regimen

When to Discharge

Patients with uncomplicated NSTEMI who remain free of serious complications during the first 2-3 hospital days can be safely discharged on day 3 or 4, while those with high-risk features require extended monitoring until stabilized. 1

Low-Risk Patients (Early Discharge Criteria - Day 3-4)

Discharge is appropriate when ALL of the following criteria are met:

• Hemodynamically stable (no hypotension, no cardiogenic shock) 1
• No major arrhythmias (no sustained ventricular tachycardia, no high-grade AV block) 1
• Left ventricular ejection fraction (LVEF) ≥40% 1
• Successful reperfusion without complications if PCI performed 1
• No additional critical coronary stenoses requiring intervention 1
• GRACE risk score ≤140 1
• No recurrent chest pain or ischemia at rest or with minimal activity 1
• Rhythm monitoring completed for minimum 24 hours (or until PCI, whichever comes first) 1, 2

Patients meeting these criteria have 99.1% event-free survival at 30 days and 98.1% at 1 year when discharged on day 3. 3

High-Risk Patients (Extended Hospitalization Required)

Continue hospitalization if ANY of the following are present:

• Hemodynamic instability or cardiogenic shock 1
• Major arrhythmias (sustained ventricular arrhythmias, high-grade heart block) 1
• LVEF <40% 1
• Failed reperfusion or complications from PCI 1
• Additional critical coronary stenoses requiring staged intervention 1
• GRACE risk score >140 1
• Recurrent angina despite medical therapy 1

Post-PCI Timing

• Uncomplicated PCI: Discharge next day (day 1 post-procedure) 1
• Post-CABG: Discharge 4-7 days post-operatively 1

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Discharge Medications (The "ABCDE" Regimen)

All NSTEMI patients must be discharged on the following evidence-based medications unless specific contraindications exist:

A - Antiplatelet Therapy (Dual Antiplatelet Therapy - DAPT)

Aspirin:

• 81 mg daily indefinitely 1, 2
• Continue lifelong for secondary prevention 1

P2Y12 Inhibitor (choose one) for 12 months:

• Ticagrelor 90 mg twice daily (preferred for most patients) 2
• Prasugrel 10 mg daily (if age <75, weight >60 kg, no prior stroke/TIA) 2
• Clopidogrel 75 mg daily (if ticagrelor or prasugrel contraindicated or not tolerated) 1, 2

Duration: Continue DAPT for 12 months unless excessive bleeding risk 1, 2

B - Beta-Blockers

• Initiate and continue indefinitely 1
• Start within first few days if not initiated acutely 1
• Gradual titration required for patients with moderate-severe LV dysfunction 1
• Continue even in low-risk patients with normal LV function post-revascularization 1

Contraindications: Active heart failure signs, cardiogenic shock risk, PR interval >0.24 seconds, second/third-degree heart block, active asthma 2

C - Cholesterol Management (High-Intensity Statins)

• Atorvastatin 40-80 mg daily OR Rosuvastatin 20-40 mg daily 2
• Initiate regardless of baseline LDL levels 2
• Target: LDL-C <1.4 mmol/L (<55 mg/dL) with ≥50% reduction from baseline 1

D - ACE Inhibitors or ARBs

ACE Inhibitors (first-line):

• Mandatory for: Heart failure, LVEF <40%, hypertension, diabetes mellitus, or anterior MI 1, 2
• Start within 24 hours unless contraindicated 2
• Continue indefinitely 1

ARBs (alternative):

• Use if ACE inhibitor not tolerated (cough, angioedema) 1
• Same indications as ACE inhibitors 1

Aldosterone Receptor Antagonist (Mineralocorticoid Receptor Antagonist):

• Add if LVEF ≤40% AND symptomatic heart failure OR diabetes mellitus 1
• Requires: Creatinine clearance >30 mL/min and potassium ≤5 mEq/L 1
• Must already be on therapeutic ACE inhibitor dose 1

E - Education and Emergency Medications

Sublingual/Spray Nitroglycerin:

• Prescribe to ALL patients with instructions 1, 2
• Instructions: If chest pain lasts >2-3 minutes despite rest, take 1 dose. If pain unimproved or worsening after 5 minutes, call 9-1-1 immediately. May take up to 2 additional doses at 5-minute intervals while awaiting EMS 1

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Additional Discharge Medications

Anti-Ischemic Medications

• Continue all anti-ischemic medications used in hospital (nitrates, calcium channel blockers if prescribed) 1
• Titrate doses as needed for symptom control 1

Proton Pump Inhibitor (PPI)

• Recommended with DAPT to reduce gastric bleeding risk 1

Anticoagulation (if indicated)

• For patients with atrial fibrillation or other anticoagulation indication:
  • Triple therapy (DOAC + aspirin + clopidogrel) for 1 week to 1 month (typically until hospital discharge) 4
  • Dual therapy (DOAC + clopidogrel) for up to 1 year 4
  • DOAC monotherapy thereafter 4
  • Prefer DOAC over warfarin 4

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Critical Medications to AVOID

Never prescribe the following at discharge:

• NSAIDs (except aspirin) - Increase mortality, reinfarction, hypertension, heart failure, and myocardial rupture risk 2
• Immediate-release dihydropyridine calcium channel blockers without adequate beta-blockade 2

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Follow-Up Schedule

Early Follow-Up (1-2 Weeks Post-Discharge)

• Assess medication tolerance and adherence 1
• Evaluate symptom status 1
• Review risk factor modification plan 1

Intermediate Follow-Up (4-6 Weeks)

• Reassess functional status 1
• Consider stress testing if not performed during hospitalization 1
• Optimize medical therapy doses 1

Long-Term Follow-Up (3 Months and Beyond)

• Monitor for recurrent symptoms 1
• Assess achievement of LDL-C goals 1
• Reinforce lifestyle modifications 1
• The acute phase risk typically resolves by 2-3 months, after which patients follow a course similar to chronic stable CAD 1

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Patient Education at Discharge

Mandatory education topics:

• Warning signs of recurrent ischemia: More frequent chest pain, pain at rest, pain with less exertion, or pain lasting >2-3 minutes 1
• When to call 9-1-1: Chest pain unimproved after 5 minutes and 1 nitroglycerin dose 1
• Medication purpose, dosing, and side effects in culturally sensitive, easily understood language 1
• Activity restrictions: Private drivers can resume driving 1 week post-discharge if stable; commercial drivers require 3-month restriction 5
• Risk factor modification: Smoking cessation, diet, exercise, weight management 1

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Common Pitfalls to Avoid

• Discharging too early: Patients with any high-risk feature require extended monitoring until stabilized 1
• Inadequate DAPT duration: Must continue for 12 months unless prohibitive bleeding risk 1, 2
• Suboptimal statin dosing: Must use high-intensity statin regardless of baseline LDL 2
• Missing ACE inhibitor indication: Mandatory for LVEF <40%, heart failure, diabetes, hypertension, or anterior MI 1, 2
• Forgetting nitroglycerin prescription: Required for ALL patients 1, 2
• Inadequate patient education: Patients must understand warning signs and when to seek emergency care 1