What is the treatment for Non-ST-Elevation Myocardial Infarction (NSTEMI)?

From the Guidelines

Treatment of NSTEMI requires immediate medical attention with a dual approach of medications and possible invasive procedures, with the most recent guidelines recommending an early invasive strategy with coronary angiography within 24-72 hours for most patients, especially those with high-risk features. The initial management includes administering aspirin, a P2Y12 inhibitor such as ticagrelor (preferred over clopidogrel) 1, and anticoagulation with unfractionated heparin, low molecular weight heparin, or fondaparinux. Additional medications include beta-blockers, high-intensity statins, and nitroglycerin for chest pain relief. The choice of antithrombotic regimen should be based on the selected management strategy and the chosen revascularization modality, with dosing taking into account patient age and renal function 1. Key considerations in the management of NSTEMI include:

• Early invasive strategy with coronary angiography within 24-72 hours for most patients, especially those with high-risk features like elevated troponin, dynamic ECG changes, or recurrent symptoms
• Administration of aspirin, a P2Y12 inhibitor, and anticoagulation
• Use of beta-blockers, high-intensity statins, and nitroglycerin as needed
• Consideration of patient age and renal function in dosing of antithrombotic agents
• Selection of revascularization modality based on coronary anatomy, with options including percutaneous coronary intervention (PCI) with stent placement or coronary artery bypass grafting (CABG). The most recent and highest quality study, the 2015 ESC guidelines 1, provides the basis for these recommendations, emphasizing the importance of an early invasive strategy and tailored antithrombotic therapy in improving outcomes for patients with NSTEMI.

From the FDA Drug Label

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.

• Treatment of NSTEMI:
  • Administer clopidogrel in conjunction with aspirin to reduce the rate of myocardial infarction and stroke in patients with NSTEMI.
  • Alternatively, tirofiban can be used in combination with heparin and aspirin to treat patients with NSTEMI, as shown in the PRISM-PLUS trial, which demonstrated a 32% risk reduction in the composite endpoint of refractory ischemia, new MI, and death within 7 days 2.
  • The choice of treatment should be individualized based on patient-specific factors and clinical judgment.

From the Research

Treatment of NSTEMI

The treatment of Non-ST-Elevation Myocardial Infarction (NSTEMI) involves the use of anticoagulant and antiplatelet therapy.

• Dual antiplatelet therapy composed of aspirin plus a third generation P2Y12 inhibitor (prasugrel or ticagrelor) represents the gold standard 3.
• Aspirin plus second generation P2Y12 inhibitor (clopidogrel) may be used as an alternative in the presence of contraindications for third generation P2Y12 inhibitors and/or a high risk of bleeding 3.
• Unfractionated heparin (UFH) has been the mainstay in anticoagulation for ACS for many decades and is still widely used in patients with ACS treated interventionally 3.
• Novel alternative parenteral anticoagulant strategies include the low molecular weight heparin enoxaparin and the synthetic pentasaccharide fondaparinux 3.

Antiplatelet Therapy

• Patients with unstable angina pectoris/NSTEMI should be treated with dual antiplatelet therapy with the use of aspirin plus either clopidogrel, prasugrel, or ticagrelor depending on the clinical circumstances 4.
• If ticagrelor is used, the dose of aspirin must not exceed 100 mg daily 4.
• Prasugrel must not be used in patients with a history of stroke or transient ischemic attack 4.

Aspirin Dosage

• The optimal dose of aspirin is unclear, but studies suggest that an initial dose of 162 mg may be as effective as and perhaps safer than 325 mg for the acute treatment of ST-elevation myocardial infarction 5.
• Aspirin dose was not associated with 24-hour, 7-day, or 30-day mortality rates, but 325 mg was associated with a significant increase in moderate/severe bleeding 5.