From the Guidelines
Not all NSTEMI patients require immediate cardiac catheterization, and a selective invasive approach can be appropriate for lower-risk patients. The evidence from trials such as FRISC-II 1 and TACTICS-TIMI 18 1 suggests that while high-risk NSTEMI patients benefit from an early invasive strategy, lower-risk patients can be managed conservatively with medical therapy without immediate catheterization.
Key Findings
- The FRISC-II trial 1 found that patients with UA/NSTEMI who are not at very high risk for revascularization and who first receive an average of 6 days of treatment with LMWH, ASA, nitrates, and beta blockers have a better outcome at 6 months with a delayed routine invasive approach than with a routine conservative approach.
- The TACTICS-TIMI 18 trial 1 demonstrated that an early invasive strategy with routine coronary angiography within 48 hours followed by revascularization if the coronary anatomy was deemed suitable reduced death, MI, or rehospitalization for ACS at 6 months compared to a more conservative strategy.
Trial Names
- FRISC-II 1
- TACTICS-TIMI 18 1
- RITA-3 1
- VINO trial (Value of first day angiography/angioplasty In evolving Non–ST-segment elevation myocardial infarction: Open multicenter randomized trial) 1
- ISAR-COOL trial 1
Recommendations
- A selective invasive approach can be appropriate for lower-risk NSTEMI patients, reserving catheterization for patients with recurrent ischemia or high-risk features.
- High-risk NSTEMI patients benefit from an early invasive strategy, which should be considered on a case-by-case basis.
- The use of a GP IIb/IIIa inhibitor, such as tirofiban, may eliminate the excess risk of early MI in the invasive arm, as seen in the TACTICS-TIMI 18 trial 1.
From the Research
Evidence of NSTEMI Management
- Not all NSTEMI patients undergo catheterization, as seen in the study 2, which compared invasive versus non-invasive management of older patients with NSTEMI.
- The study 2 found that invasive management was associated with lower adjusted cumulative 5-year mortality and lower incidence of hospital admissions for heart failure in patients aged 80 years or older with NSTEMI.
Trial Name
- The trial name mentioned in the provided studies is the CURE (clopidogrel in unstable angina to prevent recurrent events) trial, which demonstrated the benefit of dual anti-aggregation therapy with aspirin and clopidogrel in patients with acute coronary syndromes (ACS) undergoing invasive treatment 3.
Management of NSTEMI
- Anticoagulants play a vital role as part of the antithrombotic therapy of myocardial infarction and are complementary to antiplatelet therapies 4.
- Patients presenting with NSTEMI should be initiated on anticoagulation for the initial hospitalization period or until percutaneous coronary intervention 4.
- Longer-term management of NSTEMI for patients with an existing indication for long-term anticoagulation should comprise triple antithrombotic therapy of anticoagulant with aspirin and clopidogrel for up to 1 month, followed by anticoagulant plus clopidogrel for up to 1 year, and then anticoagulant monotherapy thereafter 4.