What is the management of Non-ST-Elevation Myocardial Infarction (NSTEMI)?

From the Guidelines

The management of NSTEMI should prioritize dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor, along with anticoagulation and risk stratification, as recommended by the 2015 ESC guidelines 1. The initial treatment should include aspirin 325mg loading dose followed by 81mg daily indefinitely, plus a P2Y12 inhibitor such as ticagrelor 180mg loading dose followed by 90mg twice daily, which is preferred over clopidogrel 1. Anticoagulation should be started with unfractionated heparin, enoxaparin, or fondaparinux. Key considerations in NSTEMI management include:

• High-risk patients should undergo coronary angiography within 24 hours, while intermediate-risk patients can be evaluated within 72 hours.
• Additional medications include beta-blockers, high-intensity statins, and ACE inhibitors or ARBs for patients with left ventricular dysfunction.
• Risk factor modification is essential post-discharge, including smoking cessation, blood pressure control, diabetes management, and cholesterol management. The choice of antithrombotic regimen should be based on the selected management strategy and revascularization modality, taking into account patient age and renal function 1. The TACTICS-TIMI 18 trial and the RITA 3 trial have shown that an invasive strategy can reduce the risk of death or infarction in high- and intermediate-risk patients with NSTEMI 1. However, the most recent and highest quality study, the 2015 ESC guidelines, should be prioritized in guiding NSTEMI management 1.

From the FDA Drug Label

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 are indicated to reduce the rate of myocardial infarction (MI) and stroke. 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)

NSTEMI Management:

• Clopidogrel: 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]) 2
• Prasugrel: 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), including patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) 3
• The choice between clopidogrel and prasugrel should be based on individual patient factors, including the risk of bleeding and the potential benefits of each medication.
• Key considerations:
  • Bleeding risk: Prasugrel may have a higher risk of bleeding compared to clopidogrel, particularly in patients ≥75 years of age or those with a history of prior transient ischemic attack or stroke.
  • Concomitant medications: Avoid concomitant use of medications that increase the risk of bleeding, such as warfarin, heparin, fibrinolytic therapy, or chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs).

From the Research

NSTEMI Management Overview

• NSTEMI management involves anticoagulation and antiplatelet therapy to prevent further clotting and reduce the risk of adverse outcomes 4, 5.
• Anticoagulants, such as heparin or low molecular weight heparin, are recommended for the initial hospitalization period, while patients with existing indications for long-term anticoagulation may require triple antithrombotic therapy 4.

Anticoagulation Strategies

• The use of anticoagulants, such as unfractionated heparin, low molecular weight heparin, or fondaparinux, is essential in the acute setting to antagonize the ongoing clotting cascade 5.
• Novel anticoagulant strategies, including the use of direct oral anticoagulants (DOACs), may be considered for long-term management, especially in patients with atrial fibrillation 4, 6.

Antiplatelet Therapy

• Dual antiplatelet therapy, consisting of aspirin and a P2Y12 inhibitor, is the gold standard for patients with NSTEMI 5, 7.
• The choice of P2Y12 inhibitor, such as clopidogrel, ticagrelor, or prasugrel, depends on the patient's risk profile and the presence of contraindications 5, 7, 6.

Upstream Loading of P2Y12 Inhibitors

• Upstream loading of P2Y12 inhibitors, given at least 4 hours before diagnostic angiography, may be associated with low rates of bleeding and short length of stay in patients with NSTEMI 7.

Special Patient Populations

• Patients with atrial fibrillation undergoing percutaneous coronary intervention may require triple antithrombotic therapy, including oral anticoagulation, aspirin, and a P2Y12 inhibitor 6.
• The choice of P2Y12 inhibitor in these patients should be based on the risk of bleeding and major adverse cardiac events 6.