From the Guidelines
NSTEMI management should prioritize dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor, along with anticoagulation and risk stratification to reduce morbidity, mortality, and improve quality of life. 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. Initial treatment includes:
- Aspirin (325mg loading dose, then 81mg daily indefinitely)
- A P2Y12 inhibitor such as ticagrelor (180mg loading dose, then 90mg twice daily) or clopidogrel (600mg loading dose, then 75mg daily)
- Anticoagulation with unfractionated heparin, enoxaparin, or fondaparinux
- Beta-blockers (metoprolol 25-50mg orally twice daily) and high-intensity statins (atorvastatin 40-80mg daily) should be started early
- Pain management with nitroglycerin and morphine as needed is important
- Oxygen should be administered only if saturation is below 90%
- An early invasive strategy with coronary angiography within 24 hours is recommended for high-risk patients (elevated troponins, dynamic ECG changes, GRACE score >140), while those at lower risk may undergo angiography within 72 hours 1. Key considerations in NSTEMI management include:
- Risk stratification to guide treatment decisions
- Early initiation of evidence-based therapies to reduce morbidity and mortality
- Individualized treatment plans based on patient characteristics and clinical presentation
- Close monitoring and adjustment of treatment as needed to optimize outcomes.
From the FDA Drug Label
1.1 Acute Coronary Syndrome 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) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.
NSTEMI Management:
- Prasugrel is indicated to reduce the rate of thrombotic CV events in patients with NSTEMI who are to be managed with PCI.
- The recommended dosage is a single 60 mg oral loading dose and then continue at 10 mg orally once daily.
- Patients taking prasugrel should also take aspirin (75 mg to 325 mg) daily.
- The loading dose of prasugrel should not be administered until coronary anatomy is established in UA/NSTEMI patients 2.
From the Research
NSTEMI Management Overview
- NSTEMI management involves antithrombotic therapy, including antiplatelet and anticoagulant therapy 3, 4
- Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor is the mainstay of treatment for NSTEMI patients 3, 4
Anticoagulation Therapy
- Unfractionated heparin (UFH) is widely used in patients with ACS treated interventionally, but novel alternative parenteral anticoagulant strategies include low molecular weight heparin enoxaparin and the synthetic pentasaccharide fondaparinux 3
- The direct parenteral factor IIa (thrombin) inhibitor bivalirudin is as effective as the regimen of UFH plus GPIIb/IIIa inhibitor in NSTEMI patients undergoing PCI 3
Antiplatelet Therapy
- DAPT with aspirin and clopidogrel significantly reduces ischemic events in NSTEMI patients, but novel generation P2Y12 receptor blockers, such as prasugrel and ticagrelor, may provide more potent antithrombotic treatment regimens 4
- Adjunctive antiplatelet or anticoagulant therapies, such as vorapaxar or rivaroxaban, may also be used for long-term prevention of atherothrombotic events in NSTEMI patients 4
Treatment Duration and Risks
- Prolonging intensified antiplatelet therapy beyond 1 year has been investigated, but this occurs at the expense of an increased risk of bleeding complications 4
- The novel approach of long-term low-dose factor Xa inhibition with rivaroxaban has been shown to reduce cardiovascular mortality in clinical trials, but its use in daily clinical practice is still being established 3