Which acute coronary syndrome medications should be given to a patient with an NSTEMI and rising troponin I but no chest pain?

Medications for NSTEMI with Rising Troponin I but No Chest Pain

All NSTEMI patients require immediate antiplatelet and anticoagulation therapy regardless of whether chest pain is present, as rising troponin I indicates ongoing myocardial injury that demands urgent pharmacologic intervention. 1, 2

Immediate Antiplatelet Therapy

Aspirin

• Administer 162-325 mg non-enteric-coated aspirin immediately (chewed for faster absorption), followed by 75-100 mg daily indefinitely 1, 2
• This is a Class I, Level A recommendation and should be given to all NSTEMI patients at presentation 1

P2Y12 Inhibitor Selection

Choose ticagrelor as the preferred P2Y12 inhibitor for NSTEMI patients:

• Loading dose: 180 mg orally, then 90 mg twice daily 1, 2
• Ticagrelor is superior to clopidogrel and can be given before coronary anatomy is known 1, 2
• Continue for at least 12 months regardless of whether a stent is placed 1, 2

Alternative options if ticagrelor is unavailable or contraindicated:

• Clopidogrel: 600 mg loading dose, then 75 mg daily 1
• Prasugrel: 60 mg loading dose, then 10 mg daily (but only AFTER coronary anatomy is defined at angiography, and contraindicated if prior stroke/TIA) 1, 3

Immediate Anticoagulation Therapy

All NSTEMI patients require parenteral anticoagulation in addition to dual antiplatelet therapy 1, 2:

First-Line Options:

• Enoxaparin: 1 mg/kg subcutaneously every 12 hours (reduce to 1 mg/kg daily if CrCl <30 mL/min) 1, 2

  • Continue for duration of hospitalization, up to 8 days 1, 2
  • No routine monitoring required 2

• Fondaparinux: 2.5 mg subcutaneously daily 1

  • Lowest bleeding risk among anticoagulants 2
  • Continue for duration of hospitalization, up to 8 days 1
  • Critical: Must add UFH during PCI to prevent catheter thrombosis 2

• Unfractionated heparin (UFH): 60 U/kg IV bolus (max 4,000 U), then 12 U/kg/h infusion (max 1,000 U/h) 1, 2

  • Target aPTT 1.5-2.0 × control (50-70 seconds) 2
  • Continue for at least 48 hours or until PCI 1, 2
  • Preferred if severe renal impairment (CrCl <30 mL/min) 2

Anti-Ischemic Therapy (Even Without Chest Pain)

Beta-Blockers

• Initiate oral beta-blocker within first 24 hours unless contraindications exist (heart failure, low-output state, risk of cardiogenic shock) 1
• Class I, Level A recommendation 1
• Reduces myocardial oxygen demand by decreasing heart rate, blood pressure, and contractility 2

High-Intensity Statin

• Initiate immediately regardless of baseline LDL levels 1
• Class I, Level A recommendation 1
• Examples: atorvastatin 80 mg daily or rosuvastatin 40 mg daily 1

Nitroglycerin (If Needed)

• Not required if patient is pain-free, but have available for recurrent symptoms 1
• Contraindicated if recent phosphodiesterase inhibitor use (sildenafil/vardenafil within 24h, tadalafil within 48h) 1

Risk Stratification for Invasive Strategy

Rising troponin I is a high-risk feature mandating early invasive strategy 1, 2:

Immediate Invasive (<2 hours) if:

• Hemodynamic instability or cardiogenic shock 1, 2
• Life-threatening arrhythmias or cardiac arrest 1, 2
• Refractory ischemia despite medical therapy 1, 2

Early Invasive (24-48 hours) for:

• Elevated troponin with high-risk features (your patient) 1, 2
• High GRACE or TIMI risk score 1, 2
• Diabetes mellitus 1, 2

Critical Medications to AVOID

• NSAIDs (except aspirin): Absolutely contraindicated - increase mortality, reinfarction, heart failure, and myocardial rupture 1, 2
• Immediate-release nifedipine without beta-blocker: Contraindicated - causes reflex tachycardia 1
• IV beta-blockers: Potentially harmful if risk factors for shock present 1
• Routine upstream GP IIb/IIIa inhibitors: Not recommended - increased bleeding without benefit 2

Common Pitfalls

• Do not delay antiplatelet/anticoagulation therapy because patient lacks chest pain - troponin elevation alone indicates myocardial injury requiring immediate treatment 1, 2
• Do not switch between anticoagulants - increases bleeding risk 2
• Do not give prasugrel before knowing coronary anatomy - may need urgent CABG 1, 2, 3
• Do not discontinue aspirin or P2Y12 inhibitor early - dramatically increases risk of recurrent MI and stent thrombosis 1, 2