What is the management of Non-ST-Elevation Myocardial Infarction (NSTEMI) in the Emergency Department (ED)?

From the Guidelines

Management of NSTEMI in the ED should prioritize stabilization, risk stratification, and initiating appropriate therapy, with a focus on administering aspirin, anticoagulation, and a P2Y12 inhibitor, as well as pain control and beta-blockers, as recommended by the most recent guidelines 1. The initial management of NSTEMI in the ED involves several key components, including:

• Administering aspirin 325mg chewed immediately, followed by a maintenance dose of 81mg daily
• Starting anticoagulation with either unfractionated heparin or enoxaparin
• Giving a P2Y12 inhibitor such as ticagrelor (180mg loading dose, then 90mg twice daily) or clopidogrel (600mg loading dose, then 75mg daily)
• Pain control with nitroglycerin and morphine
• Administering beta-blockers like metoprolol if there are no contraindications
• Initiating high-intensity statins such as atorvastatin 80mg daily
• Providing oxygen only if saturation is below 90%
• Continuous cardiac monitoring, serial ECGs, and cardiac biomarkers are essential
• Risk stratification using the TIMI or GRACE score helps determine the timing of cardiac catheterization, with high-risk patients requiring intervention within 24 hours, as supported by the 2020 ESC guidelines 1. In patients with NSTEMI and heart failure or cardiogenic shock, emergency coronary angiography and PCI of the culprit lesion are recommended, with a focus on culprit-lesion-only PCI, as demonstrated by the CULPRIT-SHOCK trial 1. The management of NSTEMI in the ED requires a comprehensive approach that addresses the thrombotic cascade, reduces myocardial oxygen demand, and prepares the patient for definitive management, with a focus on improving morbidity, mortality, and quality of life, as emphasized by the European Society of Cardiology guidelines 1.

From the FDA Drug Label

Prasugrel tablets are a P2Y12 platelet inhibitor indicated for the reduction of thrombotic cardiovascular events (including stent thrombosis) in patients with acute coronary syndrome who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina or non-ST-elevation myocardial infarction (NSTEMI) (1. 1).

The management of NSTEMI in the ED involves the use of prasugrel, a P2Y12 platelet inhibitor, as part of the treatment for patients who are to be managed with percutaneous coronary intervention (PCI).

• The initial dose is a single 60 mg oral loading dose, followed by 10 mg once daily.
• Patients should also take aspirin (75 mg to 325 mg) daily. 2

From the Research

Management of NSTEMI in the ED

The management of Non-ST-segment elevation myocardial infarction (NSTEMI) in the Emergency Department (ED) involves several key components, including:

• Risk stratification to determine the individualized patient risk assessment
• Anti-anginal, anticoagulant, antiplatelet, and other pharmacologic therapies based on the patient's risk assessment 3
• Consideration of the patient's comorbidity burden and diverse etiologies that add complexity to therapeutic decision-making 3

Pharmacologic Therapies

Pharmacologic therapies for NSTEMI patients include:

• Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 receptor inhibitor, such as clopidogrel, prasugrel, or ticagrelor 4, 5
• Anticoagulant therapy, such as warfarin, in patients who require systemic anticoagulation and undergo percutaneous coronary intervention (PCI) 6
• Pretreatment with P2Y12 inhibitors before PCI to reduce the incidence of recurrent ischemic events without increasing the risk of major bleeding 7

Considerations for P2Y12 Inhibitors

Considerations for the use of P2Y12 inhibitors in NSTEMI patients include:

• Timing: Pretreatment with P2Y12 inhibitors before PCI may be beneficial in reducing ischemic events 7
• Selection: The choice of P2Y12 inhibitor, such as clopidogrel, prasugrel, or ticagrelor, should be based on individual patient characteristics and risk factors 5
• Modulation: The dose and duration of P2Y12 inhibitor therapy should be tailored to the individual patient's needs and risk factors 5
• Duration: The duration of P2Y12 inhibitor therapy should be based on the individual patient's risk of ischemic and bleeding events 5

Bleeding Risks

Bleeding risks associated with P2Y12 inhibitors and other antithrombotic therapies should be carefully considered, particularly in patients who require triple antithrombotic therapy with aspirin, a P2Y12 inhibitor, and warfarin 6