Medication Management After NSTEMI Confirmation

Initial Antiplatelet Therapy

• The American College of Cardiology recommends administering aspirin as soon as possible after hospital presentation and continuing indefinitely in patients who tolerate it, with a recommended dose of 81 mg daily 1, 4, 5, 6
• For invasive strategy patients, the American Heart Association suggests using a P2Y12 inhibitor, such as clopidogrel (loading dose 600 mg) or ticagrelor (loading dose 180 mg), before PCI, and maintaining with clopidogrel 75 mg daily, prasugrel 10 mg daily, or ticagrelor 90 mg twice daily for at least 12 months 1, 2, 3, 4, 5
• For conservative strategy patients, the American College of Cardiology recommends using clopidogrel (loading dose followed by 75 mg daily) or ticagrelor (loading dose followed by 90 mg twice daily) and continuing for up to 12 months 2, 4, 6

Anticoagulation

• The American College of Cardiology suggests initiating anticoagulant therapy along with antiplatelet therapy, with options including unfractionated heparin, low molecular weight heparin, fondaparinux, or bivalirudin (particularly if PCI is planned) 1, 3, 4, 9

Beta-Blockers

• The American Heart Association recommends starting beta-blockers within a few days of the event if not initiated acutely and continuing indefinitely unless contraindicated 6

Special Considerations

• For patients unable to take aspirin, the American College of Cardiology suggests using clopidogrel, prasugrel (in PCI-treated patients), or ticagrelor as monotherapy 1, 9
• For patients with recurrent symptoms on initial conservative therapy, the American College of Cardiology recommends adding a GP IIb/IIIa inhibitor (eptifibatide or tirofiban) before diagnostic angiography 2, 3
• For patients with indication for anticoagulation, the American College of Cardiology suggests considering adding warfarin to maintain INR 2.0-3.0 5, 6

Common Pitfalls to Avoid

• The American College of Cardiology advises against inappropriate use of prasugrel in contraindicated populations (prior stroke/TIA, elderly ≥75 years, low body weight <60 kg) 7
• The American Heart Association recommends avoiding the use of two concurrent P2Y12 receptor inhibitors (not recommended) 1, 9