Management of Non-ST-Elevation Myocardial Infarction (NSTEMI)

Initial Assessment and Management

• The American College of Cardiology recommends an early invasive strategy (within 12-24 hours of admission) for high-risk NSTEMI patients, with dual antiplatelet therapy consisting of aspirin and a P2Y12 inhibitor, along with anticoagulation therapy 1, 2
• High-sensitivity cardiac troponin (hs-cTn) should be measured serially for both diagnosis and prognostic assessment in NSTEMI patients 4
• Echocardiography should be performed to evaluate regional and global left ventricular function in NSTEMI patients 4

Antiplatelet Therapy

• The American Heart Association recommends aspirin to be administered to all NSTEMI patients without contraindications at an initial oral loading dose of 150-300 mg, followed by 75-100 mg daily for long-term treatment 5
• A P2Y12 receptor inhibitor should be added to aspirin and maintained for 12 months unless contraindicated or there is excessive bleeding risk, according to the American College of Cardiology 2
• Options for P2Y12 inhibitors include clopidogrel, ticagrelor, and prasugrel, with specific loading and maintenance doses 5, 6

Anticoagulation Therapy

• Parenteral anticoagulation is recommended for all NSTEMI patients in addition to antiplatelet therapy, according to the American Heart Association 7
• Options for anticoagulation include unfractionated heparin, enoxaparin, fondaparinux, and bivalirudin, with specific administration guidelines 6, 7

Management Strategy Selection

• An early invasive strategy is indicated for NSTEMI patients with refractory angina, hemodynamic or electrical instability, elevated risk for clinical events, or positive troponin, according to the American College of Cardiology 1, 2
• A conservative strategy may be considered for initially stabilized NSTEMI patients with elevated risk for clinical events, according to the American College of Cardiology 1, 2

Post-Angiography Management

• For NSTEMI patients undergoing PCI, aspirin should be continued indefinitely and a P2Y12 inhibitor should be given for at least 12 months, according to the American College of Cardiology 2, 6
• For NSTEMI patients undergoing CABG, aspirin should be continued and clopidogrel should be discontinued 5-7 days before elective CABG, according to the American Heart Association 8

Long-term Pharmacotherapy

• Beta-blockers are indicated for all NSTEMI patients recovering from NSTEMI unless contraindicated, according to the American College of Cardiology 3, 4
• ACE inhibitors should be given and continued indefinitely for NSTEMI patients with heart failure, LV dysfunction, hypertension, or diabetes, according to the American College of Cardiology 3