NSTEMI Treatment Guidelines

Initial Management

The American College of Cardiology recommends administering aspirin 162-325 mg immediately upon presentation to patients with NSTEMI, followed by admission to a monitored unit with continuous rhythm monitoring for at least 24 hours 1, 2
The American College of Cardiology suggests administering supplemental oxygen if arterial oxygen saturation is <90% to patients with NSTEMI 1, 3
Consider nitroglycerin for ongoing ischemic symptoms unless contraindicated (systolic BP <90 mmHg, severe bradycardia, tachycardia without heart failure, right ventricular infarction, or recent use of phosphodiesterase inhibitors) in patients with NSTEMI 1, 2
Initiate beta-blockers to reduce myocardial oxygen demand by decreasing heart rate, blood pressure, and myocardial contractility in patients with NSTEMI 1, 3

The European Society of Cardiology recommends continuing aspirin indefinitely at a dose of 75-162 mg daily in patients with NSTEMI 1, 4
Add a P2Y12 receptor inhibitor to aspirin for 12 months, unless contraindicated or at high risk of bleeding, in patients with NSTEMI 3, 1
The European Society of Cardiology suggests using ticagrelor (loading dose 180 mg, 90 mg twice daily) regardless of the planned treatment strategy in patients with NSTEMI 4, 3

The American Heart Association recommends administering parenteral anticoagulation to all NSTEMI patients in addition to antiplatelet therapy 1, 3
Options include unfractionated heparin (UFH) for at least 48 hours or until discharge if given before diagnostic angiography in patients with NSTEMI 1, 5

An early invasive strategy (angiography within 24-48 hours) is indicated for patients with refractory angina, hemodynamic or electrical instability, elevated cardiac biomarkers, or high GRACE or TIMI risk score 1, 3, 2

If PCI is selected, continue aspirin (Level of Evidence: A) and administer a loading dose of P2Y12 inhibitor if not started before diagnostic angiography in patients with NSTEMI 1, 5

Measure left ventricular ejection fraction (LVEF) and consider diagnostic angiography if LVEF ≤0.40 in patients with NSTEMI 1, 3
Initiate ACE inhibitors for patients with heart failure, LV dysfunction (LVEF <0.40), hypertension, or diabetes 1, 3
Consider ARBs for ACE inhibitor-intolerant patients with NSTEMI 1, 3

Avoid NSAIDs (except for aspirin) during hospitalization due to increased risks of mortality, reinfarction, hypertension, heart failure, and myocardial rupture in patients with NSTEMI 1, 2
Do not administer immediate-release dihydropyridine calcium channel blockers without adequate beta-blockade in patients with NSTEMI 1, 2