Management of NSTEMI Without Revascularization

Immediate Antiplatelet Therapy

The European Society of Cardiology recommends initiating dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor (preferably ticagrelor or prasugrel over clopidogrel) for 12 months, combined with parenteral anticoagulation, beta-blockers, statins, ACE inhibitors, and anti-ischemic medications in NSTEMI patients managed medically without stent or CABG 1
Aspirin should be administered immediately at 150-300 mg loading dose, then 75-100 mg daily indefinitely 1
Ticagrelor is recommended as the first choice P2Y12 inhibitor, with a loading dose of 180 mg, then 90 mg twice daily for 12 months, regardless of conservative management strategy 1, 2, 3
Prasugrel is an alternative P2Y12 inhibitor, with a loading dose of 60 mg, then 10 mg daily (reduce to 5 mg daily if age ≥75 years or body weight <60 kg) 1

Fondaparinux 2.5 mg subcutaneously once daily is the preferred option for medical management, with the best efficacy-safety profile for conservative management 1
Low molecular weight heparin (LMWH) such as enoxaparin is an alternative, dosed according to weight and renal function, and is at least as effective as unfractionated heparin with easier administration 1
Unfractionated heparin (UFH) can be used if LMWH or fondaparinux are unavailable, with a weight-adjusted IV bolus followed by continuous infusion (aPTT target 1.5-2.5 times control) 1

Beta-blockers should be initiated early in patients with ongoing ischemic symptoms without contraindications (heart failure, hypotension, bradycardia, or heart block) 1
Nitrates can be used for ongoing chest pain, uncontrolled hypertension, or signs of heart failure 1

High-intensity statin therapy should be initiated immediately, regardless of baseline cholesterol, to reduce recurrent events 4, 2
Aspirin plus P2Y12 inhibitor should be continued for 12 months, unless excessive bleeding risk, then transition to aspirin monotherapy indefinitely 1, 2, 3

In patients with renal impairment, anticoagulant and antiplatelet doses should be adjusted accordingly, and low- or iso-osmolar contrast should be used if angiography is performed 5, 6
In elderly patients (≥75 years), the same diagnostic and therapeutic strategies should be applied, but with reduced prasugrel dose to 5 mg daily if used, and antithrombotic dosing adjusted based on renal function and bleeding risk 1, 5, 6

For NSTEMI patients with atrial fibrillation, triple therapy (aspirin + clopidogrel + OAC) should be transitioned to dual therapy with oral anticoagulant plus single antiplatelet agent (preferably clopidogrel) after the acute phase (up to 1 week) 1

Patients with high-risk features (GRACE score >140, ongoing ischemia, hemodynamic instability, or life-threatening arrhythmias) require intensive monitoring and reconsideration of invasive strategy 1, 5, 4, 2
Low-risk patients (GRACE <109) can be managed conservatively with selective invasive strategy only if ischemia testing demonstrates significant reversible ischemia 5, 4, 2