Blood Pressure Management and Antiplatelet Therapy in Post‑NSTEMI Patients

Target Blood Pressure

The primary blood‑pressure goal for patients after a non‑ST‑segment elevation myocardial infarction (NSTEMI) is < 140/90 mm Hg. (Class I, Level A) 2

Bisoprolol (or an equivalent β‑blocker) should be continued indefinitely after NSTEMI and titrated to an adequate dose before adding other agents. (Class I) 3

ACE inhibitors are Class I, Level A recommendations for all post‑NSTEMI patients, especially when hypertension persists despite β‑blocker therapy. (Class I, Level A) 3
Initiate an ACE inhibitor (e.g., lisinopril, ramipril, enalapril) at standard starting doses early after the event and continue indefinitely in patients with hypertension, heart failure, left‑ventricular ejection fraction < 40 %, or diabetes mellitus. (Class I) 1
ACE‑inhibitor therapy confers a mortality benefit beyond blood‑pressure reduction in post‑MI patients. (Class I) 2
If an ACE inhibitor is not tolerated (e.g., cough, angio‑edema), substitute an angiotensin‑receptor blocker (ARB). (Class I) 3

If blood pressure remains ≥ 140/90 mm Hg after ACE‑inhibitor addition, add a thiazide‑type diuretic (hydrochlorothiazide or chlorthalidone). (Class I) 2
Long‑acting dihydropyridine calcium‑channel blockers (e.g., amlodipine) may be added for further BP control, but short‑acting nifedipine should be avoided because it may increase post‑MI mortality. (Class I) 2

Add an aldosterone antagonist (spironolactone or eplerenone) when LVEF ≤ 40 % with heart failure or diabetes mellitus, provided renal function and potassium are acceptable. (Class I) 3
Renal‑function and potassium thresholds before aldosterone‑blockade: serum creatinine < 2.5 mg/dL (men) or < 2.0 mg/dL (women) and potassium ≤ 5.0 mmol/L. (Class I) 4

Aspirin plus clopidogrel is the recommended DAPT regimen after NSTEMI. (Class I) 3
DAPT duration varies by stent type:
- Bare‑metal stent: aspirin 162–325 mg daily ≥ 1 month, then 75–162 mg indefinitely; clopidogrel 75 mg daily ≥ 1 month (ideally up to 12 months). (Class I) 3
- Drug‑eluting stent: aspirin 162–325 mg daily for 3–6 months (depending on stent), then 75–162 mg indefinitely; clopidogrel 75 mg daily ≥ 12 months. (Class I) 3
- No stent (medical management): aspirin 75–162 mg indefinitely; clopidogrel 75 mg daily ≥ 1 month, ideally up to 12 months. (Class I) 3

Avoid short‑acting dihydropyridines (e.g., immediate‑release nifedipine) because they may increase mortality after MI. (Class III, Harm) 2
Avoid non‑dihydropyridine CCBs (diltiazem, verapamil) in patients with heart failure, left‑ventricular dysfunction, or bradyarrhythmias. (Class III, Harm) 2

Re‑measure blood pressure 2–4 weeks after ACE‑inhibitor initiation to assess response. (Class I) 2
Check serum creatinine and potassium 1–2 weeks after starting an ACE inhibitor (and again after adding an aldosterone antagonist) to detect renal impairment or hyperkalaemia. (Class I) 3
Assess medication adherence and side‑effects at each follow‑up visit. (Class I) 3