Acute coronary syndrome: management of NSTEMI
NICE produced guidelines in 2013 on the Secondary prevention in primary and secondary care for patients following a myocardial infarction management of unstable angina and non-ST elevation myocardial infarction (NSTEMI). These superceded the 2010 guidelines which advocated a risk-based approach to management which determined whether drugs such as clopidogrel were given.
All patients should receive
Whilst it is common that non-hypoxic patients receive oxygen therapy there is little evidence to support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic.
Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l unfractionated heparin should be given.
Ticagrelor Is recommended as a treatment option in addition to aspirin for up to 12 months for patients with acute coronary syndromes (STEMI, NSTEMI, unstable angina)
Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
Coronary angiography should be considered within 96 hours of first admission
to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.
The table below summaries the mechanism of action of drugs commonly used in the management of acute coronary syndrome:
All patients should receive
- aspirin 300mg (then continued indefinitely. Offer clopidogrel if intolerant)
- nitrates or morphine to relieve chest pain if required
Whilst it is common that non-hypoxic patients receive oxygen therapy there is little evidence to support this approach. The 2008 British Thoracic Society oxygen therapy guidelines advise not giving oxygen unless the patient is hypoxic.
Antithrombin treatment. Fondaparinux should be offered to patients who are not at a high risk of bleeding and who are not having angiography within the next 24 hours. If angiography is likely within 24 hours or a patients creatinine is > 265 µmol/l unfractionated heparin should be given.
Ticagrelor Is recommended as a treatment option in addition to aspirin for up to 12 months for patients with acute coronary syndromes (STEMI, NSTEMI, unstable angina)
OR
Clopidogrel 300mg initial dose then 75mg daily continued for 12 months.Intravenous glycoprotein IIb/IIIa receptor antagonists (eptifibatide or tirofiban) should be given to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
Coronary angiography should be considered within 96 hours of first admission
to hospital to patients who have a predicted 6-month mortality above 3.0%. It should also be performed as soon as possible in patients who are clinically unstable.
The table below summaries the mechanism of action of drugs commonly used in the management of acute coronary syndrome:
| Medication | Mechanism of action |
|---|---|
| Aspirin | Antiplatelet - inhibits the production of thromboxane A2 |
| Clopidogrel | Antiplatelet - inhibits ADP binding to its platelet receptor |
| Ticagrelor | Antiplatelet - P2Y12 ADP receptor blocker inhibits platelet activation |
| Enoxaparin | Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa |
| Fondaparinux | Activates antithrombin III, which in turn potentiates the inhibition of coagulation factors Xa |
| Bivalirudin | Reversible direct thrombin inhibitor |