The following are key points to remember from this document on antithrombotic therapy and revascularization strategies in non-ST-elevation acute coronary syndrome (NSTE-ACS):

Antiplatelet management in NSTE-ACS:

1. Among patients with NSTE-ACS undergoing an invasive approach, there is no benefit of pretreatment with a P2Y₁₂ inhibitor. After percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) (aspirin + P2Y₁₂ inhibitor) is recommended for 12 months but can be considered for a shorter duration (P2Y₁₂ inhibitor therapy alone without aspirin after 3 months) for patients who are high risk of bleeding.
2. Patients with high-risk clinical (diabetes, multivessel coronary artery disease [CAD], systemic inflammatory diseases, chronic kidney disease) or technical features (>3 stents, >3 lesions treated, >60 mm of stents, chronic total occlusion, or bifurcation PCI) for recurrent ischemic events and low bleeding risk after initial NSTE-ACS, should be considered for longer-duration antithrombotic therapy (beyond 12 months). Treatment options include a dual antithrombotic therapy (DAT) regimen with aspirin and rivaroxaban (2.5 mg twice daily) or a DAPT regimen with aspirin and ticagrelor (60 mg BID), prasugrel (5 or 10 mg once daily), or clopidogrel (75 mg once daily).

Anticoagulation and antiplatelet therapy:

1. No interruption of vitamin K antagonist (VKA) or non-VKA oral anticoagulant (NOAC) is needed if a radial approach is chosen among patients undergoing invasive management on chronic systemic anticoagulation.
2. For most patients who undergo PCI, NOAC is preferred over VKA for stroke prevention related to atrial fibrillation and elevated thromboembolic risk. Triple antithrombotic therapy (TAT) with ASA + P2Y₁₂ inhibitor + NOAC for 1 week followed by NOAC and single antiplatelet therapy (preferably clopidogrel) is recommended for 12 months. For patients who are at high ischemic/thrombotic risk, TAT can be continued for up to 1 month.
3. Use of HAS-BLED and ARC-HBR are useful to assess bleeding risk in individual patients and to facilitate informed decision making.

Revascularization strategies:

1. At least 50% of patients with NSTE-ACS and obstructive CAD have multivessel CAD. Echocardiogram-based wall motion abnormality or electrocardiogram-based localization should be considered to identify a culprit lesion/vessel given that registry data suggest increased in-hospital mortality with a single-stage complete revascularization strategy compared to culprit lesion-only PCI.
2. Less is more with NSTE-ACS and cardiogenic shock. Culprit lesion-only PCI is associated with reduced mortality at 30 days and 1 year compared to immediate multivessel CAD (CULPRIT-SHOCK trial).
3. Mechanical circulatory support (MCS) and/or venoarterial extracorporeal membrane oxygenation (VA-ECMO) is being evaluated in randomized controlled trials for very high risk NSTE-ACS and cardiogenic shock. MCS or VA-ECMO support might be considered after heart team discussion in certain patients based on age, comorbidities, and severity of cardiogenic shock.
4. For patients with out-of-hospital arrest and NSTE-ACS, an unselected immediate invasive strategy is not superior over a delayed invasive strategy in out-of-hospital cardiac arrest and hemodynamically stable NSTE-ACS (based on results from the COACT [Coronary Angiography After Cardiac Arrest] trial).
5. For patients presenting with myocardial infarction with no obstructive coronary arteries, intravascular imaging with optical coherence tomography can help ascertain the mechanism of NSTE-ACS (plaque disruption, spontaneous coronary artery dissection [SCAD]).
6. Management of SCAD is usually conservative. Medical therapy with antihypertensive therapy is preferred over PCI.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Anticoagulants, Antihypertensive Agents, Aspirin, Atrial Fibrillation, Coronary Angiography, Coronary Artery Disease, Diabetes Mellitus, Dissection, Electrocardiography, Extracorporeal Membrane Oxygenation, Fibrinolytic Agents, Myocardial Revascularization, Out-of-Hospital Cardiac Arrest, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Renal Insufficiency, Chronic, Secondary Prevention, Shock, Cardiogenic, Stents, Stroke, Tomography, Optical Coherence, Vitamin K

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