The following are 10 points to remember about the evaluation and treatment of patients without persistent ST-segment elevation (electrocardiographic [ECG] changes may include transient ST-segment elevation lasting <20 minutes, persistent or transient ST-segment depression, T-wave inversion, flat T waves, pseudonormalization of T waves, or no ECG changes):

1. In non–ST-segment elevation acute coronary syndrome (NSTE-ACS), the Global Registry of Acute Coronary Events (GRACE) risk score provides the most accurate stratification of risk both on admission and at discharge. A GRACE score >140 signifies high risk.
2. In patients at risk of developing cardiogenic shock (i.e., age >70 years, heart rate >110 bpm, systolic blood pressure <120 mm Hg), the observed shock or death rate was significantly increased in patients receiving beta-blockers within 24 hours of hospital admission.
3. As the optimal timing of ticagrelor or clopidogrel administration in NSTE-ACS patients scheduled for an invasive strategy has not been adequately investigated, no recommendation for or against pretreatment with these agents can be formulated. Based on the ACCOAST (the Comparison of Prasugrel at the Time of Percutaneous Coronary Intervention or as Pretreatment at the Time of Diagnosis in Patients with Non-ST Elevation Myocardial Infarction) trial, pre-treatment with prasugrel is not recommended.
4. A P2Y₁₂ inhibitor is recommended in addition to aspirin, for 12 months following NSTE-ACS unless there are contraindications. Clopidogrel (300-600 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation (Class I, Level of Evidence B). Prasugrel is contraindicated in patients with prior stroke/transient ischemic attack; and there is no apparent benefit with prasugrel in patients >75 years of age or with low bodyweight (60 kg). Previous intracranial hemorrhage is a contraindication to the use of ticagrelor.
5. Cangrelor is an intravenous adenosine triphosphate (ATP) analogue that binds reversibly and with high affinity to the platelet P2Y₁₂ receptor, and has a high affinity to the platelet P2Y₁₂ receptor and has a short plasma half-life (<10 minutes). Cangrelor may be considered in P2Y₁₂ inhibitor-naïve patients undergoing percutaneous coronary intervention (PCI) (Class IIb, Level of Evidence A).
6. In patients on an oral anticoagulant, the following are suggested strategies to reduce bleeding risk related to PCI:
   • In patients on vitamin K antagonists, avoid administration of unfractionated heparin if international normalized ratio is >2.5 (Class I, Level of Evidence C)
   • In patients on novel oral anticoagulants (NOACs), regardless of the timing of the administration of the NOAC, low-dose parenteral anticoagulation should be used (Class I, Level of Evidence C).
   • Glycoprotein IIb/IIIa inhibitors should be used only for bailout of periprocedural complications.
7. If a patient is at high bleeding risk (HAS-BLED ≥3), triple therapy with oral anticoagulant (OAC), aspirin (75-100 mg/day), and clopidogrel 75 mg/day should be considered for a duration of 1 month, followed by OAC and aspirin 75-100 mg/day or clopidogrel (75 mg/day) continued up to 12 months. The use of ticagrelor or prasugrel as part of triple therapy is not recommended (Class III, Level of Evidence C).
8. Radial over femoral access is recommended for coronary angiography and PCI (Class I, Level of Evidence A). In NSTE-ACS, fractional flow reserve (FFR) may be overestimated (underestimating the relevance of a coronary stenosis); accordingly, the value of FFR-guided PCI has not been properly addressed.
9. Among patients with diabetes mellitus, multivessel coronary artery disease, and acceptable surgical risk, coronary artery bypass grafting is recommended over PCI.
10. High-intensity statin therapy should be initiated as early as possible (unless contraindicated) and maintained long-term.

Keywords: Acute Coronary Syndrome, Adenosine Triphosphate, Anticoagulants, Aspirin, Blood Pressure, Coronary Angiography, Coronary Artery Bypass, Coronary Stenosis, Diabetes Mellitus, Lipoatrophic, Electrocardiography, Heparin, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Intracranial Hemorrhages, Percutaneous Coronary Intervention, Platelet Glycoprotein GPIIb-IIIa Complex, Shock, Cardiogenic, Vitamin K

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