Abstract
Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.
Highlights
Results from the French Registry of Acute ST-Elevation or NonST-Elevation Myocardial Infarction (FAST-myocardial infarction (MI)) and the Swedish Websystem for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry showed that the 6-month and 1-year mortality of patients with segment elevation myocardial infarction (STEMI) or Non-ST-segment elevation myocardial infarction (NSTEMI) have generally decreased since 1995.11,12 since 2010, there has been no improvement in the 6-month mortality of patients with NSTEMI, regardless of whether or not they received percutaneous coronary intervention (PCI); in striking contrast, mortality has continued to decline in patients with STEMI during this time.[11]
Major international guidelines recommend initiation of at least 12 months of dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor in patients with NSTEMI who are managed with medical therapy and/or who are treated with revascularization, unless there are previous or ongoing contraindications.[13,14,15,16,17,18]
Ticagrelor is recommended over clopidogrel for patients with NSTEMI, including those pretreated with clopidogrel
Summary
Non-ST-segment elevation myocardial infarction (NSTEMI) is the leading cause of emergency hospitalization for acute coronary syndrome (ACS) in Europe and North America.[1,2,3,4] both patients with NSTEMI and ST-segment elevation myocardial infarction (STEMI) are at a high risk of recurrent cardiovascular events, patients with NSTEMI have higher long-term mortality and cardiovascular risk than those with STEMI.[5,6,7,8] the proportion of patients with acute myocardial infarction (MI) who have NSTEMI is increasing relative to those with STEMI.[9,10,11]. For clopidogrel: no indication for prasugrel or ticagrelor with no high bleeding risk Main QI (2): proportion of patients with NSTEMI treated with fondaparinux, unless candidates for immediate (≤2 hours) invasive strategy, or with eGFR ≥20 mL/min Secondary QI: proportion of patients with AMI discharged on dual antiplatelet therapy/patients with AMI without clear and documented contraindication
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