Acute Coronary Syndrome: Management of NSTEMI

Key points

• All patients: aspirin 300 mg loading dose as soon as possible, continued indefinitely unless contraindicated · offer pain relief if required
• Do not give oxygen routinely — only if hypoxic
• Antithrombin: offer fondaparinux if not at high bleeding risk, unless undergoing immediate coronary angiography · use dose-adjusted unfractionated heparin if creatinine > 265 µmol/l · give systemic UFH in the cath lab to those undergoing PCI
• Dual antiplatelet therapy: for those having angiography, offer prasugrel or ticagrelor with aspirin (prasugrel only once anatomy is defined and PCI intended) · if managed without PCI, offer ticagrelor with aspirin · use clopidogrel with aspirin, or aspirin alone, if high bleeding risk · if a separate indication for anticoagulation exists, offer clopidogrel with aspirin
• Risk-stratify with GRACE: predicted 6-month mortality > 3.0% = intermediate or higher risk → coronary angiography (with follow-on PCI if indicated) within 72 hours · immediate angiography if clinically unstable · conservative management if ≤ 3.0%, with angiography if ischaemia develops or is shown on testing

Decision points in this pathway

• Undergoing immediate coronary angiography, or creatinine > 265 µmol/l?
• Predicted 6-month mortality > 3.0% on GRACE (intermediate or higher risk)?

The full step-by-step algorithm, including what to do at each branch, opens in the app for approved members.