Jose M Castellano et al. N Engl J Med. 2022 Sep 15. As per ACC 2014 guidelines, manage older patients with NSTEMI with guideline-directed medical therapy, an early invasive strategy, and revascularization as appropriate. A Show 4 more Female patients: manage female patients with NSTEMI with the same pharmacological therapy as for male patients for acute care and for secondary prevention, with attention to weight and/or renally calculated doses of antiplatelet and anticoagulant agents to reduce bleeding risk. B Show 2 more Pregnant patients: As per ACC 2022 guidelines, consider adopting an invasive strategy in pregnant patients with NSTEMI if medical therapy is ineffective for the management of life-threatening complications. C As per AHA 2014 guidelines, consider performing myocardial revascularization in pregnant patients with NSTEMI if an ischemia-guided strategy is ineffective for the management of life- threatening complications. C Patients with diabetes mellitus: initiate medical treatment in the acute phase of NSTEMI and decide on stress testing, angiography, and revascularization in patients with diabetes mellitus similarly to patients without diabetes mellitus. A Patients with chronic kidney disease: As per ACC 2022 guidelines, take measures to minimize the risk of contrast-induced AKI in patients with CKD undergoing contrast media injection for coronary angiography. B Show 2 more As per ESC 2021 guidelines, apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as for patients with normal renal function. B Show 5 more As per AHA 2014 guidelines, assess the CrCl in patients with NSTEMI and adjust the doses of medications excreted by kidneys according to the pharmacokinetic data for specific medications. B Show 2 more Landmark trials: ACT In patients undergoing an intravascular angiographic procedure with at least 1 risk factor for contrast-induced AKI (age > 70 years, renal failure, diabetes mellitus, HF, or hypotension), https://web.pathway.md/diseases/recGYrMGdIRdWzUih 16/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway acetylcysteine was not superior to placebo with respect to a contrast-induced AKI. ACT Investigators. Circulation. 2011 Sep 13. Patients with atrial fibrillation: Discontinue aspirin therapy after 1-4 weeks while maintaining P2Y12 inhibitors in addition to a non-vitamin K OAC (rivaroxaban, dabigatran, apixaban, or edoxaban) or warfarin to reduce the risk of bleeding in patients with AF undergoing PCI and taking OACs. B Prefer a non-vitamin K OAC over warfarin to reduce the risk of bleeding in patients with AF undergoing PCI, taking OACs and treated with dual antiplatelet therapy or a P2Y12 inhibitor monotherapy. B Patients with preexisting heart failure: treat patients with a history of HF and NSTEMI according to the same risk stratification guidelines and recommendations as for patients without HF. B Show 2 more Patients with previous CABG: initiate antiplatelet and anticoagulant therapy according to guideline-directed medical therapy in patients with prior CABG and NSTEMI, and proceed with an early invasive strategy because of the increased risk. B Patients with postoperative myocardial infarction: Initiate guideline-directed medical therapy in patients with NSTEMI following noncardiac surgery as recommended in patients in the general population but with modifications imposed by the specific noncardiac surgical procedure and the severity of the NSTEMI. B Direct management of patients with NSTEMI following noncardiac surgery to the underlying cause. B Updated evidence: MANAGE In patients who had undergone noncardiac surgery and were within 35 days of myocardial injury after noncardiac surgery, dabigatran was superior to placebo with respect to major vascular complications. Devereaux PJ et al. Lancet. 2018 Jun 9. Patients with spontaneous coronary artery dissection: Consider performing revascularization if feasible in patients with spontaneous coronary artery dissection with hemodynamic instability or ongoing ischemia despite conservative therapy. C Do not perform routine revascularization for spontaneous coronary artery dissection. D Patients with stress cardiomyopathy: suspect stress (Takotsubo) cardiomyopathy in patients presenting with apparent acute coronary syndrome and nonobstructive coronary artery disease at angiography. B Show 7 more https://web.pathway.md/diseases/recGYrMGdIRdWzUih 17/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Patients with MINOCA: follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses in all patients with an initial working diagnosis of MINOCA. B Show 3 more Patients with microvascular angina: consider obtaining invasive physiological assessment, such as coronary flow reserve measurement, if coronary angiography reveals normal coronary arteries and endothelial dysfunction is suspected. C Patients with vasospastic angina: As per ESC 2021 guidelines, consider administering CCBs and nitrates in patients with suspected/confirmed vasospastic angina. Avoid using -blockers. C As per AHA 2014 guidelines, consider administering CCBs alone or in combination with long- acting nitrates to treat and reduce the frequency of vasospastic angina. B Administer long- acting CCBs and nitrates in patients with coronary artery vasospasm. B Show 3 more Cocaine and methamphetamine users: manage patients with NSTEMI and a recent history of cocaine or methamphetamine use in the same manner as patients without cocaine- or methamphetamine-related NSTEMI, except for patients with signs of acute intoxication (such as euphoria, tachycardia, and/or hypertension) and -blocker use unless receiving coronary vasodilator therapy. B Show 2 more 12. Patient education Counseling before discharge: inform patients with NSTEMI about symptoms of worsening myocardial ischemia and myocardial infarction and provide verbal and written instructions on how and when to seek emergency care for such symptoms. B Show 3 more 13. Preventative measures Statin therapy: initiate statins for primary prevention of CVDs in 40-75 years old adults with 1 CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and an estimated 10-year CVD risk 10%. B Show 2 more Immunizations: As per ESC 2021 guidelines, offer annual influenza vaccination to improve morbidity in patients with coronary artery disease, especially in older patients. B As per ACC 2014 guidelines: Offer pneumococcal vaccination in patients 65 years of age and in high-risk patients with CVD. B Offer annual influenza vaccination in patients with CVD. B https://web.pathway.md/diseases/recGYrMGdIRdWzUih 18/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Hormone therapy: do not use hormone therapy with estrogen plus progestin or estrogen alone as new drugs for secondary prevention of coronary events in postmenopausal patients after NSTEMI and discontinue in previous users unless the benefits outweigh the estimated risks. D Vitamin supplements: Do not offer antioxidant vitamin supplements (such as vitamins E, C, or -carotene) for secondary prevention in patients with NSTEMI. D Do not offer folic acid, with or without vitamins B6 and B12, for secondary prevention in patients with NSTEMI. D 14. Follow-up and surveillance Discharge from hospital: use posthospital systems of care designed to prevent hospital readmissions to facilitate the transition to effective, coordinated outpatient care for all patients with NSTEMI. B Show 5 more Cardiac rehabilitation: As per ACC 2022 guidelines: Offer a comprehensive home-based or center-based cardiac rehabilitation program either before hospital discharge or during the first outpatient visit in patients undergone revascularization, to reduce deaths and hospital readmissions and improve quality of life. A Educate patients undergone revascularization about CVD risk factors and their modification to reduce cardiovascular events. B As per ESC 2021 guidelines, advise improving lifestyle factors in addition to appropriate pharmacological management to reduce all-cause and cardiovascular mortality and morbidity and improve health-related quality of life. A Show 4 more As per ACC 2014 guidelines, refer all eligible patients with NSTEMI to a comprehensive cardiovascular rehabilitation program either before hospital discharge or during the first outpatient visit. B 15. Quality improvement Healthcare system and hospital requirements: As per ACC 2022 guidelines, ensure that cardiac surgery and PCI programs participate in state, regional, or national clinical data registries and receive periodic reports of their risk-adjusted outcomes as a quality assessment and improvement strategy with the goal of improving patient outcomes. B Show 2 more As per AHA 2014 guidelines, consider participating in a standardized quality-of-care data registry designed to track and measure outcomes, complications, and performance measures https://web.pathway.md/diseases/recGYrMGdIRdWzUih 19/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway for improving the quality of NSTEMI. C Clinical findings Symptoms Past medical history Abdominal pain CKD Arm pain Coronary artery disease Back pain Diabetes mellitus Chest pain Dyslipidemia Chest pain radiating to back HF Chest pain radiating to left arm Hypertension Chest pain radiating to neck or jaw Metabolic syndrome Obesity Epigastric pain Social history Heartburn Jaw pain Cocaine use Left shoulder pain Tobacco use Nausea Neck pain Vascular exam Palpitations Peripheral edema Shortness of breath Shoulder pain Respiratory exam Syncope Vomiting Rales Weakness Lab findings Medication history CK-MB Combined oral contraceptives serum troponin I serum troponin T Vital signs Hypotension Tachycardia Cardiac exam AR murmur Cardiogenic shock Fourth heart sound Levine's sign MR murmur Split S2 heart sound Third heart sound https://web.pathway.md/diseases/recGYrMGdIRdWzUih 20/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway Integument exam Diaphoresis ECG findings St-segment depression Studies 2023 RENOVATE-COMPLEX-PCI In adult patients undergoing PCI for complex coronary artery lesions, intravascular imaging was superior to angiography with respect to the composite of death from cardiac causes, target-vessel- related myocardial infarction or revascularization. Joo Myung Lee et al. N Engl J Med. 2023 May 4. 2022 SMART-CHOICE (3-year follow-up) In patients who underwent PCI with drug-eluting stent, P2Y12 inhibitor monotherapy was noninferior to prolonged dual antiplatelet therapy with respect to major adverse cardiac and cerebrovascular events at 3 years. Ki Hong Choi et al. JAMA Cardiol. 2022 Nov 1. Show 42 more References 1. Jennifer S Lawton, Jacqueline E Tamis-Holland, Sripal Bangalore et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan 18;145 3):e18-e114. Open 2. Amsterdam EA, Wenger NK, Brindis RG et al. 2014 AHA/ACC Guideline for the Management of Patients with Non-ST Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64 24):e139-e228. Open 3. Jean-Philippe Collet, Holger Thiele, Emanuele Barbato et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021 Apr 7;42 14 1289 1367. Open 4. Miguel Sousa-Uva, Franz-Josef Neumann, Anders Ahlsson et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019 Jan 1;55 1 4 90. Open 5. US Preventive Services Task Force, Carol M Mangione, Michael J Barry et al. Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2022 Aug 23;328 8 746 753. Open https://web.pathway.md/diseases/recGYrMGdIRdWzUih 21/22 6/30/23, 1:17 AM Non-ST-elevation myocardial infarction Pathway 6. O'Gara PT, Kushner FG, Ascheim DD et al. 2013 ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jan 29;61 4):e78 140. Open 7. Nicolai Tegn, Michael Abdelnoor, Lars Aaberge et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris After Eighty study): an open-label randomised controlled trial. Lancet. 2016 Mar 12;387 10023 1057 1065. Open 8. Glenn N Levine, Eric R Bates, John A Bittl et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2016 Nov;152 5 1243 1275. Open 9. Alexander C Fanaroff, Anita Y Chen, Laine E Thomas et al. Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST Segment-Elevation Myocardial Infarction. J Am Heart Assoc. 2018 May 25;7 11):e008894. Open https://web.pathway.md/diseases/recGYrMGdIRdWzUih 22/22