Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

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.

Oral Antiplatelet Therapy in Acute Coronary Syndromes, Clinical Experience in an Emergency Hospital With Percutaneous Coronary Intervention Facilities

“…Antiplatelets represent a first line medical therapy in ACS management and this drug class continues to evolve as novel agents with increasingly antiplatelet actions are identified. Antiplatelet drugs are focused on the inhibition of three key platelet activation pathways: thromboxane A2 generation via cyclooxygenase-1; adenosine diphosphate mediated activation of the P2Y12 receptor and thrombin mediated activation of protease activated receptor-1 [1,5]. Acetylsalicylic acid (ASA) remains the first line treatment of ACS.…”

Predictors of Long-Term Outcome in STEMI and NSTEMI—Insights from J-MINUET

“…As yet, the underlying causes that explain this phenomenon are not fully understood, but various pathomechanisms have been proposed. Patients presenting with NSTEMI have a worse clinical risk profile (i.e., are significantly older, have a higher burden of comorbidities and a more frequently history of coronary artery disease) [ 3 , 5 ], higher rates of recurrent ischemia [ 3 ], and are less likely to receive guideline-recommended treatment strategies at discharge [ 5 , 6 , 7 ].…”

“…In addition, the investigators propose risk-scores to predict long-term prognosis in patients after AMI, which consequently could be a step towards personalized risk-calculation, especially in patients at an increased risk. This is also of interest, as several studies have shown that NSTEMI patients are less likely to receive guideline-recommended treatment strategies and less frequently participate in cardiac rehabilitation programs [ 5 , 6 , 7 ].…”

Comparison of the CAMI-NSTEMI and GRACE Risk Model for Predicting In-Hospital Mortality in Chinese Non-ST-Segment Elevation Myocardial Infarction Patients

“…Compared to ST-segment elevation myocardial infarction (STEMI) patients, NSTEMI patients present with more heterogeneous variation in ischemic risk and comorbidities so that the risk classification has been considered as a fundamental component to select the most appropriate therapeutic strategy for NSTEMI patients [ 1 – 3 , 17 ]. However, in clinical practice the treatment-risk paradox is widespread [ 5 – 7 ], which is partly due to the suboptimal risk assessment underestimating the ischemic risk [ 18 , 19 ], especially in China [ 4 , 6 , 20 ]. In conformity with this, according to the H–L calibration plots in the present study, the GRM dramatically underestimated the in-hospital mortality and classified nearly 40% in-hospital death into the low- or medium-risk category, which may cause underuse of invasive strategy for patients at high risk [ 1 , 2 ].…”