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.

Keywords: antiplatelet therapy; early invasive strategy; non-ST-segment elevation myocardial infarction; treatment-risk paradox.

Figure 1

Kaplan‐Meier survival curves showing all‐cause mortality rates for patients with NSTEMI who did not undergo coronary angiography vs. those who did. Adapted from Feldman et al. with permission from SAGE Ltd.43 Abbreviation: CAG, coronary angiography

Figure 2

Association between the European Society of Cardiology Acute Cardiovascular Care Association quality indicators for acute myocardial infarction and crude 30‐day mortality. Adapted from Bebb et al.72 The composite opportunity QI was divided into the following categories: zero, received no interventions out of those eligible for; low, received <40% of interventions eligible for; intermediate, received ≥40% to <80% of interventions eligible for; and high, received ≥80% of interventions eligible for. Abbreviations: ACEI; angiotensin‐converting enzyme inhibitor; ARB; angiotensin receptor blocker; BB, β‐blocker; CI, confidence interval; DAPT, dual antiplatelet therapy; EF, ejection fraction; HF, heart failure; LV, left ventricular; NSTEMI, non‐ST‐segment elevation myocardial infarction; PCI, percutaneous coronary intervention; QI, quality indicator; STEMI, ST‐segment elevation myocardial infarction