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Non-ST-elevation myocardial infarction

What's new

The American College of Cardiology (ACC) and American Heart Association (AHA) have updated their guidelines for the management of non-ST-elevation acute coronary syndromes (NSTE-ACS). A routine invasive approach is recommended for high- and intermediate-risk patients, while a routine or selective invasive approach is suggested for low-risk patients. Angiography before hospital discharge is suggested for non-high-risk patients intended for an invasive strategy. Upstream clopidogrel or ticagrelor is suggested for patients planned for an invasive strategy when angiography is expected to be delayed >24 hours, while ticagrelor is recommended for those managed without planned invasive evaluation. PCI of significant non-culprit lesions is recommended at the time of the index procedure or as a staged procedure in stable patients with multivessel disease but without left main stenosis undergoing culprit-lesion PCI. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of non-ST-elevation myocardial infarction are prepared by our editorial team based on guidelines from the American College of Chest Physicians (ACCP 2025), the Society for Cardiovascular Angiography and Interventions (SCAI/NAEMSP/AHA/ACC/ACEP 2025), the American Academy of Family Physicians (AAFP 2024), the Canadian Cardiovascular Society (CCS/CAIC 2024), the European Society of Cardiology (ESC/EACTS ...
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Screening and diagnosis

Diagnosis: as per ESC 2023 guidelines, base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and high-sensitivity cardiac troponin.
B
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Classification and risk stratification

Prognostic assessment: as per AAFP 2024 guidelines, refer patients presenting with acute chest pain and high suspicion of ACS to the emergency department and use predictive risk scores there to aid in the prognosis, diagnosis, and management.
B
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Diagnostic investigations

History and physical examination: as per AAFP 2024 guidelines, elicit medical history and perform a physical examination in patients presenting with acute chest pain and high suspicion of ACS.
B
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  • ECG

  • Echocardiogram

  • Cardiac troponin

  • Coronary CTA

  • Cardiac MRI

  • Lipid profile

Diagnostic procedures

Coronary angiography
As per ACC/ACEP/AHA/…/SCAI 2025 guidelines:
Consider performing angiography before hospital discharge to reduce major adverse cardiovascular events in patients with non-ST-elevation ACS who are not at high risk and are intended for an invasive strategy.
C
Do not perform immediate angiography in resuscitated patients who are comatose after cardiac arrest, electrically and hemodynamically stable, and without evidence of STEMI.
D
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Respiratory support

Supplemental oxygen
As per ACC/ACEP/AHA/…/SCAI 2025 guidelines:
Administer supplemental oxygen in patients with ACS and confirmed hypoxia (oxygen saturation < 90%) to increase oxygen saturations to ≥ 90% in order to improve myocardial oxygen supply and decrease anginal symptoms.
B
Do not routinely administer supplemental oxygen in patients with ACS and oxygen saturations ≥ 90%, as it does not improve cardiovascular outcomes.
D
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Medical management

Transfer: as per ESC 2023 guidelines, transfer patients requiring primary PCI directly to the catheterization laboratory bypassing the emergency department and coronary care unit/ICU.
B
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  • Shared-decision making

  • Fibrinolytic therapy

  • Nitrates

  • Beta-blockers (IV)

  • Beta-blockers (PO)

  • Renin-angiotensin system inhibitors

  • Mineralocorticoid receptor antagonists

  • CCBs

  • Low-dose colchicine

  • Antiplatelet therapy (aspirin)

  • Antiplatelet therapy (P2Y12 inhibitors, initiation)

  • Antiplatelet therapy (P2Y12 inhibitors, maintenance and de-escalation)

  • Antiplatelet therapy (intravenous GP IIb/IIIa inhibitors)

  • Anticoagulant therapy

  • Management of cardiogenic shock (setting of care)

  • Management of cardiogenic shock (revascularization)

  • Management of cardiogenic shock (intra-aortic balloon counterpulsation)

  • Management of cardiogenic shock (mechanical circulatory support)

  • Management of cardiac arrest

  • Management of AF (antithrombotic therapy)

  • Management of AF (rate control)

  • Management of AF (rhythm control)

  • Management of bradyarrhythmias

  • Management of ventricular arrhythmias (revascularization)

  • Management of ventricular arrhythmias (pharmacotherapy)

  • Management of ventricular arrhythmias (transvenous pacing)

  • Management of ventricular arrhythmias (ICD)

  • Management of ventricular arrhythmias (radiofrequency ablation)

  • Management of LV thrombus

  • Management of dyslipidemia

  • Management of pain and anxiety

Inpatient care

Setting of monitoring: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, offer telemetry monitoring in patients with ACS to reduce cardiovascular events, with the duration determined by cardiac risk.
B
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  • ECG monitoring

  • Imaging monitoring

Nonpharmacologic interventions

Lifestyle modifications: as per ESC 2023 guidelines, advise adopting a healthy lifestyle, including smoking cessation, healthy diet (Mediterranean style), alcohol restriction, regular aerobic physical activity and resistance exercise, and reduced sedentary time, in all patients with ACS.
B
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  • Smoking cessation

  • Psychological interventions

Therapeutic procedures

Indications for PCI: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, use an invasive approach with the intent to proceed with revascularization during hospitalization in patients with non-ST-elevation ACS who are at intermediate or high risk of ischemic events and are appropriate candidates for revascularization to reduce major adverse cardiovascular events.
A
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  • Technical considerations for PCI (arterial approach)

  • Technical considerations for PCI (choice of stent)

  • Technical considerations for PCI (intravascular imaging)

  • Technical considerations for PCI (hemodynamic support device)

  • Technical considerations for PCI (aspiration thrombectomy)

  • Technical considerations for PCI (multivessel disease)

  • Technical considerations for PCI (non-infarct artery revascularization)

  • RBC transfusion

Perioperative care

General principles
As per ACC/AHA/SCAI 2022 guidelines:
Establish multidisciplinary, evidence-based perioperative management programs to optimize analgesia, minimize opioid exposure, prevent complications and to reduce time to extubation, length of stay, and healthcare costs in patients undergoing CABG.
B
Ensure a comprehensive approach to reduce sternal wound infection in patients undergoing CABG.
B
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  • Perioperative beta-blockers

  • Perioperative amiodarone

  • Perioperative management of antithrombotics

  • Intraoperative insulin infusion

Surgical interventions

Indications for CABG: as per ACC/ACEP/AHA/…/SCAI 2025 guidelines, perform emergency revascularization of the culprit vessel by PCI or CABG in patients with ACS and cardiogenic shock or hemodynamic instability to improve survival, irrespective of time from symptom onset.
B
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  • Bypass conduits

  • Cardiopulmonary bypass

Specific circumstances

Elderly patients: as per ESC 2023 guidelines, apply the same diagnostic and treatment strategies in older patients as in younger patients.
B
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  • Female patients

  • Pregnant patients

  • Patients with diabetes mellitus

  • Patients with CKD

  • Patients with cancer

  • Patients scheduled for noncardiac surgery

  • Patients with AF

  • Patients with preexisting HF

  • Patients with postoperative myocardial infarction

  • Patients with spontaneous coronary artery dissection

  • Patients with stress cardiomyopathy

  • Patients with MINOCA

  • Patients with microvascular angina

  • Patients with vasospastic angina

  • Cocaine and methamphetamine users

Patient education

Patient-centered care: as per ESC 2023 guidelines, provide patient-centered care by assessing and adhering to individual patient preferences, needs, and beliefs, ensuring that patient values are used to inform all clinical decisions.
B
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  • Counseling before discharge

Preventative measures

Low-dose aspirin
As per CAIC/CCS 2024 guidelines:
Do not initiate aspirin routinely for primary prevention of ASCVD in patients without ASCVD, regardless of sex, age, or diabetes status.
D
Consider initiating aspirin for primary prevention of ASCVD in certain patients deemed at high risk of ASCVD but with low bleeding risk in the context of a patient-centered and informed shared decision-making process.
E
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  • Statin therapy

  • Hormone therapy

  • Vitamin supplements

  • Influenza immunization

Follow-up and surveillance

Cardiac rehabilitation
As per ACC/ACEP/AHA/…/SCAI 2025 guidelines:
Refer patients with ACS to an outpatient cardiac rehabilitation program prior to hospital discharge to reduce death, myocardial infarction, hospital readmissions, and improve functional status and QoL.
A
Consider offering a home-based cardiac rehabilitation program as a reasonable alternative to a center-based program in patients with ACS to improve functional status and QoL.
C
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  • Follow-up imaging

  • Lipid monitoring

Quality improvement

Healthcare system and hospital requirements, pre-hospital settings: as per ESC 2023 guidelines, ensure that:
pre-hospital management of patients with a working diagnosis of STEMI is based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make primary PCI available to as many patients as possible
B
patients transferred for primary PCI bypassing the emergency department and coronary care unit/ICU and are transferred directly to the catheterization laboratory
B
emergency medical services transfer patients with suspected STEMI to a PCI-capable center bypassing non-PCI centers
B
strategies are in place to facilitate the transfer of all patients with suspected ACS after resuscitated cardiac arrest directly to a hospital offering 24/7 primary PCI via one specialized emergency medical service
B
ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation and fibrinolysis when applicable
B
all emergency medical services participating in the care of patients with suspected STEMI record and audit delay times and work together to achieve and maintain quality targets.
B
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  • Healthcare system and hospital requirements (hospital settings)