NSTEMI:

How to risk
stratify?
Dr. dr. Hariadi Hariawan, SpPD, SpJP(K)

Department of Cardiology and Vascular Medicine

FK-KMK UGM
 Types of MI

Thygesen K et al. Eur Heart Journal. 2012;33:2551-2567

2
 Acute Coronary Syndrome

Acute thrombosis induced

by a ruptured or eroded
atherosclerotic coronary
plaque, with or without
concomitant
vasoconstriction, causing a
sudden and critical
reduction in blood flow

Bentzon JF et al. Circ Res. 2014;114:1852-1866

3
 ACS Spectrum

1. Roffi M et al. Eur Heart J 2016;37(3):267-315;

4 2. Ibanez B et al. European Heart Journal 2017; 00; 1–66
 Spectrum of ACS1

Admission Chest Pain

ST
ST
depression
elevation ST segment
ECG

Bio-chemistry Troponin Troponin

rise/fall normal

Diagnosis STEMI NSTEMI UA

Reference: 1. Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054

 Patient with Chest Pain with below ECG

What’s your strategy ?

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 Proportion of Acute MI patients with
NSTEMI has increased over time1,2

Real-world evidence studies analysing US and French registry data* trends in acute MI
over time report that the proportion of patients with NSTEMI has increased 1,2

Findings from the US Nationwide Inpatient Sample databases

which analysed AMI patients ≥40 years with acute MI from
2002–20111

1. Khera S et al. J Am Heart Assoc 2014;3:e000995. 2. Puymirat E et al. Circulation 2017;136:1908–1919.

 NSTEMI patients remain at high and persistent risk
of CV events post discharge from hospital1

2-year rate of MI, stroke or all-cause mortality in NSTEMI and STEMI

patients ≥65 years of age.

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Both NSTEMI and STEMI patients are at high risk of recurrent CV events,
NSTEMI is associated with greater long-term risk than
STEMI

Vora AN et al. Circ Cardiovasc Qual Outcomes 2016;9:513–522.

Pathophysiology NSTEACS1

NSTE-ACS patients have varying degrees of coronary obstruction, undergo more

heterogeneous management, and have worse long-term outcomes

12 Reference: 1. Chang H, et al. Circ Cardiovasc Imaging 2012;5:536-546.

 Angiography
B

Which one is NSTEMI ?

 Key Steps on NSTEACS Management Strategy1

Step 1. initial evaluation

Step 2. Diagnosis validation, risk assessment and

rhythm monitoring

Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge and post-discharge

management
Reference: 1. Roffi M et al. European Heart Journal 2015. doi:10.1093/eurheartj/ehv320
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 Selection of NSTE-ACS treatment strategy and timing
according to initial risk stratification

Neumann
19
FJ, et al. Eur Heart J. 2019;40:87-165
 Risk Stratification: GRACE Score1

Points for Each Predictive Factor

Killip Score SBP, Score
Class Mm Hg
I 0 < 80 63
II 21 80 – 99 58
III 43 100 - 119 47 High risk: Score >140
IV 64 120 - 139 37 In-hospital death: >3%
140 - 159 26
Heart Rate, Score 160 - 199 11
Beats/min > 200 0
< 70 0
70-89 7 Age Score
90-109 13 < 40 0 Intermediate risk: 109 – 140
110 - 149 23 40 - 49 18 In-hospital death: 1-3 %
150 - 199 36 50 - 59 36
> 200 46 60 - 69 55
70 – 79 73
Predictive Score 80 91
Factor
Creatinine, Score Low risk: Score ≤ 108
• Cardiac • 43 (µmol/L)
arrest at • 15 In-hospital death: <1%
admission • 30 0 - 34 2
• Elevated 35 – 70 5
cardiac 71 – 105 8
20
markers 106 – 140 11
• ST 141 – 176 14
Segment 177 – 353 23
deviation ≥ 354 31

Reference: 1. Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 – e30; 2. Hamm
Cath lab or later ?
Benefit of early intervention in high risk patients

Kaplan–Meier Cumulative Risk of the Primary Outcome (death, myocardial infarction, or stroke),
Stratified According to GRACE Risk Score at Baseline.
21
Mehta, SR et al. N Engl J Med 2009;360:2165-75.
Aggressive approach recommended in NSTEACS
Patient with HIGH RISK

Reference: 1. Adapted from : Roffi M et al. Eur Heart J 2016;37(3):267-315

Initial Treatment when an ACS diagnosis appears likely
based on ESC NSTEACS Guideline1,2

Aspirin Initial dose of 150 – 300 mg non-enteric formulation followed by 75-100

mg/day (I.v. administration is acceptable)

P2Y12 inhibitor Loading dose of ticagrelor or clopidogrel

Anticoagulation Choice between different options depends on strategy:

• Fondaparinux 2.5 mg/daily subcutaneously
• Enoxaparin 1 mg/kg twice daily subcutaneously
• UHF Lv. Bolus 60-70 IU/kg (maximum 5000 IU) followed by infusion
of 12-15 IU/kg/h (maximum 1000 IU/h) titrated to aPTT 1.5 – 2.5 ×
control
• Bivalirudin is indicated only in patients with a planned invasive
strategy

Oral β-Blocker If tachycardic or hypertensive without signs of heart failure

P2Y12 inhibitor is recommended in initiation soon after the diagnosis of NSTE-

ACS irrespective of management strategy2

23 Reference: 1. Hamm CW et al. Eur Heart J. 2011; 32:2999-30354; 2. Roffi M et al. Eur Heart J 2016;37(3):267-315
 The Importance of antiplatelet in NSTEACS

Antiplatelet therapy should be instituted as

early as possible when the diagnosis of
NSTE-ACS is made in order to reduce the risk
of both acute ischaemic complications and
recurrent atherothrombotic events

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25
 ANTIPLATELET AGENT

Aspirin
Thienopyridine
• Ticlopidine
• Clopidogrel
• Prasugrel

Reversible
P2Y12 inhibitors
• Ticagrelor
• Cangrelor
• Elinogrel

GPIIb/Iia Antagonists

Angiolillo DJ. Drugs. 2012 Nov 12;72(16):2087-116 26

 Profile P2Y12 inhibitor

*Prasugrel is not yet approved and available in Indonesia

Adapted from Hamm CW et al. Eur Heart J 2011;32:2999 – 3054
 Ticagrelor significantly reduces CV events (17% RRR) and
all cause death (24% RRR) compared to clopidogrel

Lindholm D, et al. Eur Heart J. 2014;35:2083-93

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 Ticagrelor (More Potent OAP) is preferred OAP for
NSTEACS based on Updated ESC Guideline1,2

Guideline Recommendation Class Level

A P2Y12 inhibitor is recommended, in addition to aspirin,

for 12 months unless there are contraindications such as I A
excessive risk of bleeds.
Ticagrelor (180 mg loading dose, 90 mg twice daily) is
recommended, in the absence of contraindications, for all
patients at moderate-to-high risk of ischaemic events (e.g.
ESC 20151 I B
elevated cardiac troponins), regardless of initial treatment
strategy and including those pretreated with clopidogrel
(which should be discontinued when ticagrelor is started).
Clopidogrel (300–600 mg loading dose, 75 mg daily dose) is
recommended for patients who cannot receive ticagrelor I B
or prasugrel or who require oral anticoagulation.

1. Roffi M et al. Eur Heart J 2016;37(3):267-315. 2. Hamm CW et al. Eur Heart J. 2011; 32:2999-30354
 PERKI Guideline: NSTEACS Management1

Ticagrelor direkomendasikan untuk semua

pasien dengan risiko kejadian iskemik sedang
hingga tinggi (misalnya peningkatan troponin)
dengan dosis loading 180 mg, dilanjutkan
2x90 mg/hari. Pemberian dilakukan tanpa
memandang strategi pengobatan awal.
Pemberian ini juga dilakukan pada pasien
yang sudah mendapatkan clopidogrel
(pemberian clopidogrel kemudian dihentikan).
(Kelas I-B)

Clopidogrel direkomendasikan untuk pasien yang

tidak bisa menggunakan ticagrelor. Dosis loading
clopidogrel adalah 300 mg, dilanjutkan 75 mg
setiap hari (Kelas I-A)

30 Referensi: Buku Pedoman Tatal Laksana Sindrom Koroner Akut, Perki 2018
 Treat NSTEACS Patients Aggressively to reduce
CV event
• Risk stratification is important in NSTEACS to define the right
patients for Aggressive approach

• NSTEACS High Risk recommended for Invasive strategy

• Antiplatelet therapy should be given as early as possible for NSTE-

ACS to reduce the risk of both acute ischaemic complications and
recurrent atherothrombotic events

• Ticagrelor show superior efficacy in reduce CV event vs

clopidogrel both in invasive strategy vs non invasive strategy

• Ticagrelor as more potent OAP , has recommended by

international and local guidelines as preferred OAP for NSTEACS
 THANK YOU
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