Role of anticoagulation in non-ST-elevation myocardial infarction: a contemporary narrative review

ABSTRACT

Introduction

Anticoagulants play a vital role as part of the antithrombotic therapy of myocardial infarction and are complementary to antiplatelet therapies. In the acute setting, the rationale for their use is to antagonize the ongoing clotting cascade including during percutaneous coronary intervention. Anticoagulation may be an important part of the longer-term antithrombotic strategy especially in patients who have other existing indications (e.g. atrial fibrillation) for their use.

Areas covered

In this narrative review, the authors provide a contemporary summary of the anticoagulation strategies of patients presenting with NSTEMI, both in terms of anticoagulation during the acute phase as well as suggested antithrombotic regimens for patients who require long-term anticoagulation for other indications.

Expert opinion

Patients presenting with non-ST-elevation myocardial infarction (NSTEMI) should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period for those medically managed or until percutaneous coronary intervention. Longer term management of NSTEMI for patients with an existing indication for long-term anticoagulation should comprise triple antithrombotic therapy of anticoagulant (preferably DOAC) with aspirin and clopidogrel for up to 1 month (typically 1 week or until hospital discharge), followed by DOAC plus clopidogrel for up to 1 year, and then DOAC monotherapy thereafter.

KEYWORDS:

• Acute coronary syndrome
• non-ST-elevation myocardial infarction
• anticoagulation
• warfarin
• direct oral anticoagulant

Article highlights

• Patients presenting with non-ST-elevation myocardial infarction (NSTEMI) should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period for those medically managed or until percutaneous coronary intervention in those on an invasive management strategy.

• Longer term management of NSTEMI for patients with an existing indication for long-term anticoagulation should comprise triple antithrombotic therapy of anticoagulant (preferably DOAC) with aspirin and clopidogrel for up to 1 month (typically 1 week or until hospital discharge), followed by DOAC plus clopidogrel for up to 1 year, and then DOAC monotherapy thereafter.

• Adding low dose direct oral anticoagulants (DOACs) to antiplatelet therapy may provide more protection from cardiovascular events but with the tradeoff of an even greater increase in bleeding risk. Low dose rivaroxaban has shown promise, but more research is required to identify the optimal combinations of antiplatelet and anticoagulant at the right dose to balance these risks.

• Guidelines suggest the use of monotherapy with DOAC or VKA in the management of chronic coronary syndrome in patients with existing indications for anticoagulation.

Declaration of interest

KK Yeo received research funding, consultancy, and speaker fees from Abbott Vascular and Boston Scientific. JWC Tan received honoraria from Medtronic, Abbott Vascular and Boston Scientific. CT Chin received honoraria from Astrazeneca. J Yap received speaker’s honorarium from Abbott, Biosensors, Biotronik, Boston Scientific, Edwards, GE healthcare, J&J, Kaneka, Medtronic and Terumo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

One peer reviewer is on the executive committee of the LEGACY trial investigating P2Y12 monotherapy after ACS. Another peer reviewer has received consulting and/or speaker fees from Abbott Vascular, Abiomed, Amarin, Amgen, Astra Zeneca, Bayer, Daichii, MedAlliance, Mundipharma, Novartis, OMpharma, SIS Medical and Vifor. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.