Non-ST-elevation myocardial infarction

Last reviewed: 1 Jun 2022
Last updated: 30 Mar 2022
30 Mar 2022

New US guideline on coronary artery revascularization recommends a shorter 1- to 3-month duration of dual antiplatelet therapy after percutaneous coronary intervention in select patients

A new guideline on coronary artery revascularization has been published by the American Heart Association and American College of Cardiology in partnership with the Society for Cardiovascular Angiography.

The guideline provides recommendations on treatment strategies for patients undergoing percutaneous coronary intervention (PCI), including the following.

  • A shorter 1- to 3-month duration of dual antiplatelet therapy (DAPT) following PCI is recommended for selected patients, with subsequent transition to P2Y12 inhibitor monotherapy, to reduce the risk of bleeding events. Previously, DAPT was recommended for 6 to 12 months following PCI.

  • Anticoagulation therapy (subcutaneous low molecular weight heparin, intravenous unfractionated heparin, or the alternative agent bivalirudin) should be started on earliest recognition of non-ST-elevation myocardial infarction in patients undergoing PCI. Fondaparinux alone is no longer recommended due to a higher incidence of guiding-catheter thrombosis.

  • PCI using radial artery access is preferred for suitable patients over femoral artery access when a clinician experienced in radial access is available as it decreases procedural site complications.

See Management: approach

See Management: treatment algorithm

Original source of update



History and exam

Key diagnostic factors

  • chest pain
  • diaphoresis
More key diagnostic factors

Other diagnostic factors

  • shortness of breath
  • weakness
  • anxiety
  • nausea and vomiting
  • abdominal pain
  • hypertension
  • early morning onset
  • syncope
  • hypotension
  • arrhythmias
  • abnormal heart sounds
Other diagnostic factors

Risk factors

  • atherosclerosis (history of angina, myocardial infarction, stroke, transient ischemic attack, peripheral vascular disease)
  • diabetes
  • smoking
  • dyslipidemia
  • family history of premature coronary artery disease (CAD)
  • age >65 years
  • hypertension
  • obesity and metabolic syndrome phenotype
  • physical inactivity
  • cocaine use
  • depression
  • stent thrombosis or restenosis
  • chronic kidney disease
  • surgical procedures (including intraoperative and postoperative periods)
  • sleep apnea
More risk factors

Diagnostic investigations

1st investigations to order

  • ECG
  • cardiac biomarkers
  • echocardiography
  • CBC
  • BUN and serum creatinine
  • electrolytes
  • LFTs
  • blood glucose
  • chest x-ray
More 1st investigations to order

Investigations to consider

  • lipids
  • brain natriuretic peptide (BNP) or N-terminal pro-BNP (NT-pro-BNP)
  • angiography/cardiac catheterization
  • stress testing
  • coronary CT angiography (CCTA)
More investigations to consider

Treatment algorithm


acute presentation





Cody S. Deen, MD

Assistant Professor of Medicine

Director of Cardiology

Hillsborough Hospital

University of North Carolina




CSD was previously the Director of Cardiac Rehab for Chatham Hospital, which was financially set up as a consultancy relationship, until 2017. CSD has spoken (unpaid) at the Update in Cardiology and Update in Internal Medicine Conferences at UNC for the last 5 years. CSD has served as the PI for the Dal-GeneE (site now closed) and the ACCELERATE Trials at the University of North Carolina (trial now completed). Each trial required paid travel to an investigator meeting.


Dr Cody S. Deen would like to gratefully acknowledge Dr Sripal Bangalore, Dr Mina Owlia, Dr Thomas Vanhecke, and Dr Dena Krishnan, the previous contributors to this topic.


SB, MO, TV, and DK declare that they have no competing interests.

Peer reviewers

Syed Wamique Yusuf, MBBS, FRCPI

Professor of Medicine

Department of Cardiology

University of Texas

MD Anderson Cancer Center




SWY declares that he has no competing interests.

  • Non-ST-elevation myocardial infarction images
  • Differentials

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    • Pulmonary embolism
    • Peptic ulcer disease
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  • Guidelines

    • Non-invasive imaging in coronary syndromes
    • 2021 ACC/AHA/SCAI guideline for coronary artery revascularization
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  • Patient leaflets

    Heart attack

    Coronary artery bypass surgery

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  • Calculators

    Thrombolysis in Myocardial Infarction (TIMI) Score for Unstable Angina Non ST Elevation Myocardial Infarction

    GRACE Score for Acute Coronary Syndrome Prognosis

    More Calculators
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