Tarlan Hedayati, MD, of Cook County Hospital in Chicago, spoke to a crowded room at ACEP14 Tuesday about treatment of patients with non-ST segment elevation myocardial infarction (NSTEMI). She explained that more than 780,000 patients in the United States will experience acute coronary syndrome (ACS). The majority of these will be NSTEMI. The main question that comes to the mind of an emergency doctor: Which drugs am I supposed to give to these patients?

Dr. Hedayati directed the audience to the 2014 NSTEMI Guidelines from the American Heart Association and the American College of Cardiology. In particular, she focused on Figure 3 on page 46 of the guideline because: “It has everything that you need to know.”

Pointing out that the mission of the emergency physician is to destroy the platelets, she went through useful therapies for doing just that. All NSTEMI patients in her department receive aspirin when they arrive. Patients might also receive oxygen or nitrates. Although morphine used to be commonly prescribed, newer data suggest otherwise; Dr. Hedayati admonished the audience to “watch out for the morphine.”

She next discussed the P2Y₁₂ receptor inhibitors, three of which are approved in the United States for treatment of ischemic myocardial disorders, including NSTEMI. Ticagrelor is a potent reversible P2Y₁₂ inhibitor and the most popular of the three because both the parent drug and the metabolite are active. A 2009 multicenter, double-blind, randomized trial compared ticagrelor to clopidogrel in patients admitted to the hospital with ACS, with or without ST-segment elevation. Treatment with ticagrelor significantly reduced the rate of death from vascular causes, myocardial infarction, or stroke compared to clopidogrel. It did this without increasing the rate of overall major bleeding. Ticagrelor did, however, increase in the rate of non–procedure-related bleeding.

A second study compared ticagrelor to clopidogrel in patients with ACS. It also identified ticagrelor as a better option than clopidogrel for patients with ACS for whom an early invasive strategy is planned. Some patients, however, did not experience a benefit from ticagrelor. These patients included those that weigh less than 60 kg, those with normal biomarkers, and those enrolled in North America. This appears to be due to the fact that most patients in North America receive higher doses of aspirin than patients in Europe, and the benefit of ticagrelor over clopidogrel was limited to patients taking the lower dose of 75 mg to 100 mg of aspirin.