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NICE guidelines STEMI and NSTEMI management plan in table, differnece in detail but summarize

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site:nice.org.uk guidance acute coronary syndromes STEMI NSTEMI NG185 recommendations 2026

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acute coronary syndrome AND management

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https://www.nice.org.uk/guidance/ng185/chapter/Recommendatio…

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"acute coronary syndrome" AND "systematic review"

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NICE NG185: STEMI vs NSTEMI management

Core distinction: STEMI usually reflects an acutely occluded coronary artery, so it requires immediate reperfusion. NSTEMI has no persistent ST elevation and is managed with antithrombotic therapy plus risk-stratified timing of angiography. This is why the ECG distinction drives the initial pathway. Frameworks for Internal Medicine, lines 654-658.
StepSTEMINSTEMI
Initial recognitionPersistent ST-segment elevation or equivalent ECG pattern with clinical ACS. Do not wait for troponin before activating reperfusion pathway.Ischaemic symptoms with raised/falling troponin but no persistent ST elevation. ECG may show ST depression, T-wave inversion, or be non-diagnostic.
Immediate actions for bothABCDE, cardiac monitoring, IV access, 12-lead ECG promptly, repeat ECG if uncertainty, serial troponins, treat arrhythmia/shock/heart failure, assess bleeding risk and contraindications. Give oxygen only if hypoxaemic or in respiratory distress. Give analgesia as needed.Same initial stabilisation and testing.
AspirinGive 300 mg loading dose ASAP unless allergy, then continue long term.Give 300 mg loading dose ASAP unless allergy, then continue indefinitely unless contraindicated.
Main early decisionReperfuse immediately. Preferred approach is primary PCI.Risk stratify, then decide urgency of angiography. Routine immediate thrombolysis is not used.
Primary PCIOffer coronary angiography with follow-on primary PCI if indicated when symptom onset is within 12 hours and PCI can be delivered within 120 minutes of the time fibrinolysis could have been given. Use radial access where appropriate.Immediate angiography and PCI if indicated if the patient is clinically unstable. For stable patients, timing depends on predicted risk.
If PCI unavailable in timeIf within 12 hours and primary PCI cannot be delivered within the 120-minute window, offer fibrinolysis, with an antithrombin concurrently.Do not give fibrinolysis. It does not have the same benefit-risk profile in NSTEMI and can cause serious bleeding.
After fibrinolysisPerform ECG 60-90 minutes afterward. Residual ST elevation suggests failed reperfusion: immediate angiography/rescue PCI. Do not repeat fibrinolysis. Consider angiography during the same admission even after successful lysis.Not applicable.
Anticoagulation / antithrombinDuring radial primary PCI: unfractionated heparin, with glycoprotein IIb/IIIa inhibitor only as bailout. Bivalirudin may be considered when femoral access is required.Fondaparinux if no high bleeding risk, except when immediate angiography is planned. Use dose-adjusted unfractionated heparin as an alternative in significant renal impairment or when indicated for PCI.
Second antiplatelet agentFor primary PCI, give DAPT with aspirin plus prasugrel if no oral anticoagulant indication. Ticagrelor or clopidogrel are alternatives, particularly when prasugrel bleeding risk is a concern.Do not give DAPT before NSTEMI/unstable-angina diagnosis is established. Once angiography/PCI is intended, use aspirin plus prasugrel or ticagrelor if no ongoing oral anticoagulant indication. Use clopidogrel when ongoing oral anticoagulation is indicated.
Risk assessmentTime-critical reperfusion takes priority. Shock, ongoing ischaemia and late presentation influence the need for angiography.After aspirin and antithrombin, formally assess risk, for example with GRACE 6-month mortality risk.
Timing of angiographyImmediate primary PCI pathway. Consider PCI beyond 12 hours when there is continuing ischaemia; offer angiography/PCI in cardiogenic shock within 12 hours.Immediate if unstable. Within 72 hours if intermediate/high risk, defined by predicted 6-month mortality >3%, with no contraindication. Consider angiography even in lower-risk patients if appropriate.
Before dischargeAssess left ventricular (LV) function in all patients.Assess LV function and residual ischaemia/risk as clinically indicated.
Secondary preventionSame post-MI package.Same post-MI package.
NICE specifically recommends aspirin 300 mg promptly for both syndromes, primary PCI as the preferred STEMI reperfusion strategy within the stated time target, and fibrinolysis only when timely PCI cannot be achieved. See the NICE acute coronary syndrome recommendations.

Practical management plans

PhaseSTEMI planNSTEMI plan
0-10 minutesConfirm STEMI on ECG, activate cath lab/transfer pathway, give aspirin, assess haemodynamic stability.Confirm ACS with ECG plus serial troponin, give aspirin, begin antithrombin strategy, assess instability.
First 2 hoursPrimary PCI if within the time window. If not achievable, consider immediate fibrinolysis if eligible and within 12 hours of symptom onset.Calculate GRACE or equivalent risk after initial treatment. Unstable patient: immediate invasive pathway. Stable patient: plan early invasive versus selective strategy.
Same admissionRescue PCI for failed lysis; otherwise angiography/PCI strategy and complication surveillance.Angiography within 72 hours for intermediate/high-risk disease; PCI or CABG according to coronary anatomy and overall risk.
Discharge and long-term careAspirin long term; DAPT duration individualized, commonly 12 months after ACS if bleeding risk permits; high-intensity statin; beta-blocker where indicated; ACE inhibitor/ARB especially with LV dysfunction, diabetes, hypertension, or CKD; cardiac rehabilitation; smoking cessation and risk-factor control.Same secondary-prevention package, tailored to bleeding risk, renal function, LV function and revascularisation result.

Key differences to remember

  1. STEMI = “open the artery now.”
    Immediate PCI is preferred. Fibrinolysis is an alternative only when timely PCI cannot be delivered.
  2. NSTEMI = “stabilise, risk-stratify, then intervene at the right urgency.”
    Immediate angiography is for instability. Otherwise, use a validated risk score and arrange angiography, typically within 72 hours for intermediate/high risk.
  3. Fibrinolysis is a STEMI treatment, not an NSTEMI treatment.
  4. NSTEMI begins with fondaparinux in many stable patients, while STEMI anticoagulation is tied closely to the primary PCI strategy.
  5. Both require the same high-quality secondary prevention, but STEMI has a stronger immediate time-pressure because rapid reperfusion reduces myocardial loss. The medical-text summary similarly identifies immediate PCI or fibrinolysis as beneficial specifically in STEMI. Frameworks for Internal Medicine, lines 654-658.

Escalate immediately in either STEMI or NSTEMI if

  • Cardiogenic shock or hypotension
  • Ongoing/refractory chest pain or recurrent ischaemia
  • Acute heart failure/pulmonary oedema
  • Sustained ventricular arrhythmia
  • Mechanical complication suspected
  • Syncope, severe bradycardia, or high-grade AV block
This is a guideline summary for study and clinical orientation, not a substitute for local PCI-network protocols, senior cardiology input, or patient-specific prescribing decisions.

drug management difference in tablw with dosesin detail ,summarize

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site:nice.org.uk/guidance/ng185 STEMI NSTEMI drug management doses aspirin prasugrel ticagrelor fondaparinux unfractionated heparin

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acute coronary syndrome AND antithrombotic

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STEMI vs NSTEMI: drug-management differences with usual adult doses

Use local ACS/PCI protocol for prescribing, especially for renal impairment, frailty, low body weight, active bleeding, oral anticoagulation, and planned CABG. The table shows common adult doses used in UK practice; NICE NG185 specifies the treatment choices, while exact procedural anticoagulant and fibrinolytic dosing follows local specialist protocols and product information.
Drug groupSTEMINSTEMIMain difference
Aspirin300 mg PO chewed/loading dose immediately, then 75 mg PO once daily long term.300 mg PO chewed/loading dose immediately, then 75 mg PO once daily long term.Same. NICE recommends 300 mg loading as soon as possible in both.
P2Y12 inhibitor: primary PCIPrasugrel: 60 mg PO loading, then 10 mg once daily. Consider 5 mg daily maintenance if body weight <60 kg. Avoid in prior stroke/TIA. In patients ≥75 years, assess bleeding risk carefully; ticagrelor or clopidogrel may be preferred. Ticagrelor alternative: 180 mg loading, then 90 mg twice daily. Clopidogrel alternative: 600 mg loading, then 75 mg daily.If PCI is planned, give after coronary anatomy is known and PCI is intended: Prasugrel: 60 mg loading, then 10 mg daily, subject to the same cautions. Ticagrelor: 180 mg loading, then 90 mg twice daily. Clopidogrel: 600 mg loading, then 75 mg daily, especially if oral anticoagulation is required.In STEMI primary PCI, P2Y12 loading is part of immediate reperfusion treatment. In NSTEMI, do not routinely pre-treat before diagnosis, and NICE advises giving prasugrel only after anatomy is defined and PCI is intended.
P2Y12 inhibitor: STEMI treated with fibrinolysis/no PCIClopidogrel is generally used with fibrinolysis: age ≤75 years: 300 mg loading then 75 mg daily; age >75 years: 75 mg daily without a loading dose. If STEMI is managed without PCI, NICE supports ticagrelor plus aspirin where bleeding risk permits, but the pathway should be cardiologist-led.No fibrinolysis. If managed medically after confirmed NSTEMI, antiplatelet selection is individualized by cardiology, bleeding risk and planned angiography.Fibrinolysis has a specific clopidogrel-based regimen in STEMI.
DAPT durationAspirin plus a P2Y12 inhibitor is often continued for up to 12 months after ACS, unless bleeding risk requires a shorter duration.Same general principle. Duration must be individualized after PCI, CABG, medical management, bleeding events, or need for anticoagulation.Usually same, but NSTEMI patients more often require decisions after angiography and risk assessment.
Anticoagulant before/in PCIPrimary PCI: unfractionated heparin (UFH) is standard. Typical catheter-lab dosing is 70-100 units/kg IV bolus if no glycoprotein IIb/IIIa inhibitor is used, or 50-70 units/kg IV if one is used. Exact dose follows the PCI unit protocol and ACT monitoring. Bivalirudin, where chosen: 0.75 mg/kg IV bolus then 1.75 mg/kg/hour infusion during PCI, with renal adjustment.Stable, not for immediate angiography: fondaparinux 2.5 mg SC once daily if not at high bleeding risk. Immediate angiography/PCI: UFH is used according to cath-lab protocol. Significant renal impairment, for example creatinine >265 micromol/L: consider UFH with clotting-based dose adjustment rather than fondaparinux.STEMI: anticoagulation supports immediate PCI. NSTEMI: fondaparinux is preferred while awaiting a non-immediate invasive strategy, unless bleeding risk or renal impairment changes the choice.
Glycoprotein IIb/IIIa inhibitorNot routine before cath lab. Use only as bailout during primary PCI, for example major thrombus burden, no-reflow, or thrombotic complication.Not routine. May be used selectively in the catheter lab as bailout.No routine use in either syndrome.
Fibrinolytic drugIf symptom onset is within 12 hours and PCI cannot be delivered within NICE’s 120-minute window, give fibrinolysis plus antithrombin. Common regimens include weight-based tenecteplase single IV bolus or an alteplase regimen, but selection and exact dose must follow local thrombolysis protocol.Contraindicated/not indicated. Do not use fibrinolysis for NSTEMI.The most important medication difference.
Nitrates for pain/ischaemiaGTN 400 micrograms sublingual, repeat every 5 minutes up to 3 doses if BP permits; IV GTN may be used for persistent pain, hypertension or pulmonary oedema per local protocol. Avoid with hypotension, right-ventricular infarction, severe aortic stenosis, or phosphodiesterase-5 inhibitor use.Same symptomatic use and same cautions.Same. Does not replace reperfusion or reduce mortality.
Opioid analgesiaIV morphine in small titrated doses, often 2-5 mg IV, with antiemetic if required. Use cautiously because it can cause hypotension/respiratory depression and may delay absorption of oral antiplatelets.Same.Same. Use only for severe pain not controlled by nitrates/initial therapy.
OxygenGive only if hypoxaemia, respiratory distress or shock, typically if SpO₂ <90%.Same.Same. Do not give routinely to a normoxic patient.
High-intensity statinAtorvastatin 80 mg PO once daily as early as appropriate, unless contraindicated or not tolerated.Same.Same secondary-prevention therapy.
Beta-blockerStart oral beta-blocker when haemodynamically stable, for example bisoprolol 1.25-2.5 mg daily, then titrate. Avoid early use in shock, acute heart failure, marked bradycardia, hypotension or high-grade heart block.Same.Same principle. Not an automatic IV emergency drug.
ACE inhibitor / ARBStart once stable, especially if LV systolic dysfunction, heart failure, diabetes, hypertension or CKD. Example: ramipril 1.25-2.5 mg twice daily, titrated as tolerated.Same.Same long-term risk reduction.
Mineralocorticoid receptor antagonistIf LVEF ≤40% with heart failure or diabetes and renal function/potassium allow: eplerenone 25 mg daily, increasing to 50 mg daily as tolerated.Same.Same, based on LV function and clinical indication rather than ECG type.

High-yield summary

PointSTEMINSTEMI
Aspirin300 mg load then 75 mg daily300 mg load then 75 mg daily
AnticoagulantUFH for primary PCIFondaparinux 2.5 mg SC daily if stable and not having immediate angiography
P2Y12 agentPrasugrel/ticagrelor with immediate PCI; clopidogrel is generally used with fibrinolysisPrasugrel/ticagrelor once diagnosis is confirmed and PCI strategy is established; clopidogrel if oral anticoagulation needed
FibrinolysisYes, if timely PCI unavailable and eligibleNever routine
Core principleImmediate reperfusionRisk-stratified invasive management
NICE recommends aspirin promptly in both syndromes, fondaparinux for NSTEMI patients not undergoing immediate angiography, and UFH with DAPT for STEMI primary PCI. See the NICE NG185 recommendations. For ticagrelor, the standard licensed ACS regimen is a 180 mg loading dose followed by 90 mg twice daily with low-dose aspirin, as described in NICE TA236.
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