title: Long-term outcomes in high-risk patients with non-ST-segment elevation myocardial infarction.
abstract: Greater use of evidence-based therapies has improved outcomes for patients with acute coronary syndromes (ACS) in recent decades. Consequently, more ACS patients are surviving beyond 12 months; however, limited data exist to guide treatment in these patients. Long-term outcomes have not improved in non-ST-segment elevation myocardial infarction (NSTEMI) patients at the same rate seen in ST-segment elevation myocardial infarction patients, possibly reflecting NSTEMI patients' more complex clinical phenotype, including older age, greater burden of comorbidities and higher likelihood of a previous myocardial infarction (MI). This complexity impacts clinical decision-making, particularly in high-risk NSTEMI patients, in whom risk-benefit assessments are problematical. This review examines the need for more effective long-term management of NSTEMI patients who survive ≥12 months after MI. Ongoing risk assessment using objective measures of risk (for bleeding and ischemia) should be used in all post-MI patients. While 12 months appears to be the optimal duration of dual antiplatelet therapy for most patients, this may not be the case for high-risk patients, and more research is urgently needed in this population. A recent subgroup analysis from the DAPT study in patients with or without MI who had undergone coronary stenting (31 % presented with MI; 53 % had NSTEMI) and the prospective PEGASUS-TIMI 54 trial in patients with a prior MI and at least one other risk factor (40 % had NSTEMI) demonstrated that long-term dual antiplatelet therapy improved cardiovascular outcomes but increased bleeding. Further studies will help clarify the role of dual antiplatelet therapy in stable post-NSTEMI patients.
authors.affiliation: Division of Cardiology, Newark Beth Israel Medical Center, 201 Lyons Avenue, Newark, NJ, 07112, USA. marcohen@barnabashealth.org.
authors.forename: Marc
authors.initials: M
authors.lastname: Cohen
mesh_terms: D054058:Acute Coronary Syndrome / Q000401:mortality / Q000628:therapy; D002986:Clinical Trials as Topic; D018572:Disease-Free Survival; D006801:Humans; D009203:Myocardial Infarction / Q000401:mortality / Q000628:therapy; D010975:Platelet Aggregation Inhibitors / Q000009:adverse effects* / Q000627:therapeutic use*; D018570:Risk Assessment; D015607:Stents; D015996:Survival Rate
chemical_list: D010975:Platelet Aggregation Inhibitors
keywords: Acute coronary syndromes; Dual antiplatelet therapy; Non-ST-segment elevation myocardial infarction