In patients with NSTEMI and elevated troponins, which initial therapy is recommended before coronary catheterization?

• A. Clopidogrel, heparin, and aspirin, followed by PCI
• B. Nitrates and morphine only
• C. Stress testing
• D. Thrombolytics

Answer: (A)

In NSTEMI with elevated troponins, the priority is to prevent further thrombus formation and prepare for definitive reperfusion with PCI. Starting aspirin to inhibit platelet aggregation, adding a P2Y12 inhibitor such as clopidogrel to provide dual antiplatelet therapy, and providing anticoagulation with heparin addresses the underlying clotting cascade and reduces recurrent ischemia while awaiting catheterization. This combination directly targets the pathophysiology of ACS and improves outcomes when an invasive strategy is planned.

Nitrates and morphine can help with chest pain but don’t prevent thrombosis, so they alone don’t constitute the initial therapy for NSTEMI in this setting. Stress testing is inappropriate during an acute NSTEMI with elevated troponins. Thrombolytics are reserved for STEMI when PCI isn’t available, not NSTEMI, due to lack of benefit and higher bleeding risk.