Contemporary treatment strategies and implementation gaps in non–ST-segment elevation acute coronary syndrome

Non–ST-Segment Elevation Acute Coronary Syndrome (NSTE-ACS) represents a significant proportion of acute coronary syndrome cases, encompassing non–ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA), and remains a leading cause of hospitalization and mortality worldwide. Unlike ST-segment elevation myocardial infarction (STEMI), NSTE-ACS lacks persistent ST-segment elevation on electrocardiogram (ECG), making diagnosis reliant on cardiac biomarkers and clinical presentation. Risk stratification is central to guiding management, with tools such as the Global Registry of Acute Coronary Events (GRACE) score, which estimates short- and intermediate-term mortality risk, and the Thrombolysis in Myocardial Infarction (TIMI) score, a bedside tool predicting early ischemic events, informing decisions between conservative medical therapy and invasive strategies. Despite these recommendations, substantial gaps persist between guideline-directed care and real-world practice, including underuse of validated risk assessment tools, delays in invasive evaluation, and inconsistent adoption of potent P2Y12 inhibitors, particularly in resource-limited settings. This review synthesizes contemporary evidence and guideline recommendations to identify key challenges in the management of NSTE-ACS and highlights practice-level barriers that contribute to suboptimal outcomes. Key findings emphasize that systematic risk stratification, early invasive strategies for high-risk patients, and appropriate selection of antithrombotic therapy are frequently underimplemented. To address these gaps, the article proposes pragmatic solutions, including strengthening adherence to risk-based treatment algorithms, optimizing pharmacological choices based on bleeding and ischemic risk, and adapting guideline recommendations to local resource availability. By outlining actionable strategies to bridge the divide between evidence and practice, this review provides a comprehensive framework for improving NSTE-ACS care across diverse healthcare settings.