INTRODUCTION — Most patients with a non-ST-elevation acute coronary syndrome (NSTEACS; unstable angina and non-ST-elevation myocardial infarction [NSTEMI]) undergo coronary angiography and revascularization during the index hospitalization. This topic will summarize the evidence supporting this invasive strategy and discuss our approach to revascularization.
The diagnostic evaluation of a NSTEACS and the general management of these patients are presented elsewhere. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Overview of the acute management of non-ST-elevation acute coronary syndromes".)
DEFINITION OF UA AND NSTEMI — Unstable angina (UA) and NSTEMI are part of the continuum of acute coronary syndrome (ACS), which also includes ST-elevation MI (STEMI). A detailed discussion of the diagnosis of UA and NSTEMI is presented elsewhere. (See "Diagnosis of acute myocardial infarction", section on 'Definitions'.)
According to the Fourth Universal Definition (see "Diagnosis of acute myocardial infarction", section on 'Definitions'), the term "acute myocardial infarction" should be used when there is acute myocardial injury with clinical evidence of acute myocardial ischemia and with detection of a rise and/or fall of cardiac troponin values with at least one value above the 99th percentile upper reference limit and at least one of the following [1]:
●Symptoms of myocardial ischemia.
●New ischemic ECG changes.
●Development of pathological Q waves.
●Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology.
●Identification of a coronary thrombus by angiography or autopsy (not for type 2 or 3 MIs).
UA and NSTEMI differ primarily in whether the ischemia is severe enough to cause sufficient myocardial damage to release detectable quantities of a marker of myocardial injury [2].
EARLY RISK ASSESSMENT — Individual patients with unstable angina (UA) and NSTEMI can be at widely varying risks of complications such as death, recurrent MI, or recurrent angina requiring revascularization. We recommend that all patients with NSTEACS undergo risk assessment soon after the diagnosis is made, as it helps not only to provide patients with information about their prognosis, but it may guide the timing of coronary angiography and possible percutaneous coronary intervention (PCI). Risk assessment is performed using a risk stratification tool, such as the Thrombolysis in Myocardial Infarction (TIMI) risk score (calculator 1) or Global Registry of Acute Coronary Events (GRACE) risk score (http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html), in some patients (table 1). These might include individuals for whom the need for urgent cardiac catheterization is not necessary or those who refuse cardiac interventional procedures. Risk stratification is discussed in detail separately. (See "Risk stratification after non-ST elevation acute coronary syndrome", section on 'Early risk stratification tools'.)
APPROACH TO REVASCULARIZATION — Risk assessment, as discussed directly above, is used to determine whether coronary angiography and revascularization should be performed and when. After risk assessment, patients should be assigned to one of three categories: immediate angiography, an invasive approach, or a conservative approach. In general, unstable patients are referred for immediate angiography, high-risk patients are assigned to an invasive strategy, and low-risk patients are assigned to a conservative strategy.
The risk assessment tools (see 'Early risk assessment' above) are not perfect predictive instruments and judgement needs to be exercised from time to time in terms of deciding on the best strategy for each patient. Patients assessed to be at low risk (eg, TIMI score of 0 to 2; in-hospital death/MI rate of up to 3 percent or GRACE risk score ≤108) are considered for a conservative approach. In addition, these individuals typically have no significant ST-segment deviation on the electrocardiogram and no troponin elevation. Even with a low risk score, however, we often refer patients who have a low risk score but a positive troponin or significant ST-segment deviation for angiography during the index hospitalization.
The three strategies are:
●The strategy of immediate angiography followed by revascularization takes place soon after the diagnosis and is indicated for patients assessed to have a poor short-term (or long-term) prognosis due the NSTEACS.
●The invasive strategy of angiography followed by revascularization is aimed at improving long-term prognosis. In these patients, angiography followed by revascularization is intended and usually performed within 4 to 48 hours of admission. Some experts refer to intended angiography within 24 hours as an early invasive approach and intended angiography within 48 hours a delayed invasive approach.
●The conservative strategy begins with rapidly intensifying medical therapy. Patients who become asymptomatic on this regimen are given several days to "cool off," during which time intravenous medications are discontinued. If the patient remains symptom-free, stress testing is performed, most often with some form of myocardial imaging (nuclear or echocardiography). Persistence of symptoms, symptom recurrence, or a positive stress test should lead to prompt cardiac catheterization. (See "Overview of the acute management of non-ST-elevation acute coronary syndromes".)
Immediate angiography — We recommend immediate angiography with an intention to proceed to immediate revascularization for the following groups of unstable patients, as the risk of a poor outcome in both the short and long term is high:
●Hemodynamic instability with or without cardiogenic shock. (See 'Cardiogenic shock' below and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
●Severe left ventricular dysfunction or overt heart failure [3]. (See "Treatment of acute decompensated heart failure in acute coronary syndromes", section on 'Revascularization'.)
●Recurrent or persistent rest angina despite intensive medical therapy.
●Mechanical complications (eg, acute mitral regurgitation, ventricular septal defect). (See "Acute myocardial infarction: Mechanical complications".)
●Sustained ventricular tachycardia. (See "Ventricular arrhythmias during acute myocardial infarction: Incidence, mechanisms, and clinical features".)
●Dynamic ST-T wave electrocardiographic changes.
While the prognosis for these patients is poor, there are no well-performed studies comparing the strategy of immediate angiography to an invasive strategy with percutaneous coronary angiography (PCI) in 4 to 48 hours. The evidence supporting a recommendation for immediate angiography comes from a few observational studies in patients with cardiogenic shock or mechanical complications. (See "Acute myocardial infarction: Mechanical complications" and "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction", section on 'Percutaneous coronary intervention'.)
The only reasons to exclude angiography in patients with any of the above risks would be if they would not consider revascularization or if they have underlying conditions (such as severe co-morbid disease) that preclude PCI or coronary artery bypass grafting (CABG).
Invasive approach — For most patients who do not meet criteria for immediate angiography (see 'Immediate angiography' above), coronary angiography with a view toward revascularization, referred to as the invasive strategy, should be performed within the first 24 to 48 hours. Among these patients, those at the highest risk should undergo coronary angiography within 12 hours (see 'Timing' below). An invasive strategy, even if not carried out immediately, can limit the extent of MI and potentially improve long-term prognosis.
A 2006 meta-analysis of seven trials with 8375 NSTEACS patients, including the FRISC II, TACTICS-TIMI 18, RITA-3, and ICTUS trials, concluded that an invasive approach led to better outcomes compared to a conservative strategy [4]. There were four studies with 3961 patients that performed an early invasive strategy within 24 hours; in the other three studies, this approach was performed between 24 and 48 hours.
The following benefits were noted with an early invasive strategy at a mean follow-up of two years:
●A lower rate of all-cause mortality (4.9 versus 6.5 percent with conventional therapy, RR = 0.75, 95% CI 0.63-0.90).
●A lower rate of nonfatal MI (7.6 versus 9.1 percent, RR = 0.83, 95% CI 0.72-0.96).
●A lower rate of rehospitalization for unstable angina at 13 months of follow-up (RR = 0.69, 95% CI 0.65-0.74).
These findings were despite the fact that the ICTUS trial found no benefit from an early invasive compared to a selective invasive strategy in 1200 patients with a NSTEACS who had chest pain, an elevated serum cardiac troponin T, and either electrocardiogram (ECG) evidence of ischemia or a documented history of coronary disease [5,6]. It cannot be determined with confidence why the results in this trial were different from others in the meta-analysis. Some factors that have been proposed include differences in study design, differing definitions of periprocedural MI, and the intensity of lipid lowering therapy.
The benefits found in the above studies are durable. At 15-year follow-up of the FRISC study, which was included in the above meta-analysis, the early invasive treatment strategy postponed the occurrence of death or next MI by an average of 18 months [7].
The benefits of an early invasive approach found in the randomized trials discussed directly above have been confirmed in a real-world setting. In a retrospective cohort study of 19,704 propensity score-matched patients with an ACS, an early invasive strategy (compared with a conservative approach) was associated with a lower risk for cardiac death (5.9 versus 7.6 percent; adjusted hazard ratio [HR] 0.75, 95% CI 0.66-0.84), rehospitalization for MI (3.4 versus 5.0 percent; adjusted HR 0.67, 95% CI 0.58-0.77), and all-cause death (7.3 versus 10.7 percent; 0.65, 95% CI 0.59-0.72) [8].
The relationship between risk score and benefit from an invasive strategy was evaluated in TACTICS-TIMI 18. The TIMI risk score identified patients who might benefit from an early invasive strategy (calculator 1) [9]:
●Among patients at low risk (score 0 to 2), there was no difference in the primary end point (death, MI, rehospitalization for an ACS at six months) between the invasive and conservative approaches (12.8 versus 11.8 percent).
●There was a significant reduction in the primary end point with the invasive approach in patients at intermediate risk (score 3 to 4, 16.1 versus 20.3 percent) and particularly in those at high risk (score 5 to 7, 19.5 versus 30.6 percent). Similarly, in the five-year follow-up from the RITA 3 trial, the benefit was primarily seen in patients at highest risk at presentation [10].
Timing — For patients in whom an invasive strategy has been chosen, we perform early angiography with a view toward revascularization within 48 hours of diagnosis. For those patients who are at very high risk for an adverse cardiovascular event, such as those with a GRACE risk score (table 1) >140, we attempt to perform angiography within 12 hours.
A 2017 meta-analysis evaluated mortality in eight randomized trials that compared early to delayed invasive treatment in 5324 patients with NSTEACS [11]. The studies were performed between 2000 and 2016 and the median follow-up was 180 days. The TIMACS trial (n = 3031) was the largest [12]. Coronary angiography was before 24 hours in the early invasive arms of the studies and between 12 and 108 hours in the delayed arms. There was no survival benefit associated with the early invasive strategy (hazard ratio 0.81, 95% CI 0.64-1.03). In prespecified analyses of patients at high risk, mortality was lower with the early invasive strategy (elevated biomarker [HR 0.76, 95% CI 0.58-1.00]), diabetes (HR 0.67, 95% CI 0.45-0.99), a GRACE risk score (table 1) more than 140 (HR 0.70, 95% CI 0.52-0.95), and age 75 years or older (HR 0.65, 95% CI 0.46-0.93).
The Very EaRly vs Deferred Invasive evaluation using Computerized Tomography (VERDICT) trial was published subsequent to the meta-analysis and supports its conclusions. VERDICT randomly assigned 2147 patients with NSTEACS and indications for an invasive approach to angiography within 12 hours (very early angiography group) or within 48 to 72 hours (standard angiography group) of the diagnosis [13]. Early and standard angiography occurred at a median of 4.7 and 61.6 hours, respectively, after randomization. Within a median follow-up of 4.3 years, there was no difference in the rate of the primary composite end point of all-cause death, nonfatal MI, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure (27.5 versus 29.5 percent, respectively; HR 0.92, 95% CI 0.78-1.08). With regard to mortality, there was no difference between the two groups. However, among the subgroup of patients with a GRACE risk score >140 (table 1), there was a trend toward a lower rate of the primary outcome with very early angiography (HR 0.81, 95% CI 0.67-1.01).
Based on the above studies, early intervention can be performed any time up to 60 hours in stable patients with NSTEACS. We believe that patients at very high risk, such as those with a TIMI risk score of 5 or greater (calculator 1) or a GRACE risk score >140 (table 1), but who do not fall into the "immediate angiography" group (see 'Immediate angiography' above), derive benefit from coronary angiography within 12 hours of symptoms.
Aspiration thrombectomy — Thrombus plays an important role in the pathogenesis of NSTEACS and up to a 50 percent of patients have significant thrombus at the time of angiography [14]. While the role of thrombus aspiration in patients with ST elevation MI has been relatively well studied, this is not the case for NSTEACS. (See "Suboptimal reperfusion after primary percutaneous coronary intervention in acute ST-elevation myocardial infarction", section on 'Thrombectomy'.)
In the TATORT-NSTEMI trial, which randomly assigned 440 patients to adjunctive thrombectomy at the time of PCI or PCI alone, there was no difference in the primary end point of the extent of microvascular obstruction assessed by cardiac magnetic resonance imaging as a percentage of left ventricular mass (2.0 versus 1.4 percent; p = 0.17) [15].
We do not recommend the routine use of thrombus aspiration in these patients. However, it may be reasonable to perform in patients with large thrombus burden or TIMI flow grade 0 [16].
Radial versus femoral access — In patients undergoing an invasive approach for NSTEMI, we prefer the radial to the femoral approach if performed by skilled operators. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Radial artery access' and "Percutaneous arterial access techniques for diagnostic or interventional procedures", section on 'Radial artery'.)
Conservative approach — For those patients whose short-term risk of death or recurrent MI is assessed to be low, medical therapy plus risk stratification using noninvasive testing with an assessment of left ventricular function and stress testing may be appropriate. For those with recurrent angina, reduced left ventricular function, or evidence of significant ischemia on stress testing, coronary angiography is indicated assuming the patient is a candidate for revascularization. This recommendation is consistent with the approach to patients who have not had NSTEACS. (See "Chronic coronary syndrome: Indications for revascularization", section on 'Patients without clear indications' and "Chronic coronary syndrome: Indications for revascularization", section on 'Indications'.)
METHOD OF REVASCULARIZATION IN MULTIVESSEL DISEASE — In patients found to have multivessel disease (including the culprit lesion) after coronary angiography, there are three major options for revascularization:
●Culprit lesion/vessel percutaneous coronary intervention (PCI) only
●Multivessel PCI (including the culprit lesion)
●Coronary artery bypass graft surgery (CABG)
The following discussion applies to patients in whom revascularization will be undertaken.
Percutaneous coronary intervention versus coronary artery bypass graft surgery — In patients for whom multivessel revascularization is deemed necessary, CABG is often preferred over PCI for the treatment of patients with left main or left main equivalent disease, or three-vessel disease involving the left anterior descending artery in patients with a reduced left ventricular ejection fraction or treated diabetes [17,18]. (See "Revascularization in patients with stable coronary artery disease: Coronary artery bypass graft surgery versus percutaneous coronary intervention".)
In patients who are angiographically eligible for either approach, CABG was compared with PCI in the AWESOME and ERACI II trials [19-21]. These studies came to similar conclusions: long-term mortality was comparable with both strategies but revascularization rates were higher with PCI as the primary strategy. A limitation to both trials is that they were performed before the availability of drug-eluting stents, which markedly reduce the rate of revascularization.
The safety of multivessel PCI among patients with an acute MI (both NSTEMI and STEMI) was also suggested in a retrospective study from the Mayo Clinic [22]. Multivessel PCI (97 percent with stents) was not associated with an excess risk of mortality or the combined end point of death, MI, CABG, or target vessel revascularization compared to single vessel PCI (both performed at mean of about two days after the MI).
Patients with concomitant valvular disease are frequently cited as another subgroup that requires surgical intervention. While surgery for significant valve dysfunction may be necessary, performing PCI prior to valve surgery may be an appropriate alternative to a combined valve/CABG operation. This was suggested by a study of initial PCI followed by valve surgery in 26 patients, most presenting with an ACS [23].
Multivessel versus culprit only PCI — In NSTEACS patients with multivessel disease for whom PCI is chosen as the revascularization strategy, the operator must decide between culprit only or multivessel PCI. There have been no randomized trials directly comparing complete to incomplete revascularization (ICR) in these patients. Until further studies inform decision making between culprit lesion only or multivessel PCI (even as a staged approach), we individualize decision making, using clinical status and disease severity (eg, symptoms, anatomic risk, and functional significance) to guide our approach.
For example, after considering the risk benefit ratio, we perform PCI on tight (greater than 75 percent diameter stenosis) non-culprit lesions that supply a large portion of the left ventricular myocardium, assuming the anatomy is of relatively low risk and the procedure time and contrast volume have not exceeded a threshold for increased risk with a longer procedure, Confirmation of the hemodynamic significance of a lesion using fractional flow reserve may guide the decision [24].
The following studies provide some evidence to support a multivessel approach:
●In a 2018 observational cohort study of 21,857 patients with NSTEMI and multivessel disease, 11,737 underwent single-stage complete revascularization and 10,120 underwent culprit-only revascularization [25]. Comparing the two groups, all-cause mortality was lower with complete revascularization (22.9 versus 25.9 percent, respectively; hazard ratio 0.90, 95% CI 0.85-0.97) at a median follow-up of 4.1 years. The study did not evaluate outcomes in patients who underwent deferred complete revascularization. Other observational studies have come to a similar conclusion [26,27].
●In a substudy of the ACUITY trial (of patients with NSTEACS treated with an early invasive strategy who were randomly assigned to differing antithrombotic regimens), quantitative coronary angiography of the entire coronary tree was performed in 2954 individuals [28]. (See "Anticoagulant therapy in non-ST elevation acute coronary syndromes", section on 'Unfractionated heparin compared with bivalirudin'.).
ICR was variably defined if any lesion with diameter stenosis cutoffs ranging from ≥30, ≥40, ≥50, ≥60, and ≥70 percent remained after PCI. With these cutoffs, the prevalence of ICR was 75, 55, 37, 25, and 17 percent, respectively. The primary composite outcome (one-year rate of death, MI, or ischemia-driven unplanned revascularization) was increased at all cutoffs compared individuals with complete revascularization. Using ≥50 percent as the definition, ICR was associated with higher rates of the primary end point (23.4 versus 16.6 percent; hazard ratio [HR] 1.47, 95% CI 1.24-1.74), MI (12.0 versus 6.2 percent; HR 1.50, 95% CI 1.18-1.89), and ischemia-driven unplanned revascularization (15.7 versus 10.2 percent; HR 1.58, 95% CI 1. 28-1.96), with a trend toward increased mortality (3.1 versus 2.2 percent).
Single sitting versus staged multivessel PCI — In NSTEMI patients found to have significant multivessel disease and in whom a decision has been made to perform multivessel PCI prior to hospital discharge (see 'Multivessel versus culprit only PCI' above), non-culprit PCI can be accomplished at the time of culprit PCI or at a separate catheterization laboratory session prior to discharge. The SMILE trial randomly assigned 584 such patients to complete PCI at the time of culprit PCI or complete PCI of non-culprit lesions at a second procedure performed between three and seven days after hospitalization and prior to discharge [29]. The primary end point (incidence of major adverse cardiovascular and cerebrovascular events, defined as cardiac death, death, reinfarction, rehospitalization for unstable angina, repeat coronary revascularization of the target vessel, and stroke at one year) occurred less often in the group with a single procedure (13.6 versus 23.2 percent; hazard ratio 0.55, 95% CI 0.36-0.83). This finding was attributable primarily to an unexpectedly higher rate of target vessel revascularization in the multistage group (8.3 versus 15.2 percent). Due to significant limitations of this trial (eg, open label and primary composite end point) and the unexpected finding, we continue to perform both single and multisession multivessel PCI in NSTEMI patients with significant multivessel disease. Decision making is individualized based on patient and lesion characteristics.
SPECIAL SITUATIONS — Three situations in patients with NSTEACS merit comment: cardiogenic shock, recurrent ischemia, and chronic kidney disease.
Cardiogenic shock — There are no randomized trials assessing the efficacy of coronary angiography and revascularization in the setting of NSTEMI and cardiogenic shock. Series of unselected patients with acute MI and cardiogenic shock have reported a lower mortality in those who undergo successful percutaneous coronary intervention (PCI) compared to those with failed PCI, those not selected for coronary angiography and PCI, and historical controls [30]. (See "Prognosis and treatment of cardiogenic shock complicating acute myocardial infarction".)
Recurrent ischemia — Early recurrent coronary ischemia after NSTEACS can be symptomatic or silent (detected primarily by stress testing or continuous electrocardiographic monitoring). (See "Silent myocardial ischemia: Epidemiology, diagnosis, treatment, and prognosis", section on 'Revascularization'.)
Patients with recurrent angina after acute MI are at high risk of reinfarction and death. As a result, coronary angiography followed by revascularization is recommended in this setting [31].
Chronic kidney disease — Patients with chronic kidney disease (CKD) are at risk for worse outcomes after MI, but also are more likely to suffer complications of cardiac catheterization, such as acute kidney injury or cholesterol embolism [32]. (See "Risk stratification after non-ST elevation acute coronary syndrome", section on 'Early risk stratification tools' and "Complications of diagnostic cardiac catheterization", section on 'Acute renal failure'.)
Patients with mild (stage II) and moderate (stage III) CKD may benefit from an invasive strategy and should be strongly considered. It is uncertain whether patients with more advanced CKD benefit from this approach; the risks and benefits need to be discussed in detail with the patient.
The issue of whether the benefits of an invasive strategy found in the general population apply to patients with CKD was evaluated in a 2009 systematic review of five trials that enrolled 1453 patients [32]. All patients had a glomerular filtration rate <60 mL/min per 1.73 m2. An early invasive strategy was associated with a nonsignificant reduction in all-cause mortality (RR 0.76, 95% CI 0.49-1.17) and nonfatal MI (RR 0.78, 95% CI 0.52-1.16) at one year.
This issue was addressed further in the SWEDEHEART registry of over 23,000 patients with NSTEMI who received either an invasive or a medical strategy and then were stratified into groups based on baseline estimated glomerular filtration rate (eGFR) [33]. The adjusted one-year mortality increased as the eGFR fell from normal to dialysis dependent with either therapy, but the relative difference between the two groups narrowed with a decline in eGFR. There was no significant difference in the hazard rate for mortality between the two groups when the eGFR was less than 30 to 59 mL/min per 1.73 m2.
Older patients — There is some evidence that older patients, similar to younger individuals, benefit from an invasive compared with a noninvasive approach [34]. While most older patients should be considered for an invasive approach, the final decision should carefully weigh the potential benefits with life expectancy, comorbidity, bleeding risk, cognitive and functional status, and patient preference [35].
In the After Eighty study, 457 individuals aged 80 years or older with NSTEACS were randomly assigned to an invasive or a conservative strategy [36]. During a median follow-up of 1.53 years, the primary composite outcome (MI, need for urgent revascularization, stroke, and death) occurred less often in the invasive group (40.6 versus 61.4 percent; hazard ratio [HR] 0.53, 95% CI 0.41-0.69). There was no significant difference in the rates of major and minor bleeding complications.
In the SENIOR-NSTEMI cohort study, mortality was assessed in a nonrandomized, propensity-matched analysis in 1500 patients 80 years of age or older with NSTEMI [37]. Comparing patients who received invasive management within three days of peak troponin with those who did not (56 percent), the adjusted cumulative five-year mortality was 36 and 55 percent in the two groups, respectively (adjusted HR 0.68, 95% CI 0.55-0.84).
TIMING OF DISCHARGE — The optimal duration of hospitalization for patients with NSTEACS who have been revascularized with percutaneous coronary intervention has not been well defined. Most patients can be discharged 48 hours after hospitalization.
The employment of early angiography and revascularization has led to shorter hospitalizations, and the use of stenting and potent antiplatelet therapy in the periprocedural period has led to a reduction in recurrent ischemic events. On the other hand, antiplatelet and antithrombotic therapies are associated with an increased risk of major bleeding.
For patients with an NSTEACS, including those with a small MI, who have had an uncomplicated course (no heart failure, significant arrhythmias, recurrent ischemia, significant bleeding, or hemodynamic instability), we typically consider discharge between 24 and 48 hours. Other factors that influence the timing of discharge include the level of home support, the need for further titration of medications, active co-morbid diseases, and frailty.
RECOMMENDATIONS OF OTHERS — Our recommendations (see 'Summary and recommendations' below) are generally in accord with those published by the American College of Cardiology Foundation/American Heart Association in the 2014 guideline for the management of patients with NSTEACS and those by the 2015 European Society of Cardiology guidelines for the management of acute coronary syndrome in patients present without persistent ST-elevation [2,38].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Non-ST-elevation acute coronary syndromes (non-ST-elevation myocardial infarction)".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Stenting for the heart (Beyond the Basics)" and "Patient education: Heart attack (Beyond the Basics)" and "Patient education: Coronary artery bypass graft surgery (Beyond the Basics)")
●Basics topic (see "Patient education: Coronary artery bypass graft surgery (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Risk assessment should be performed in all patients with non-ST-elevation acute coronary syndromes (NSTEACS) soon after the diagnosis is made to identify the optimal revascularization approach. We often use tools such as the Thrombolysis in Myocardial Infarction (TIMI) (calculator 1) or Global Registry of Acute Coronary Events (GRACE) risk scores (http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html) for patients in whom the approach to management is not obvious (table 1). (See 'Early risk assessment' above.)
●Patients who have one or more of the following characteristics are at extremely high risk of an adverse cardiovascular event in the short term: hemodynamic instability or cardiogenic shock; severe left ventricular dysfunction or heart failure; recurrent or persistent rest angina despite intensive medical therapy; new or worsening mitral regurgitation or new ventricular septal defect; dynamic ST-T wave electrocardiographic changes; or sustained ventricular arrhythmias. For patients with any of these six characteristics, we recommend immediate coronary angiography and revascularization (Grade 1B). (See 'Immediate angiography' above.)
●Patients who do not need to undergo immediate coronary angiography and revascularization but have one or more of the following characteristics are at high risk of an adverse event in the short term: percutaneous coronary intervention within six months or prior coronary artery bypass graft surgery; new or presumably new ST-segment depression; elevated troponin; recurrent angina or ischemia at rest or with low level activity despite intensive antiischemic therapy; left ventricular ejection fraction <40 percent; TIMI risk score greater than 2 (calculator 1) or GRACE risk score >108 (table 1). For these patients, we recommend an invasive as opposed to a conservative strategy (Grade 1B). (See 'Invasive approach' above.)
We perform coronary angiography within 24 to 48 hours of admission in most patients. For patients at very high risk, such as those with a TIMI risk score of 5 or greater (calculator 1) or GRACE risk score >140 (table 1), we typically perform coronary angiography within 12 hours of diagnosis. (See 'Timing' above.)
●A minority of hospitalized patients with ACS are deemed to be at low risk (TIMI risk score 0 to 2 or a GRACE risk score ≤108) (calculator 1) (table 1) (http://www.outcomes-umassmed.org/grace/acs_risk/acs_risk_content.html). These patients typically have no significant ST-segment deviation on the electrocardiogram and no elevation of troponin. For these patients, we suggest a conservative rather than an invasive strategy (Grade 2C).
For those patients in whom a conservative strategy is chosen, and for whom revascularization would be reasonable, we perform stress testing before or within 48 hours of discharge. Patients in this category who subsequently develop high-risk predictors or who manifest high-risk findings on noninvasive stress testing should be referred for diagnostic coronary angiography and possible revascularization.
