Unstable angina non ST elevation myocardial infarction initial conservative versus initial invasive strategies

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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ACC / AHA Guidelines (DO NOT EDIT)

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Class I 1. An early invasive strategy (i.e., diagnostic coronary angiography with intent to perform percutaneous coronary revascularization or CABG) is indicated in UA / NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Level of Evidence: B) 2. An early invasive strategy (i.e., diagnostic angiography with intent to perform percutaneous coronary revascularization or CABG) is indicated in initially stabilized UA / NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Level of Evidence: A) Class IIb 1. In initially stabilized patients: a. An initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA / NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events including those who are troponin positive. (Level of Evidence: B) b. The decision to implement an initial conservative (vs. initial invasive) strategy in these patients may be made by considering physician and patient preference. (Level of Evidence: C) 2. An invasive strategy may be reasonable in patients with chronic renal insufficiency. (Level of Evidence: C) Class III 1. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) is not recommended in patients with extensive comorbidities (e.g., liver failure or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C) 2. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) is not recommended in patients with acute chest pain and a low likelihood of Acute coronary syndromes. (Level of Evidence: C) 3. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) should not be performed in patients who will not consent to revascularization regardless of the findings. (Level of Evidence: C)

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See Also

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction