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11 Table 9. Early Invasive and Ischemia-Guided Strategies Recommendations COR LOE An urgent/immediate invasive strateg y (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). I A An early invasive strateg y (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE- ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events. I B It is reasonable to choose an early invasive strateg y (within 24 h of admission) over a delayed invasive strateg y (within 24-72 h) for initially stabilized high-risk patients with NSTE-ACS. For those not at high/intermediate risk, a delayed invasive approach is reasonable. IIa B In initially stabilized patients, an ischemia-guided strateg y may be considered for patients with NSTE-ACS (without serious comorbidities or contraindications to this approach) who have an elevated risk for clinical events. IIb B e decision to implement an ischemia-guided strateg y in initially stabilized patients (without serious comorbidities or contraindications to this approach) may be reasonable aer considering clinician and patient preference. IIb C An early invasive strateg y (i.e., diagnostic angiography with intent to perform revascularization) is NOT recommended in patients with: a. Extensive comorbidities (e.g., hepatic, renal, pulmonary failure; cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. III: No Benefit C b. Acute chest pain and a low likelihood of ACS who are troponin-negative, C especially women. B Table 8. Initial Antiplatelet/Anticoagulant Therapy in Patients With Definite or Likely NSTE-ACS (cont'd) Recommendations COR LOE In patients with NSTE-ACS (i.e., without ST elevation, true posterior MI, or le bundle-branch block not known to be old), intravenous fibrinolytic therapy should NOT be used. III: Harm A

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