Treatment
ÎÎFor UA/NSTEMI patients in whom PCI is selected as a management
strategy, it is reasonable to omit administration of an IV GP IIb/IIIa
inhibitor if bivalirudin was selected as the anticoagulant and ≥300 mg
clopidogrel was administered ≥6 hours earlier. (IIa-B)
ÎÎIf LVEF is less than or equal to 0.40, it is reasonable to perform
diagnostic angiography. (IIa-B)
ÎÎIf LVEF is greater than 0.40, it is reasonable to perform a stress test.
(IIa-B)
ÎÎPlatelet function testing to determine platelet inhibitory response in
patients with UA/NSTEMI (or, after ACS and PCI) on P2Y12 receptor
inhibitor therapy may be considered if results of testing may alter
management. (IIb-B)
ÎÎGenotyping for a CYP2C19 loss-of-function variant in patients with
UA/NSTEMI (or after ACS with PCI) on P2Y12 receptor inhibitor therapy
might be considered if results of testing may alter management.
(IIb-C)
ÎÎIV fibrinolytic therapy is NOT indicated in patients without acute STsegment elevation, a true posterior MI, or a presumed new left bundlebranch block. (III: No Benefit-A)
Table 6. Selection of Initial Treatment Strategy:
Invasive Versus Conservative Strategy
Generally Preferred
Strategy
Patient Characteristics
Invasive
• Recurrent angina or ischemia at rest or with low-level
activities despite intensive medical therapy
• Elevated cardiac biomarkers (TnT or TnI)
• New or presumably new ST-segment depression
• Signs or symptoms of HF or new or worsening mitral
regurgitation
• High-risk findings from noninvasive testing
• Hemodynamic instability
• Sustained ventricular tachycardia
• PCI within 6 mo
• Prior CABG
• High-risk score (eg, TIMI, GRACE)
• Mild to moderate renal dysfunction
• Diabetes mellitus
• Reduced LV function (LVEF <0.40)
Conservative
• Low-risk score (eg, TIMI, GRACE)
• Patient or physician preference in the absence of high-risk
features
Reprinted from Jneid H, et al. J Am Coll Cardiol. 2012;60(7):645-681.
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