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
