Send NSTE-ACS patients with either a high-risk feature or a moderate to high TIMI score to early invasive strategy (with angiography and intent for revascularization with PCI or CABG surgery as defined by the anatomy) vs. a conservative strategy with medical therapy.
1. High-risk features that are indications for early invasive strategy
Non-ST elevation ACS patients who have one or more of the following characteristics are at extremely high risk of an adverse cardiovascular event in the short term and should be referred for immediate coronary arteriography and revascularization.
- Hemodynamic instability or cardiogenic shock
- Severe left ventricular dysfunction or signs of symptoms of heart failure
- Recurrent or persistent angina (or ischemia) at rest or with low-level activities despite intensive medical therapy
- Refractory angina
- New or worsening mitral regurgitation or new VSD
- Sustained ventricular arrhythmias (VF or VT)
“For those without one of the above extremely high-risk characteristics, randomized trials have shown benefit of an early invasive approach in high-risk ACS. While the optimal timing is uncertain, the majority of patients undergo coronary revascularization early (ie, within 24 hours).” Some studies show that this early timing is a clear benefit.
2. Using TIMI to determine early invasive strategy vs. conservative strategy with medical therapy.
“A widely used predictive model to guide invasive versus conservative strategy is the TIMI risk score, which is based upon seven variables available at presentation. Patients with high-risk TIMI scores of 5 to 7, as well as intermediate-risk TIMI scores of 3 to 4, benefited from early invasive strategy in the TACTICS-TIMI 18 trial.”
References
- https://www.uptodate.com/contents/overview-of-the-acute-management-of-non-st-elevation-acute-coronary-syndromes
- https://www.aafp.org/afp/2017/0215/p232.html