What are the strategies for use of percutaneous coronary intervention (PCI) to treat NSTE-ACS?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

The management of patients with non-STEMI (NSTEMI) and unstable angina (called NSTE-ACS in the 2014 ACC/AHA guideline update to reflect the similarity between the two groups) has changed considerably over the past 15 years. [1] Several trials have helped provide a better understanding of risk stratification, selection of initial management strategy, and appropriate use of adjunctive medical therapy and revascularization, thereby leading to improved outcomes.

In general, two pathways have emerged for the treatment of NSTE-ACS. The early invasive strategy, with a diagnostic coronary angiogram for risk stratification, allows rapid definitive evaluation and affords the option for early revascularization to prevent ACS complications and facilitate early discharge.

In contrast, the ischemia-guided strategy (previously termed conservative strategy) recommends invasive evaluation only if patients have failed medical therapy, have objective evidence of ischemia on stress test, or have high prognostic risk (ie, high Thrombolysis in Myocardial Infarction [TIMI] or Global Registry of Acute Coronary Events [GRACE] scores). This is based on the premise that medical therapy alone can stabilize some patients, thus obviating costly and possibly unnecessary invasive procedures.


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