What are the guidelines on selection of preferred management strategy for acute coronary syndrome (ACS)?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

Determination of the preferred management strategy depends on the patient’s clinical characteristics and clinical risk. The AHA/ACC and ESC provide similar recommendations for selection of the preferred management stategy, which are summarized in Table 3, below. [111, 112]

Table 3.  Recommendations for Selection of Preferred Management Strategy (Open Table in a new window)

Preferred Strategy  Patient Characteristic/Clinical Risk

Immediate invasive strategy

(< 2 hours)

Refractory angina
Signs or symptoms of heart failure, or new or worsening mitral regurgitation
Hemodynamic instability or cardiogenic shock
Recurrent angina/ischemia at rest, or with low-level activities despite intensive medical therapy
Sustained ventricular tachycardia or ventricular fibrillation
Ischemia-guided strategy Low-risk score (eg, TIMI 0 or 1, GRACE < 109)
Low-risk Tn-negative female
Patient or physician preference in the absence of high-risk features

Early invasive strategy

(< 24 hours)

GRACE score >140
Rise or fall in Tn compatible with MI
New or presumably new ST-segment depression

Delayed invasive strategy

(24-72 hours)

Diabetes mellitus
Renal insufficiency (GFR < 60 mL/min/1.73m2)
Reduced LV systolic function (LVEF < 40%)
Early postinfarction angina
PCI within 6 months
Prior CABG
GRACE score 109-140; TIMI Score ≥2
ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass grafting; GRACE = Global Registry of Acute Coronary Events; LV = left ventricle; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis in Myocardial Infarction Clinical Trial; Tn = troponin.

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