early versus invasive management for patients with unstable angina / NSTEMI

Last reviewed 01/2018

Early invasive versus conservative management

• coronary angiography should be offered (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk
• conservative management without early coronary angiography should be offered to patients with a low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less)
• coronary angiography (with follow-on PCI if indicated) should be offered to patients initially assessed to be at low risk of adverse cardiovascular events (predicted 6-month mortality 3.0% or less) if ischaemia is subsequently experienced or is demonstrated by ischaemia testing

Notes:

• as soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE])
  • include in the formal risk assessment:
    • a full clinical history (including age, previous myocardial infarction [MI] and previous percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG])
    • a physical examination (including measurement of blood pressure and heart rate)
    • resting 12-lead electrocardiography (ECG) (looking particularly for dynamic or unstable patterns that indicate myocardial ischaemia)
    • blood tests (such as troponin I or T, creatinine, glucose and haemoglobin)

• Predicted 6-month mortality	Risk of future adverse cardiovascular events
  1.5% or below	lowest
  > 1.5 to 3.0%	low
  > 3.0 to 6.0%	intermediate
  > 6.0 to 9.0% over 9.0%	high
  over 9.0%	highest

Reference:

• 1) NICE (March 2010). Unstable angina and NSTEMI The early management of unstable angina and non-ST-segment-elevation myocardial infarction