The AHA Guidelines and Scientific Statements Handbook

Chapter 2 Unstable Angina/Non-ST-Elevation Myocardial Infarction

Risk stratifi cation before discharge
Class I
1 Noninvasive stress testing is recommended in
low-risk patients who have been free of ischemia at
rest or with low-level activity and of HF for a
minimum of 12 to 24 h. (Level of Evidence: C)
2 Noninvasive stress testing is recommended in
patients at intermediate risk who have been free of
ischemia at rest or with low-level activity and of HF
for a minimum of 12 to 24 h. (Level of Evidence: C)
3 An imaging modality should be added in patients
with resting ST-segment depression (greater than or
equal to 0.10 mV), LV hypertrophy, bundle-branch
block, intraventricular conduction defect, preexcita-
tion, or digoxin who are able to exercise. In patients
undergoing a low-level exercise test, an imaging
modality can add sensitivity. (Level of Evidence: B)
4 Pharmacological stress testing with imaging is
recommended when physical limitations (e.g.,
arthritis, amputation, severe peripheral vascular
disease, severe chronic obstructive pulmonary
disease, or general debility) preclude adequate exer-
cise stress. (Level of Evidence: B)
5 A noninvasive test (echocardiogram or radionu-
clide angiogram) is recommended to evaluate LV
function in patients with defi nite ACS who are not

scheduled for coronary angiography and left ven-

triculography. (Level of Evidence: B)

Revascularization with PCI and CABG in

patients with UA/NSTEMI

a. Percutaneous coronary intervention

Class I

1 An early invasive percutaneous coronary inter-

vention (PCI) strategy is indicated for patients with

UA/NSTEMI who have no serious comorbidity and

who have coronary lesions amenable to PCI and any

high-risk features.

2 Percutaneous coronary intervention (or CABG)

is recommended for UA/NSTEMI patients with 1-

or 2-vessel CAD with or without signifi cant proxi-

mal left anterior descending CAD but with a large

area of viable myocardium and high-risk criteria on

noninvasive testing. (Level of Evidence: B)

3 Percutaneous coronary intervention (or CABG)

is recommended for UA/NSTEMI patients with

multivessel coronary disease with suitable coronary

anatomy, with normal LV function, and without

diabetes mellitus. (Level of Evidence: A)

4 An intravenous platelet GP IIb/IIIa inhibitor is

generally recommended in UA/NSTEMI patients

Relative risk of all-cause mortality for early invasive therapy compared with conservative

therapy at a mean follow-up of 2 years

Study

FRISC-II

TRUCS

TIMI-18

VINO

RITA-3

ISAR-COOL

ICTUS

Overall RR (95% Cl)

0.1

0.75 (0.63–0.90)

110

45

3

37

2

102

0

15

Favors

early invasive

therapy

Favors

conservative

therapy

Deats (n)

Invasive Conservative

Follow-up

(Months)

67

9

39

9

132

3

15

24

12

6

6

60

1

12

Fig. 2.11 Relative risk outcomes with early invasive vs. conservative therapy in UA/NSTEMI. From Bavry et al. J Am Coll Cardiol.
2006;48:1319–25.