Patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI) can be managed either by an invasive or medical strategy. The American College of Cardiology and the American Heart Association have proposed guidelines to identify patients who are candidates for an early aggressive intervention.


The early invasive strategy involves coronary angiography followed by angiographically directed revascularization if possible.


Indications for an early invasive strategy:

(1) no serious comorbidity (no obvious contraindications to coronary revascularization)

(2) presence of one or more high risk findings


High risk findings:

(1) recurrent angina or ischemia at rest or with low level activities despite intensive anti-ischemic therapy

(2) elevated serum troponin levels

(3) new or presumably new ST-segment depression

(4) recurrent angina or ischemia with congestive heart failure symptoms, an S3 gallop, pulmonary edema, worsening rales or new or worsening mitral regurgitation

(5) high risk findings on non-invasive stress testing

(6) depressed left ventricular systolic function (ejection fraction < 0.40 on noninvasive study)

(7) hemodynamic instability

(8) sustained ventricular tachycardia

(9) percutaneous coronary intervention within past 6 months

(10) prior coronary artery bypass graft (CABG)


If none of the high risk findings are present, then a patient may be offered either

(1) an early conservative strategy, or

(2) an early invasive strategy if there are no contraindications for revascularization.


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