![]() ![]() 2– 5 Given that patients’ with significant angina prior to a NSTEMI also have more angina afterwards, 6 it would be clinically logical to pursue a more aggressive treatment strategy in those with worse pre-infarct angina and angina-related quality of life. Further work is needed to understand the role of pre-infarct health status and in-hospital treatment strategy.ĭespite evidence that patients with non-ST elevation myocardial infarction (NSTEMI)with the greatest mortality risk benefit most from an invasive strategy, 1 many studies have documented that higher-risk patients are less often managed invasively. In conclusion, this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Finally, patients with a GRACE score in the highest risk decile (199.5–<321.4) had significantly lower rates of early invasive treatment (42.7%) as compared with patients with patients in the lowest decile of risk (67.6% adjusted RR for continuous GRACE score per SD, 0.96, 95% CI: 0.92–0.99, P.019). Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life due to angina (62.1.0%, 60.9%, 59.6%, vs. Of 3,768 NSTEMI patients, 2182 (57.9%) patients were referred for early invasive treatment. multi-center registries, in which the associations between pre-infarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the GRACE risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. The association between pre-infarct health status and the selecting patients for early invasive management is unknown. doi:10.1161/CIR.Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. BibliogrpahyĪmsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al ACC/AHA Task Force Members. Patients with a non–ST-elevation acute coronary syndrome who have a high or intermediate TIMI risk score should be treated with an early invasive strategy. However, in this patient with a high pretest probability of CAD, coronary CT angiography would only delay critical therapy. Coronary CT angiography is appropriate, and rest single-photon emission CT may be appropriate. In patients with suspected NSTE-ACS with a normal initial troponin level and inconclusive electrocardiographic findings, further diagnostic studies may be indicated. However, an invasive strategy has been shown to improve the composite clinical endpoint of death, recurrent myocardial infarction, and repeat hospitalization compared with an ischemia-guided approach in patients with NSTE-ACS. ![]() Stress testing with adenosine nuclear stress testing or exercise stress electrocardiography could be considered for purposes of risk stratification if this patient declines an early invasive strategy. His score places him at high risk for death and cardiac ischemic events, and despite the absence of elevated cardiac biomarker levels, urgent coronary angiography is warranted. This patient has a TIMI risk score of 5, as indicated by the presence of three traditional risk factors for coronary artery disease, aspirin use within the last week, age older than 65 years, two or more angina episodes in the past 24 hours, and significant ST-segment deviation on electrocardiogram. An early invasive strategy benefits patients with high TIMI risk scores (5-7) and intermediate TIMI risk scores (3-4). Risk stratification tools, such as the TIMI risk score, can be used to determine which patients with NSTE-ACS should be treated with an invasive strategy versus an ischemia-guided approach. Patients with a non–ST-elevation acute coronary syndrome (NSTE-ACS) should undergo risk stratification before invasive treatment because the link between revascularization and clinical outcomes is less clear in these patients than in patients with ST-elevation myocardial infarction (STEMI). This patient should undergo urgent angiography. Treat a patient with a non–ST-elevation acute coronary syndrome with an early invasive strategy. D: Urgent angiography Educational Objective ![]()
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