Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction
- Michael Simons, MD
Michael Simons, MD
- Robert W Berliner Professor of Medicine
- Yale University School of Medicine
- Section Editors
- Donald Cutlip, MD
Donald Cutlip, MD
- Section Editor — Interventional Cardiology
- Professor of Medicine
- Harvard Medical School
- Beth Israel Deaconess Medical Center
- Stephan Windecker, MD
Stephan Windecker, MD
- Section Editor — Coronary Heart Disease
- Professor of Medicine
- Department of Cardiology
- Bern University Hospital
Most patients with a non-ST elevation acute coronary syndrome (unstable angina and non-ST elevation myocardial infarction) undergo coronary angiography and revascularization during the index hospitalization. This topic will summarize the evidence supporting this invasive strategy and discuss our approach to revascularization.
The diagnostic evaluation of a non-ST elevation acute coronary syndrome and the general management of these patients are presented elsewhere. (See "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Overview of the acute management of unstable angina and non-ST elevation myocardial infarction".)
DEFINITION OF UA AND NSTEMI
Unstable angina (UA) and non-ST elevation myocardial infarction (NSTEMI) are part of the continuum of acute coronary syndrome (ACS), which also includes ST-elevation myocardial infarction (STEMI). A detailed discussion of the diagnosis of UA and NSTEMI is presented elsewhere. (See "Criteria for the diagnosis of acute myocardial infarction", section on 'Third universal definition of MI'.)
An acute, evolving, or recent MI is present when there is a typical rise and fall of biochemical markers of myocardial necrosis (troponin is preferred) with at least one of the following :
- Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. Circulation 2012; 126:2020.
- Amsterdam EA, Wenger NK, Brindis RG, et al. 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. Circulation 2014; 130:2354.
- Liebson PR, Klein LW. The non-Q wave myocardial infarction revisited: 10 years later. Prog Cardiovasc Dis 1997; 39:399.
- Bavry AA, Kumbhani DJ, Rassi AN, et al. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. J Am Coll Cardiol 2006; 48:1319.
- de Winter RJ, Windhausen F, Cornel JH, et al. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353:1095.
- Hirsch A, Windhausen F, Tijssen JG, et al. Long-term outcome after an early invasive versus selective invasive treatment strategy in patients with non-ST-elevation acute coronary syndrome and elevated cardiac troponin T (the ICTUS trial): a follow-up study. Lancet 2007; 369:827.
- Wallentin L, Lindhagen L, Ärnström E, et al. Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study. Lancet 2016; 388:1903.
- Hansen KW, Sorensen R, Madsen M, et al. Effectiveness of an early versus a conservative invasive treatment strategy in acute coronary syndromes: a nationwide cohort study. Ann Intern Med 2015; 163:737.
- Cannon CP, Weintraub WS, Demopoulos LA, et al. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med 2001; 344:1879.
- Fox KA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet 2005; 366:914.
- Navarese EP, Gurbel PA, Andreotti F, et al. Optimal timing of coronary invasive strategy in non-ST-segment elevation acute coronary syndromes: a systematic review and meta-analysis. Ann Intern Med 2013; 158:261.
- Mehta SR, Granger CB, Boden WE, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med 2009; 360:2165.
- Neumann FJ, Kastrati A, Pogatsa-Murray G, et al. Evaluation of prolonged antithrombotic pretreatment ("cooling-off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA 2003; 290:1593.
- Montalescot G, Cayla G, Collet JP, et al. Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA 2009; 302:947.
- Wang TY, Zhang M, Fu Y, et al. Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non-ST-elevation acute coronary syndromes undergoing diagnostic angiography. Am Heart J 2009; 157:716.
- Thiele H, de Waha S, Zeymer U, et al. Effect of aspiration thrombectomy on microvascular obstruction in NSTEMI patients: the TATORT-NSTEMI trial. J Am Coll Cardiol 2014; 64:1117.
- Waksman R, Lipinski MJ. The utility of thrombus aspiration for NSTEMI: déjà vu of aspiration for primary PCI. J Am Coll Cardiol 2014; 64:1125.
- Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2011; 123:2022.
- Eagle KA, Guyton RA, Davidoff R, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery). Circulation 2004; 110:e340.
- Morrison DA, Sethi G, Sacks J, et al. Percutaneous coronary intervention versus coronary artery bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: a multicenter, randomized trial. Investigators of the Department of Veterans Affairs Cooperative Study #385, the Angina With Extremely Serious Operative Mortality Evaluation (AWESOME). J Am Coll Cardiol 2001; 38:143.
- Morrison DA, Sethi G, Sacks J, et al. Percutaneous coronary intervention versus coronary bypass graft surgery for patients with medically refractory myocardial ischemia and risk factors for adverse outcomes with bypass: The VA AWESOME multicenter registry: comparison with the randomized clinical trial. J Am Coll Cardiol 2002; 39:266.
- Rodriguez A, Bernardi V, Navia J, et al. Argentine Randomized Study: Coronary Angioplasty with Stenting versus Coronary Bypass Surgery in patients with Multiple-Vessel Disease (ERACI II): 30-day and one-year follow-up results. ERACI II Investigators. J Am Coll Cardiol 2001; 37:51.
- Chen LY, Lennon RJ, Grantham JA, et al. In-hospital and long-term outcomes of multivessel percutaneous coronary revascularization after acute myocardial infarction. Am J Cardiol 2005; 95:349.
- Byrne JG, Leacche M, Unic D, et al. Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease. J Am Coll Cardiol 2005; 45:14.
- Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:2999.
- Shishehbor MH, Lauer MS, Singh IM, et al. In unstable angina or non-ST-segment acute coronary syndrome, should patients with multivessel coronary artery disease undergo multivessel or culprit-only stenting? J Am Coll Cardiol 2007; 49:849.
- Rosner GF, Kirtane AJ, Genereux P, et al. Impact of the presence and extent of incomplete angiographic revascularization after percutaneous coronary intervention in acute coronary syndromes: the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial. Circulation 2012; 125:2613.
- Sardella G, Lucisano L, Garbo R, et al. Single-Staged Compared With Multi-Staged PCI in Multivessel NSTEMI Patients: The SMILE Trial. J Am Coll Cardiol 2016; 67:264.
- Hochman JS, Boland J, Sleeper LA, et al. Current spectrum of cardiogenic shock and effect of early revascularization on mortality. Results of an International Registry. SHOCK Registry Investigators. Circulation 1995; 91:873.
- Madsen JK, Grande P, Saunamäki K, et al. Danish multicenter randomized study of invasive versus conservative treatment in patients with inducible ischemia after thrombolysis in acute myocardial infarction (DANAMI). DANish trial in Acute Myocardial Infarction. Circulation 1997; 96:748.
- Charytan DM, Wallentin L, Lagerqvist B, et al. Early angiography in patients with chronic kidney disease: a collaborative systematic review. Clin J Am Soc Nephrol 2009; 4:1032.
- Szummer K, Lundman P, Jacobson SH, et al. Influence of renal function on the effects of early revascularization in non-ST-elevation myocardial infarction: data from the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART). Circulation 2009; 120:851.
- Bach RG, Cannon CP, Weintraub WS, et al. The effect of routine, early invasive management on outcome for elderly patients with non-ST-segment elevation acute coronary syndromes. Ann Intern Med 2004; 141:186.
- Tegn N, Abdelnoor M, Aaberge L, et al. Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet 2016; 387:1057.
- Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37:267.
- DEFINITION OF UA AND NSTEMI
- EARLY RISK ASSESSMENT
- APPROACH TO REVASCULARIZATION
- Immediate angiography
- Invasive approach
- - Timing
- - Aspiration thrombectomy
- Radial versus femoral access
- Conservative approach
- METHOD OF REVASCULARIZATION IN MULTIVESSEL DISEASE
- PCI versus CABG
- Multivessel versus culprit only PCI
- Single sitting versus staged multivessel PCI
- SPECIAL SITUATIONS
- Cardiogenic shock
- Recurrent ischemia
- Chronic kidney disease
- Older patients
- TIMING OF DISCHARGE
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS