Coronary angiography and revascularization for unstable angina or non-ST elevation acute myocardial infarction
- Jeffrey A Breall, MD, PhD
Jeffrey A Breall, MD, PhD
- Professor of Clinical Medicine
- Indiana University School of Medicine
- 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 :
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- 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