Algorithm in risk stratification and management of unstable angina and non-ST elevation myocardial infarction

Algorithm in risk stratification and management of unstable angina and non-ST elevation myocardial infarction - Flowchart Unstable Angina/Non-ST Elevation Myocardial Infarction Unstable Angina/Non-ST Elevation Myocardial Infarction

«Flowchart»

USA/NSTEMI is likely or established based on history, physical examination, ECG, CXR, and cardiac enzyme

Initiate therapy with ASA (clopidogrel if ASA intolerance) plus Anticoagulant with UFH, or Enoxaparin, or Fondaparinux; can use Bivalirudin if early invasive strategy No routine P2Y₁₂ inhibitor pretreatment

Initiate therapy with ₁₂

Early Invasive Strategy Indications: 1. Elevated troponin 2. Dynamic ST-T changes 3. DM 4. Renal insufficiency 5. LVEF <40% 6. Early post-MI angina 7. PCI within 6 months 8. Prior CABG 9. Intermediate to high risk score (GRACE >109 or TIMI 2)

Immediate invasive required

Early invasive indicated

Immediate invasive within 2 hours

Early invasive within 72 hours

1. No recurrent angina

2. No clinical signs of CHF

3. No abnormalities in the initial ECG or in second ECG (6-12 hours later)

4. No elevation of serial troponin

5. Low-risk score (GRACE <109 or TIMI 0 or 1)

1. No recurrent angina

2. No clinical signs of CHF

3. No abnormalities in the initial ECG or in second ECG (6-12 hours later)

4. No elevation of serial troponin

5. Low-risk score (GRACE <109 or TIMI 0 or 1)

1. No recurrent angina

2. No clinical signs of CHF

3. No abnormalities in the initial ECG or in second ECG (6-12 hours later)

4. No elevation of serial troponin

5. Low-risk score (GRACE <109 or TIMI 0 or 1)

Non-invasive evaluation for inducible ischemia before discharge

Proceed to angiography

Coronary angiogram

Re-vascularization, can give P2Y₁₂ inhibitor if PCI

₁₂

Medical management

<Next Node>

Early Invasive Strategy Indications: 1. Refractory angina despite intensive antianginal treatment 2. Clinical CHF, new or worsening MR or hemodynamic instability 3. Life-threatening ventricular arrhythmia

1. Refractory angina 1. Refractory angina 1. Elevated troponin 1. Elevated troponin

Early Invasive Strategy

Ischemia-Guided Strategy

Refractory angina despite intensive antianginal treatment
Clinical CHF, new or worsening MR or hemodynamic instability
Life-threatening ventricular arrhythmia

Early invasive within 72 hours

1. Refractory angina despite intensive antianginal treatment
2. Clinical CHF, new or worsening MR or hemodynamic instability
3. Life-threatening ventricular arrhythmia

1. Refractory angina despite intensive antianginal treatment 1. Elevated troponin
2. Dynamic ST-T changes
3. DM
4. Renal insufficiency
5. LVEF 40%
6. Early post-MI angina
7. PCI within 6 months
8. Prior CABG
9. Intermediate to high risk score (GRACE >109 or TIMI 2)

1. Elevated troponin

Yes