The Living Guidelines: Initial Conservative versus Initial Invasive Strategies in patients with Unstable Angina / Non ST Elevation MI Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines
1. An early PCI strategy is indicated for patients with UA / NSTEMI who have no serious comorbidity and who have coronary lesions amenable to PCI and who have characteristics for invasive therapy (Class I Level of Evidence: A)

a. Apply Invasive therapy if;
1. Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy (Class I Level of Evidence: A)

2. Elevated cardiac biomarkers (cTnT or cTnI) (Class I Level of Evidence: A)

3. New or presumably new ST-segment depression (Class I Level of Evidence: A)

4. Signs or symptoms of heart failure HF or new or worsening mitral regurgitation (Class I Level of Evidence: A)

5. High-risk findings from noninvasive testing (Class I Level of Evidence: A)

6. Hemodynamic instability (Class I Level of Evidence: A)

7. Sustained ventricular tachycardia (Class I Level of Evidence: A)

8. PCI within 6 months (Class I Level of Evidence: A)

9. Prior CABG (Class I Level of Evidence: A)

10. High-risk score (e.g., TIMI risk score, GRACE risk score) (Class I Level of Evidence: A)

11. Reduced Left Ventricular function (LVEF less than 40%) (Class I Level of Evidence: A)

b. Apply Conservative Therapy if;
1. Low-risk score (e.g., TIMI risk score, GRACE risk score) (Class I Level of Evidence: A) Patient or physician preference in absence of high-risk features (Class I Level of Evidence: A)

2. Percutaneous coronary intervention (or CABG) is recommended for UA / NSTEMI patients with 1-or 2-vessel CAD with or without significant proximal left anterior descending CAD but with a large area of viable myocardium and high-risk criteria on noninvasive testing. (Class I Level of Evidence: B)

3. Percutaneous coronary intervention (or CABG) is recommended for UA / NSTEMI patients with multi vessel coronary disease with suitable coronary anatomy, with normal LV function, and without diabetes mellitus. (Class I Level of Evidence: A)

4. An intravenous Glycoprotein IIb/IIIa inhibitor is useful in UA / NSTEMI patients undergoing PCI. (Class I Level of Evidence: A)

5. An early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) is indicated in UA / NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Class I Level of Evidence: B)