The Living Guidelines: UA/NSTEMI Recommendations for Risk Stratification Before Discharge Suggest Revisions to the CLASS I Guidelines

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Class I Guidelines

 * 1) Noninvasive stress testing is recommended in low-risk patients who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 h. (Level of Evidence: C)
 * 2) Noninvasive stress testing is recommended in patients at intermediate risk who have been free of ischemia at rest or with low-level activity and of heart failure for a minimum of 12 to 24 h. (Level of Evidence: C)
 * 3) Choice of stress test is based on the resting ECG, ability to perform exercise, local expertise, and technologies available. Treadmill exercise is useful in patients able to exercise in whom the ECG is free of baseline ST segment abnormalities, bundle branch block, left ventricular hypertrophy, intraventricular conduction defect, paced rhythm, pre-excitation, and digoxin effect. (Level of Evidence: C)
 * 4) An imaging modality should be added in patients with resting ST segment depression (≥0.10 mV), left ventricular hypertrophy, bundle branch block, intraventricular conduction defect, pre-excitation, or on digoxin treatment who are able to exercise. In patients undergoing a low level exercise test, an imaging modality can add sensitivity. (Level of Evidence: B)
 * 5) Pharmacological stress testing with imaging is recommended when physical limitations (e.g., arthritis, amputation, severe peripheral vascular disease, severe chronic obstructive pulmonary disease, or general debility) preclude adequate exercise stress. (Level of Evidence: B)
 * 6) Prompt angiography without noninvasive risk stratification should be performed for failure of stabilization with intensive medical treatment. (Level of Evidence: B)
 * 7) A non invasive test (echocardiogram or radionuclide angiogram) is recommended to evaluate left ventricular function in patients with definite acute coronary syndromes who are not scheduled for coronary angiography and left ventriculography. (Level of Evidence: B)