Recommendations for Initial Invasive Versus Initial Conservative Strategies
| 2007 Recommendations | 2011 Focused Update Recommendations | Comments |
|---|---|---|
| Class I | ||
| An early invasive strategy (ie, 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). (Level of Evidence: B) | 1. An early invasive strategy (ie, 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).116,117 (Level of Evidence: B) | 2007 recommendation remains current. |
| An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (see Table 11 and Sections 2.2.6 and 3.4.3). (Level of Evidence: A) | 2. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is indicated in initially stabilized UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (see 20072 Table 11 and 2007 Sections 2.2.6 and 3.4.3).25,26,69 (Level of Evidence: A) | 2007 recommendation remains current. |
| Class IIa | ||
| 1. It is reasonable to choose an early invasive strategy (within 12 to 24 hours of admission) over a delayed invasive strategy for initially stabilized high-risk patients with UA/NSTEMI.* For patients not at high risk, a delayed invasive approach is also reasonable.38 (Level of Evidence: B) | New recommendation (modified from 2009 STEMI and PCI Focused Update).32 | |
| Class IIb | ||
| In initially stabilized patients, an initially conservative (ie, a selectively invasive) strategy may be considered as a treatment strategy for UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (see Table 11 and Sections 2.2.6 and 3.4.3), including those who are troponin positive. (Level of Evidence: B) The decision to implement an initial conservative (vs initial invasive) strategy in these patients may be made by considering physician and patient preference. (Level of Evidence: C) | 1. In initially stabilized patients, an initially conservative (ie, a selectively invasive) strategy may be considered as a treatment strategy for UA/NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (see 20072 Table 11 and Sections 2.2.6 and 3.4.3), including those who are troponin positive.69,118 (Level of Evidence: B) The decision to implement an initial conservative (vs initial invasive) strategy in these patients may be made by considering physician and patient preference. (Level of Evidence: C) | 2007 recommendation remains current. |
| An invasive strategy may be reasonable in patients with chronic renal insufficiency. (Level of Evidence: C) | Recommendation moved to Section 6.5, class changed to IIa, level of evidence changed to B. | |
| Class III: No Benefit | ||
| An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with extensive comorbidities (eg, liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C) | 1. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with extensive comorbidities (eg, liver or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C) | 2007 recommendation remains current. |
| An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with acute chest pain and a low likelihood of ACS. (Level of Evidence: C) | 2. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with acute chest pain and a low likelihood of ACS. (Level of Evidence: C) | 2007 recommendation remains current. |
| An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) should not be performed in patients who will not consent to revascularization regardless of the findings. (Level of Evidence: C) | 3. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) should not be performed in patients who will not consent to revascularization regardless of the findings. (Level of Evidence: C) | 2007 recommendation remains current. |
* Immediate catheterization/angiography is recommended for unstable patients.