Mechanical Revascularisation
Patients should be offered immediate coronary angiography if they have a diagnosis of unstable angina or NSTEMI if their clinical condition is unstable.
Coronary angiography (with followon PCI if indicated) should be considered within 72 hours of first admission for people with unstable angina or NSTEMI who have an intermediate or higher risk of adverse cardiovascular events (predicted 6month mortality above 3.0%) and no contraindications to angiography (such as active bleeding or comorbidity). A decision not to proceed to PCI should be revisited if patients develop ongoing symptoms, or in young patients with falsely reassuring low risk scores.
Table 1 [3] Benefits and risks of early invasive treatment (coronary angiography with PCI if needed) compared with conservative management for people with unstable angina or NSTEMI
| Benefits/risks/other factors | Coronary angiography and possible percutaneous coronary intervention (PCI) within 72 hours | Conservative management with later coronary angiography if problems continue or develop |
| Benefits (advantages) | Reduced deaths from all causes at 6 to 12 months and at 2 years. Reduced deaths from heart problems at 1 and 2 years. Reduced incidence of myocardial infarction (MI) at 30 days, 6 to 12 months and 2 years. Reduced incidence of stroke at 1 year, particularly in people at high risk of future adverse events. Reduced readmission to hospital and difficult-to-treat angina in the medium term, particularly in people at high risk of future adverse events. Psychological benefits people are not anxious about delaying angiography. | Avoid the immediate risks of invasive treatment, including:
These are particularly relevant for people at low risk of future adverse events. Psychological benefits people are not anxious about having an invasive procedure. |
| Risks (disadvantages) | Increased risk of death during the first 4 months, particularly for people at low risk of future adverse events. Risk of procedure-related MI. Increased risk of major bleeding during the index admission, at 30 days and 2 years. Emergency treatment leaves little time for shared decision making. | Increased risk of MI after 6 months. Increased risk of stroke at 1 year, particularly in the people at high risk of future adverse events. Psychological factors people may be anxious about delaying angiography. |
| Other factors | Recent advances in PCI might increase early benefit, particularly reducing bleeding. Coronary angiography within 72 hours ensures speedy intervention while allowing time for the correct diagnosis, identifying other conditions and treating symptoms. | – |
Learning bite
Early angiography and subsequent revascularisation should be considered alongside comprehensive anti-ischaemic and anti-thrombotic therapy for intermediate and high risk patients.