Selection of Initial Treatment Strategy: Initial

Invasive Versus Conservative Strategy

Invasive

Recurrent angina/ischemia at rest with low-level activities despite

intensive medical therapy
Elevated cardiac biomarkers (TnT or TnI)
New/presumably new ST-segment depression
Signs/symptoms of heart failure or new/worsening mitral
regurgitation
High-risk findings from noninvasive testing
Hemodynamic instability
Sustained ventricular tachycardia
PCI within 6 months
Prior CABG
High risk score (e.g., TIMI, GRACE)
Reduced left ventricular function (LVEF < 40%)

Conservati
ve

Low risk score (e.g., TIMI, GRACE)

Patient/physician presence in the absence of high-risk features
1

Algorithm for Patients with UA/NSTEMI Managed

by an Initial Conservative Strategy
Diagnosis of UA/NSTEMI is Likely or
Definite
ASA (Class I, LOE: A)
Clopidogrel if ASA intolerant (Class I, LOE: A)

Select Management Strategy

Proceed with
Invasive Strategy

Conservative Strategy
Init ACT (Class I, LOE: A):
C1
Acceptable options: enoxaparin or UFH (Class I, LOE: A) or
fondaparinux (Class I, LOE: B), but enoxaparin or
fondaparinux are preferable (Class IIa, LOE: B)

Init clopidogrel (Class I, LOE: A)

Consider adding IV eptifibatide or tirofiban (Class IIb, C2
LOE: B)

(Continued)
Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 8. ACT = anticoagulation therapy; LOE = level of evidence.

Algorithm for Patients with UA/NSTEMI Managed by

an Initial Conservative Strategy
(Continued)
Any subsequent events necessitating
angiography?

(Class I, LOE: A)

Yes

ss I,
(Cla B)
:
LOE

No

Evaluate LVEF
M

EF 40% or less

EF greater
than 40%

(Class IIa,
LOE: B)

Stress Test

(Class I, LOE: B)

(Class IIa, LOE: B)

E-1

Proceed to Dx
Angiography

(Class I, LOE: A)

Not Low Risk

E-2

Low Risk

(Class I, LOE: A)
K

Cont ASA (Class I, LOE A)

Cont clopidogrel (Class I, LOE A) and ideally up to 1 yr (Class I, LOE B)
DC IV GP IIb/IIIa if started previously (Class I, LOE A)
DC ACT (Class I, LOE A)
Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 8. ACT = anticoagulation therapy; LOE = level of evidence.

Algorithm for Patients With UA/NSTEMI Managed by an Initial Invasive Strategy

Anderson, J. L. et al. J Am Coll Cardiol 2007;50:e1-e157

Copyright 2007 American College of Cardiology Foundation. Restrictions may apply.

Management after Diagnostic Angiography in

Patients with UA/NSTEMI
Dx Angiography
F

Select Post Angiography Management Strategy

CABG

PCI

Cont ASA (Class I, LOE: A)

DC clopidogrel 5 to 7 d prior to

Cont ASA (Class I, LOE A)

LD of clopidogrel if not given

elective CABG (Class I, LOE: B)

pre angio (Class I, LOE: A)

DC IV GP IIb/IIIa 4 h prior to CABG

(Class I, LOE: B)

No significant
obstructive
CAD on
angiography

&

IV GP IIb/IIIa if not started pre

angio (Class I, LOE: A)

Cont UFH (Class I, LOE: B); DC

enoxaparin 12 to 24 h prior to
CABG; DC fondaparinux 24 h prior
to CABG; DC bivalirudin 3 h prior to
CABG. Dose with UFH per
institutional practice (Class I, LOE:
B)

Medical therapy

DC ACT after PCI for

uncomplicated cases
(Class I, LOE: B)

I
Antiplatelet
and ACT at
physicians
discretion
(Class I, LOE:
C)

Anderson JL, et al. J Am Coll Cardiol. 2007;50:e1-e157, Figure 9. ACT = anticoagulation therapy; LOE = level
of evidence.

CAD on angiography

Cont ASA (Class I, LOE: A)

LD of clopidogrel if not
given pre angio (Class I, LOE A)*
DC IV GP IIb/IIIa after
at least 12 h if started pre angio (Class I,
LOE: B)
Cont IV UFH for at least 48 h (Class I,
LOE: A) or enoxaparin or fondaparinux
for dur of hosp (LOE: A); either DC
bivalirudin or cont at a dose of 0.25
mg/kg/hr for up to 72 h at physicians
discretion (Class I, LOE: B)