Coronary Revascularization in Patients Presenting Without Persistent ST-Segment Elevation

Valgimigli M, Patrono C, Collet JP, Mueller C, Roffi M.
Questions and Answers on Coronary Revascularization: A Companion Document of the 2015 ESC Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation. Eur Heart J 2015;Aug 29:[Epub ahead of print].

The following are 10 points to remember about coronary revascularization in patients presenting without persistent ST-segment elevation:

  1. Invasive coronary angiography allows, in the majority of cases, confirmation of the diagnosis of acute coronary syndrome (ACS) related to obstructive epicardial coronary artery disease (CAD) or helps to rule out a coronary origin of chest pain, to identify the culprit lesion, to assess the suitability of coronary anatomy for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), to stratify short- and long-term patient risk and, finally, to guide antithrombotic treatment and potentially avoid unnecessary exposure to antithrombotic agents.
  2. The presence of a localized wall motion abnormality on echocardiography or ventriculography may help identify the culprit artery.
  3. There is evidence showing that the timing of invasive coronary angiography should be individualized based on ischemic risk. While patients at very high risk (e.g., ongoing ischemia, hemodynamic instability, recurrent or ongoing chest pain refractory to medical treatment) should undergo immediate (<2 hour) coronary angiography, a delay of a maximum of 24 hours is appropriate for patients at high risk [i.e., with rise or fall in troponin compatible with myocardial infarction (MI), dynamic ST- or T-wave changes (symptomatic or silent), or Global Registry of Acute Coronary Events (GRACE) score >140], while for patients at intermediate risk, a time span of 72 hours is recommended.
  4. In low-risk patients (i.e., no recurrence of chest pain, no signs of heart failure, no abnormalities in the initial or subsequent electrocardiogram (ECG), no rise in troponin level), a noninvasive assessment of inducible ischemia may be performed before or shortly after hospital discharge.
  5. An intra-aortic balloon pump may be implanted prior to surgery in patients with ongoing ischemia despite maximal medical therapy and in those with mechanical complications of MI (i.e., ventricular septal defect or mitral regurgitation due to papillary muscle rupture).
  6. Immediate coronary angiography (<2 hours) is recommended in patients with cardiogenic shock complicating non–ST-elevation (NSTE)-ACS.
  7. In NSTE-ACS patients undergoing drug-eluting stent implantation who are at increased risk of bleeding complications or who have already experienced bleeding complications, dual antiplatelet therapy duration may be shortened to 3-6 months.
  8. Troponin elevation per se is not sufficient for the diagnosis of MI. According to the universal definition of MI, at least one additional criterion is required (e.g., typical ischemic symptoms or ischemic ECG changes).
  9. The guidelines reinforce the importance of the Heart Team in the choice of the revascularization modality in patients with advanced multivessel disease.
  10. Nonsteroidal anti-inflammatory drugs (NSAIDs) (both coxibs and traditional NSAIDs) increase cardiovascular risk. Evidence of increased risk appears early, as suggested by short-term trials of coxib therapy among patients undergoing CABG, and is not attenuated by concomitant aspirin use. Therefore, exposure to NSAIDs should be minimized or avoided, if possible, in patients with established CAD, especially in the setting of a recent MI.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Echocardiography/Ultrasound, Nuclear Imaging, Mitral Regurgitation

Keywords: Acute Coronary Syndrome, Aspirin, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Cyclooxygenase 2 Inhibitors, Drug-Eluting Stents, Echocardiography, Electrocardiography, Fibrinolytic Agents, Mitral Valve Insufficiency, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Risk Factors, Shock, Cardiogenic, Troponin

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