cardiovascular disorders
Revascularization for Acute Coronary Syndromes
Unstable Angina and Non ST Segment Elevation Myocardial Infarction
Immediate reperfusion is not as urgent in patients with uncomplicated non–ST-segment elevation myocardial infarction (NSTEMI), in whom a completely occluded infarct-related artery at presentation is uncommon, or in patients with unstable angina who respond to medical therapy. Such patients typically undergo angiography within the first 24 to 48 hours of hospitalization to identify coronary lesions requiring Percutaneous coronary intervention (PCI) or A noninterventional approach and a trial of medical managementare used for patients in whom angiography demonstrates Only a small area of myocardium at risk Lesion morphology not amenable to PCI Anatomically insignificant disease (<50% coronary stenosis) Significant left main disease in patients who are candidates for CABG Further, angiography or PCI should be deferred in favor of medical management for patients with a high risk of procedure-related morbidity or mortality. By contrast, patients with persistent chest pain despite maximal medical therapy or complications (eg, markedly elevated cardiac markers, presence of cardiogenic shock, acute mitral regurgitation, ventricular septal defect, unstable arrhythmias) should proceed directly to the cardiac catheterization laboratory to identify coronary lesions requiring PCI or CABG. As in patients with Angina Pectoris , CABG has historically been preferred over PCI for patients with left main or left main equivalent disease (although the data supporting this practice are changing) and for those with left ventricular dysfunction or diabetes. CABG must also be considered when PCI is unsuccessful, cannot be used (eg, in lesions that are long or near bifurcation points), or causes acute coronary artery dissection. Fibrinolytics are not indicated for unstable angina or NSTEMI. Risk outweighs potential benefit. 