Coronary angiography

• Immediate/urgent coronary angiography (w/in 2 h) if refractory/recurrent angina or hemodynamic or electrical instability

• Routine angiography (aka “invasive strategy”) = coronary angiography for all

Early (w/in 24 h) if: ⊕ Tn, ST ∆, GRACE risk score >140 (NEJM 2009;360:2165; Circ 2018;138:2741)

Delayed (ie, w/in 72 h) acceptable if w/o above features but w/: diabetes, EF <40%, GFR <60, post-MI angina, TRS ≥3, GRACE score 109–140, PCI w/in 6 mo, prior CABG

32% ↓ rehosp for ACS, nonsignif 16% ↓ MI, no ∆ in mort. c/w select angio (JAMA 2008;300:71)

↑ peri-PCI MI counterbalanced by ↓↓ in spont. MI. Mortality benefit seen in some studies, likely only if cons. strategy w/ low rate of angio.

• Selective angiography (“conservative strategy”): med Rx w/ pre-d/c stress test; angio only if recurrent ischemia or strongly ⊕ ETT. Indicated for: low TIMI Risk Score, Pt or physician pref in absence of high-risk features, or low-risk women (JAMA 2008;300:71).