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Early invasive versus non-invasive assessment in patients with suspected non-ST-elevation acute coronary syndrome

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journal contribution
posted on 03.09.2021, 15:18 by TA Kite, A Ladwiniec, J Ranjit Arnold, GP McCann, AJ Moss
Non-ST-elevation acute coronary syndrome (NSTE-ACS) comprises a broad spectrum of disease ranging from unstable angina to myocardial infarction. International guidelines recommend a routine invasive strategy for managing patients with NSTE-ACS at high to very high-risk, supported by evidence of improved composite ischaemic outcomes as compared with a selective invasive strategy. However, accurate diagnosis of NSTE-ACS in the acute setting is challenging due to the spectrum of non-coronary disease that can manifest with similar symptoms. Heterogeneous clinical presentations and limited uptake of risk prediction tools can confound physician decision-making regarding the use and timing of invasive coronary angiography (ICA). Large proportions of patients with suspected NSTE-ACS do not require revascularisation but may unnecessarily undergo ICA with its attendant risks and associated costs. Advances in coronary CT angiography and cardiac MRI have prompted evaluation of whether non-invasive strategies may improve patient selection, or whether tailored approaches are better suited to specific subgroups. Future directions include (1) better understanding of risk stratification as a guide to investigation and therapy in suspected NSTE-ACS, (2) randomised clinical trials of non-invasive imaging versus standard of care approaches prior to ICA and (3) defining the optimal timing of very early ICA in high-risk NSTE-ACS.

Funding

British Heart Foundation provides funding support for TAK (CS/17/1/32445) and AJM (AA/18/3/34220)

National Institute of Health Research Clinician Scientist Award

National Institute of Health Research Career Development Fellowship (2014-07-045) and Research Professorship (RP-2017–08-ST2-007)

History

Author affiliation

Department of Cardiovascular Sciences, University of Leicester

Version

AM (Accepted Manuscript)

Published in

Heart

Publisher

BMJ

issn

1355-6037

eissn

1468-201X

Acceptance date

22/06/2021

Copyright date

2021

Available date

03/09/2021

Spatial coverage

England

Language

eng

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