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.
- myocardial infarction
- coronary angiography
- CT angiography
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Twitter @drtomkite, @aladwiniec
Contributors TAK prepared the first draft of the manuscript and revised it critically for important intellectual content. AL, JRA, GPMcC and AJM made critical revisions related to important intellectual content and approved the final manuscript.
Funding The British Heart Foundation provides funding support for TAK (CS/17/1/32445) and AJM (AA/18/3/34220). JRA is funded by a National Institute of Health Research Clinician Scientist Award. GPMcC is supported by a National Institute of Health Research Career Development Fellowship (2014-07-045) and Research Professorship (RP-2017–08-ST2-007).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Commissioned; externally peer reviewed.
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