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CLINICAL STATEMENTS AND GUIDELINES

Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 April 1, 2025 e807

Recommendation-Specific Supportive Text

1 Numerous clinical trials have evaluated a strategy

of early coronary angiography with possible PCI after fibrinolytic therapy. This strategy of immediate transfer and angiography has been associated with lower rates of recurrent ischemic events as compared with usual care.1–5 Regardless of the timing of angiography, immediate transfer enables earlier access to specialized centers, providing critical care services and on-site catheterization laboratory teams that can facilitate clinical assessments to determine the likelihood of reperfusion and enable earlier angiography for the unstable patient. 2.	 Rescue PCI is associated with improved outcomes in patients with clinical signs of failed reperfusion after fibrinolytic therapy. Several trials have demonstrated a trend toward lower mortality and significantly lower rates of recurrent MI and HF when rescue PCI is performed for failed fibrinolysis.6,7 The REACT (Rapid Early Action for Coronary Treatment) trial6 enrolled 427 patients with failed reperfusion at 90 minutes after fibrinolysis to 1 of 3 treatment arms, including rescue PCI, conservative care, or repeat fibrinolytic therapy. Rescue PCI significantly reduced the composite primary endpoint of death, reinfarction, stroke, or severe HF at 6 months compared with either conservative care or repeat fibrinolytic therapy. Meta-analyses also support lower rates of death or reinfarction when rescue PCI is performed in this setting.8,9 Minor and major bleeding and rates of stroke were significantly higher with rescue PCI.6–8 These studies were performed in the era of femoral artery access, with fewer options for antiplatelet and anticoagulant therapy. The use of radial artery access15 and the elimination of the routine use of glycoprotein IIb/IIIa inhibitors has reduced bleeding. For this reason, the balance of benefit from rescue PCI outweighs the risks for most patients with evidence of failed reperfusion after fibrinolysis. 3.	 Routine early angiography with the intent to perform

PCI after fibrinolysis reduces MACE in comparison to usual care (delayed coronary angiography and/ or an ischemia-guided strategy of revascularization).1–5,11,16 In these studies, >80% of patients who were transferred underwent PCI to treat a significant residual stenosis or suboptimal flow of the infarctrelated artery. Meta-analyses of the RCTs showed a reduction in the combined endpoint of death or reinfarction with an early invasive approach after fibrinolytic therapy.10,17,18 In a network meta-analysis evaluating clinical outcomes with different modes of reperfusion for STEMI, a pharmaco-invasive strategy (defined as an interval between lysis and PCI ≥2 hours) was associated with a 21% reduction in the mortality rate when compared with a strategy of fibrinolysis alone.18 Furthermore, contemporary registries have shown an association between a pharmaco-invasive approach and improved outcomes compared with PPCI when transfer times are long.19 The optimal timing of angiography and PCI after fibrinolytic therapy has not been clearly defined but a similar benefit in ischemic endpoints is evident across the spectrum of times included in the clinical trials.17,20 Although earlier studies raised concerns for increased bleeding with very early catheterization (mean time, 2.2 hours),21 more contemporary data suggest similar rates of bleeding even if cardiac catheterization is performed very early after fibrinolytic therapy.17,20

6 NSTE-ACS: ROUTINE INVASIVE OR

SELECTIVE INVASIVE INITIAL APPROACH

6.1 Rationale and Timing for a Routine Invasive

or Selective Invasive Approach Recommendations for Rationale and Timing for a Routine Invasive or Selective Invasive Approach Referenced studies that support recommendations are summarized in the Evidence Table.

COR LOE Recommendations Routine Invasive Versus Selective Invasive Strategy

1 A 1 In patients with NSTE-ACS who are at

intermediate or high risk of ischemic events and are appropriate candidates for revascularization, an invasive approach with the intent to proceed with revascularization is recommended during hospitalization to reduce MACE.*1–6

1 A 2 In patients with NSTE-ACS who are at low risk of

ischemic events, either a routine invasive or selective invasive approach is recommended to help identify those who may require revascularization and to reduce MACE.1–4,7

Timing of Coronary Angiography for Those in Whom an Invasive Approach Is Planned

1 C-LD 3 In patients with NSTE-ACS who have refractory

angina or hemodynamic or electrical instability, an immediate invasive strategy with intent to perform revascularization is indicated to reduce MACE.†8–11

2a B-R 4 In patients with NSTE-ACS who are at high risk‡

of ischemic events, it is reasonable to choose an early invasive strategy (within 24 hours) to reduce MACE.†8,9,11,12

2a B-R 5 In patients with NSTE-ACS who are not at high

risk and are intended for an invasive strategy, it is reasonable to perform angiography before hospital discharge to reduce MACE.*8,11

*Reproduced or †modified from the “2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization.”7

‡Predictors of risk are outlined in Figure 8.

Synopsis A routine invasive approach refers to a strategy of performing coronary angiography with the intent to

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