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CLINICAL STATEMENTS AND GUIDELINES

April 1, 2025 Circulation. 2025;151:e771–e862. DOI: 10.1161/CIR.0000000000001309 e808

perform coronary revascularization by PCI or CABG (as appropriate) in patients with NSTE-ACS. This approach provides important prognostic information, including delineating the extent and severity of CAD. Several RCTs have demonstrated that a routine invasive approach in patients with NSTE-ACS reduces the risk of MACE when compared with a selective invasive approach.1–3 Notably, these strategy trials were conducted in an era prior to the availability of hs-cTn assays, routine use of radial approach for coronary angiography, newer generation drug-eluting stents, and contemporary evidence-based antiplatelet therapies. Patients who are at prohibitively high risk from angiography or who have known coronary anatomy or preferences that preclude revascularization (PCI or CABG) may be managed noninvasively.13 In addition, some low-risk patients, particularly those who have normal cardiac biomarkers and in whom a diagnosis of an ACS is questioned, should be considered for a “selective invasive” approach that includes further noninvasive risk stratification prior to consideration of coronary angiography, because they derive less benefit from a routine invasive approach.4,7,13 These low-risk patients should still undergo noninvasive stress testing or coronary CT angiography prior to hospital discharge. Patients with higher risk findings on noninvasive testing or who have recurrent ischemic symptoms should be referred for invasive coronary angiography prior to hospital discharge in the absence of contraindication (Figure 7).

Recommendation-Specific Supportive Text

1 In patients with NSTE-ACS, a routine invasive

approach improves clinical outcomes, including lower rates of recurrent MI and recurrent ischemia, compared with a selective invasive approach that involves further noninvasive risk stratification prior to consideration of angiography.1–3 In a collaborative meta-analysis of RCTs, a routine invasive approach reduced death or MI by 18% (OR, 0.82 [95% CI, 0.72-0.93]), including a 25% reduction in MI (OR, 0.75 [95% CI, 0.65-0.88]) when compared with a selective invasive approach.5 The benefit was more apparent in higher risk patients with elevated biomarkers.4 The studies that established the benefit of a routine invasive approach were conducted in the late 1990s and early 2000s, and it is unknown whether contemporary

Figure 7. Selection of a Routine Invasive Versus Selected Invasive Strategy in Patients With NSTE-ACS. Colors correspond to Class of Recommendation in Table 2. *AHA Scientific Statement on MINOCA.17 CABG indicates coronary artery bypass grafting; CCTA, cardiac CT angiography; MINOCA, myocardial infarction with nonobstructive coronary artery disease; NSTE-ACS, non–STsegment elevation acute coronary syndromes; and PCI, percutaneous coronary intervention.

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