NSTE-ACS — Risk Stratification & Timing of Invasive Strategy

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Risk stratification
   Working diagnosis NSTE-ACS — which risk tier? (NSTE-ACS = ACS without persistent ST-elevation (NSTEMI / unstable angina). Immediately: serial hs-cTn + ECG, dual antiplatelet + anticoagulation, monitoring. Very-high risk = hemodynamic instability/cardiogenic shock, refractory or recurrent chest pain, life-threatening arrhythmia, mechanical complication, acute heart failure due to ACS, recurrent dynamic ST-T (especially intermittent ST-elevation). High risk = confirmed NSTEMI (rise/fall of hs-cTn), dynamic ST-T, GRACE >140. Low risk = none of the above and GRACE <140.)
   • Very-high risk → Very-high risk → immediate invasive
   • High risk → High risk → early invasive
   • Low risk → Low risk → selective
2. [End] Very-high risk → immediate invasive
   Immediate (<2 h) invasive strategy: urgent coronary angiography ± PCI. Concurrently antithrombotic therapy, stabilize hemodynamics and rhythm, mechanical circulatory support if needed.
3. [End] High risk → early invasive
   Early (<24 h) invasive strategy (Class IIa): coronary angiography ± revascularization, ideally same-day transfer to a PCI center. Continue dual antiplatelet + anticoagulation, monitor ≥24 h.
4. [End] Low risk → selective
   Low risk (GRACE <140, no high-risk features): a selective invasive strategy or non-invasive ischemia testing first, with angiography decided by the result; intermediate risk may have angiography within 72 h. Optimize secondary prevention (dual antiplatelet, statin, ACEi/beta-blocker, etc.).

Source guidelines & references

• 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023 · source ↗

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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