NSTEMI with Refractory Angina, Hemodynamic or Electrical Instability

Patients with non-ST-elevation myocardial infarction who show signs of refractory angina or cardiovascular instability represent a high-risk subset in whom the management approach differs markedly from stable presentations.

Clinical scenario

This protocol applies when NSTEMI is accompanied by refractory angina, or by hemodynamic instability (acute pulmonary edema or heart failure), or by electrical instability (sustained ventricular tachycardia or ventricular fibrillation). These features identify patients at heightened risk of adverse outcomes who require prompt escalation.

Treatment approach

An immediate invasive strategy — initiated early after hospital admission — with the intent to perform revascularization is indicated in this setting. The complete structured protocol specifies the pathway, timing criteria, and procedural considerations.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1161/CIR.0000000000001309

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.

Despite a relative paucity of clinical trial data, these patients are at heightened risk of adverse outcomes, and an immediate invasive strategy (<2 hours from hospital admission) with intention to perform revascularization is recommended.

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