NSTEMI/ACS Risk Stratification (ESC 2023)

Algorithm Steps

1. ▶

   Start

   NSTE-ACS Confirmed

   Troponin positive, no ST elevation

   • Dynamic troponin rise/fall pattern
   • Ischemic symptoms
   • ECG: ST depression, T-wave changes, or normal
   1. ◆

      Decision

      Very High Risk Features?

      Assess for immediate ICA criteria

      • Hemodynamic instability / cardiogenic shock
      • Recurrent/refractory chest pain
      • Life-threatening arrhythmias
      • Mechanical complications
      • Acute heart failure with ongoing ischemia
      • Recurrent dynamic ST/T changes

      If Yes:

      1. ●

         Action

         Immediate ICA (<2h)

         Very high risk - emergent angiography

         • Activate cath lab
         • Treat as STEMI-equivalent urgency
         • Hemodynamic support if needed
         1. ●

            Action

            Antithrombotic Therapy

            All NSTE-ACS patients

            • Aspirin loading 150-300mg
            • P2Y12 inhibitor (timing per strategy)
            • Anticoagulation: UFH or LMWH or Fondaparinux
            • Fondaparinux preferred if conservative
            1. ✓

               Outcome

               PCI/CABG as Indicated

               Based on angiographic findings

            2. ✓

               Outcome

               Optimal Medical Therapy

               If no significant CAD or not revascularizable

      If No:

      1. ◆

         Decision

         High Risk Features?

         Assess for early invasive strategy

         • Confirmed NSTEMI (troponin rise/fall)
         • GRACE score >140
         • Dynamic ST/T-wave changes
         • Transient ST-elevation

         If Yes:

         1. ●

            Action

            Early Invasive (<24h)

            Class IIa recommendation (2023 downgrade)

            • ICA within 24 hours
            • Note: Downgraded from Class I in 2020
            • Based on TIMACS, VERDICT trials

         If No:

         1. ●

            Action

            Non-High Risk

            Selective invasive or non-invasive strategy

            • No high-risk features
            • Low GRACE score
            • Stable, no dynamic changes
            1. ●

               Action

               Non-Invasive Testing

               Stress testing or CT coronary angiography

               • Stress echo or stress CMR
               • CTCA for low-intermediate PTP
               • ICA if positive stress test
   2. ●

      Action

      Calculate GRACE Score

      Risk stratification tool

      • Age, Heart rate, Systolic BP
      • Creatinine, Killip class
      • Cardiac arrest at admission
      • ST deviation, Elevated markers
      • >140 = High risk, <140 = Lower risk