Avoiding invasive angiography in non-ST-elevation MI patients: are coronary CT angiography and FFR-CT the answer?

The population of patients diagnosed as having non-ST-elevation myocardial infarction (NSTEMI) is heterogeneous. This diversity has been magnified by the routine use of high-sensitivity troponin (hsTrop) assays, since these facilitate, and thereby expand, the diagnosis of Type 1 and Type 2 myocardial infarction (MI) and myocardial injury1. Increasingly, this presents frontline clinical staff with a management dilemma in patients with a history of chest pain and troponin elevation, given that international guidelines recommend, on the basis of symptom improvement and prognostic advantage, invasive coronary angiography (ICA) with a view to revascularisation, where appropriate, in patients with Type 1 MI. There is, by contrast, no evidence of such advantages to the invasive strategy in other categories of NSTEMI.

This background helps to explain the consistent observation that a substantial proportion of cases with NSTEMI who undergo ICA do not have significant coronary artery stenosis(es). Given that ICA induces a degree of discomfort, anxiety and risk for the patient and carries a financial and bed occupancy cost to the healthcare system, such procedures can be deemed inappropriate. Strategies that seek to reduce...