Timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome: can we wait?

Strategies to optimise the care of acute coronary syndrome (ACS) remain critical given the burden of the disease, its morbimortality and related health costs. One main challenge regarding the best treatment of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is the optimal timing for an invasive strategy.

The European Society of Cardiology (ESC) Guidelines for the management of ACS have recently modified the recommended delays for intervention1. According to these updated guidelines, an inpatient invasive strategy is recommended for patients with a working diagnosis of NSTE-ACS, which makes clinical sense regarding the potential risk of early severe complications and death.

Immediate coronary angiography (i.e., <2 hours) should be performed in some clinical scenarios (e.g., patients classified at very high risk). However, this has poor scientific background (no dedicated study) and should be amended. Considering persistent chest pain certainly makes sense, since some NSTE-ACS are related to a complete coronary occlusion, as in ST-elevation myocardial infarction (STEMI) patients (in up to one-third of the cases in a recent metaÂ-analysis2). However, differential diagnoses including aortic dissection should be ruled out beforehand....