Key priorities for implementation

Key priorities for implementation

  • As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).

  • Consider intravenous eptifibatide or tirofiban[2] as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.

  • Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.

  • When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of revascularisation strategy with the patient.

  • To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography.

  • Before discharge offer patients advice and information about:

    • their diagnosis and arrangements for follow-up (in line with 'MI – secondary prevention', NICE clinical guideline 172)

    • cardiac rehabilitation (in line with 'MI – secondary prevention', NICE clinical guideline 172)

    • management of cardiovascular risk factors and drug therapy for secondary prevention (in line with 'MI – secondary prevention', NICE clinical guideline 172, and 'Lipid modification', NICE clinical guideline 67)

    • lifestyle changes (in line with 'MI – secondary prevention', NICE clinical guideline 172).



[2] Eptifibatide and tirofiban are licensed for use with aspirin and unfractionated heparin. They do not have UK marketing authorisation for use with clopidogrel. This recommendation is therefore for an off-label use of these drugs. Informed consent should be obtained and documented before they are used in combination with clopidogrel.

  • National Institute for Health and Care Excellence (NICE)