O The most recent NSTE ACC/AHA clinical practice guidelines recommend coronary angiography with either PCI or coronary artery bypass graft (CABG) surgery revascularization as an early treatment (early invasive strategy) for high-risk and moderate-risk NSTE ACS patients2 (Fig. 8-3). Several clinical trials support an "invasive" interventional strategy with early angiography and PCI or CABG versus a "conservative medical management" strategy, whereby coronary angiography with re-vascularization is reserved for patients with symptoms refractory to pharmacotherapy and patients with signs of ischemia on stress testing. An "invasive" approach results in fewer MIs, less need for additional revascularization procedures over the next year following hospitalization, and less cost than the conservative "medical stabilization" approach in patients at moderate to high risk in most trials.2,15 All patients undergoing PCI should receive aspirin (ASA) therapy indefinitely. Clopidogrel is administered (concomitantly with ASA) for at least 30 days following PCI for a patient receiving a bare metal stent and for at least 1 month and ideally up to 12 months following PCI for a patient receiving a drug eluting stent (DES) who is not at high risk for bleeding (Table 8-2).4 Drug-eluting stents reduce the rate of smooth muscle cell growth causing stent restenosis. However, there is a delay in endothelial cell regrowth at the site of the stent which places the patient at higher risk of thrombotic events following PCI. Therefore, dual antiplatelet therapy is indicated for a longer period of time following PCI with a drug-eluting stent.4 Regardless of whether or not a patient with NSTE receives a stent, the preferred duration of clopidogrel therapy is at least a year.
Table 8-1 TIMI Risk Score for NSTE ACSs
Past Medical History Clinical Presentation
ST-segment depression (0,5 mm or greater)
Two or more episodes of chest discomfort within the past 21 hours Positive biochemical marker for Infarction"
► Three or more risk factors for CAD:
Hy percho I estero lem la HTN DM Smoking Tamily history of premature CHD
■ Known CAD (50% or greater stenosis of a coronary artery)
■ Use of ASA within the past 7 days
One poinL is assigned for each of the seven medical history £rid clinical presentation findings. The point total is calculated and the paLient is assigned a risk for experiencing the composite endpoinl of death, Ml, oi urgent need for revascularization as follows:
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