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ACS management Algorithm
Unstable syndrome-
No evidence for cardiac cause of symptoms
Low-riskannual CV mortality <1% per year
High-risk coronaryanatomy known to benefit fromrevascularisation?
Revascularize
Evaluate response to medical therapy
If symptomatic control unsatisfactory, consider suitability for revascularization (PCI or CABG)
Reassure. Refer for investigationand/or management of alternative diagnosis if appropriate
Coronary arteriography if not already performed
No
Yes
History and physical ECG laboratory tests
Clinical evaluation
Assessment of ischaemia
Exercise ECG
or
Pharmacological stress imaging or exercise stress imaging
Re-assess likelihood of ischaemia as cause of symptoms
Evaluate prognosis on the basis of clinical evaluation and non-invasive tests
If diagnosis of CAD is secure, but assessment of ventricular function not already performed for class I indications,then assess ventricular function at this stage
Intermediate-riskannual CV mortality 1-2% per year
Medical therapy
+
_
Coronary arteriographyDepending on level of symptoms and clinical judgment
Medical therapy and
Coronary arteriographyfor more complete risk stratification and assessment of need for revascularization
Medical therapy
High-risk
annual CV mortality >2% per year
(or MRI) to assess structural or functional abnormalities
Echocardiography
CXR
Suspected heart failure,prior MI, abnormal ECG. or clinical examination, hypertension, or DM
Suspected pulmonary disease