A 62-year-old man with NSTEMI (troponin positive) has GRACE score >140. Coronary angiography shows 70% stenosis in the proximal LAD. His LV ejection fraction is 35%. According to current ESC/AHA guidelines, what is the preferred revascularization strategy?
- A PCI with drug-eluting stent to LAD ✓
- B Medical management only given reduced EF
- C CABG surgery for better long-term outcomes in multivessel disease
- D Thrombolysis followed by angiography (pharmaco-invasive strategy)
Explanation
For NSTEMI with high-risk features (GRACE score >140 indicates high mortality risk), early invasive strategy (PCI within 24 hours) is recommended by ESC 2020 ACS guidelines. Single-vessel proximal LAD disease is best treated with PCI using drug-eluting stent as it avoids the higher perioperative risk of CABG in the acute setting. CABG is preferred for left main, 3-vessel disease (especially with diabetes or reduced EF) in stable settings but not for single-vessel NSTEMI. Thrombolysis has no role in NSTEMI management. Medical management alone would be inappropriate given high-risk features and significant proximal LAD stenosis.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.