A 58-year-old man presents with NSTEMI. Troponin I peak is 28 ng/mL. He has a GRACE score of 148 (high risk). No hemodynamic instability. He is started on dual antiplatelet therapy (aspirin + ticagrelor) and anticoagulation (fondaparinux). The timing of coronary angiography should be:
- A Within 24 hours (early invasive) ✓
- B Within 2 hours (immediate)
- C Within 72 hours (delayed invasive)
- D Stress test first; angiography only if positive
Correct answer: A. Within 24 hours (early invasive)
Explanation
In NSTEMI with high-risk features (GRACE score ≥140 or elevated troponin), current ESC/ACC guidelines recommend an early invasive strategy with coronary angiography within 24 hours. Immediate angiography (<2 hours) is reserved for very high-risk features: hemodynamic instability, refractory chest pain, or life-threatening arrhythmias. Delayed strategy (72 hours) is acceptable for intermediate risk. Conservative (stress-test-guided) strategy is only for low-risk NSTEMI (GRACE <109, undetectable troponin, resolved symptoms).
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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