Percutaneous Coronary Interventions for NSTEMI and Unstable Angina

  • Stéphane Noble
  • Marco RoffiEmail author


Acute coronary syndromes (ACS) have been traditionally divided into unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Unstable angina is defined by the presence of ischemic symptoms at rest, or at minimal effort in the absence of myocardial injury (i.e., absence of elevation of high-sensitivity cardiac troponins). These patients are at low risk of life-threatening arrhythmias, myocardial infarction (MI), or death. In the absence of recurrent symptoms, continuous rhythm monitoring is not mandatory. Moreover, in UA patients, the benefit of intensive antiplatelet therapy and early revascularization is modest. By definition, NSTEMI is characterized by myocardial injury, which translates into an increased risk of life-threatening arrhythmias and death. These patients derive a benefit from intensive antiplatelet therapy and revascularization. The universal definition of MI requires the presence of typical ischemic symptoms or ischemic ECG changes in addition to a troponin level above the 99th percentile of healthy individuals, with a rise and/or fall of the biomarker. While there are five different types of MI, we focus on type 1 and 2. Type 3 corresponds to MI resulting in death and with no biomarkers available. Type 4 and 5 are MI post-percutaneous coronary intervention and coronary artery bypass grafting, respectively.


NSTEMI Unstable angina Acute coronary syndromes Percutaneous coronary intervention Early invasive approach Dual-antiplatelet therapy (DAPT) Prasugrel Ticagrelor Clopidogrel ECMO (ExtraCorporeal Membrane Oxygenation) 


  1. 1.
    Grosgurin O, Plojoux J, Keller PF, Niquille M, N'koulou R, Mach F, Sarasin FP, Rutschmann OT. Prehospital emergency physician activation of interventional cardiology team reduces door-to-balloon time in ST-elevation myocardial infarction. Swiss Med Wkly. 2010;140(15–16):228–32.PubMedGoogle Scholar
  2. 2.
    Thygesen K, Alpert JS, Jaffe AS, Simoons ML, Chaitman BR, White HD, Writing Group on the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction, Thygesen K, Alpert JS, White HD, Jaffe AS, Katus HA, Apple FS, Lindahl B, Morrow DA, Chaitman BA, Clemmensen PM, Johanson P, Hod H, Underwood R, Bax JJ, Bonow RO, Pinto F, Gibbons RJ, Fox KA, Atar D, Newby LK, Galvani M, Hamm CW, Uretsky BF, Steg PG, Wijns W, Bassand JP, Menasché P, Ravkilde J, Ohman EM, Antman EM, Wallentin LC, Armstrong PW, Simoons ML, Januzzi JL, Nieminen MS, Gheorghiade M, Filippatos G, Luepker RV, Fortmann SP, Rosamond WD, Levy D, Wood D, Smith SC, Hu D, Lopez-Sendon JL, Robertson RM, Weaver D, Tendera M, Bove AA, Parkhomenko AN, Vasilieva EJ, Mendis S; ESC Committee for Practice Guidelines (CPG). Third universal definition of myocardial infarction. Eur Heart J. 2012;33(20):2551–67.CrossRefPubMedGoogle Scholar
  3. 3.
    Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, et al. ESC working group position paper on myocardial infarction with non-obstructive coronary arteries. Eur Heart J. 2016;38(3):143–53. Scholar
  4. 4.
    Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267–315. Scholar
  5. 5.
    Valgimigli M, Patrono C, Collet JP, Mueller C, Roffi M. Questions and answers on coronary revascularization: a companion document of the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2015;37(3):e8–e14. Scholar
  6. 6.
    Noble S. Radial access in patients invasively treated for acute coronary syndromes: a lifesaving approach. JACC Cardiovasc Interv. 2016;9(7):671–3. Scholar
  7. 7.
    Andò GCD. Radial access reduces mortality in patients with acute coronary syndromes: results from an updated trial sequential analysis of randomized trials. JACC Cardiovasc Interv. 2016;9(7):660–70.CrossRefPubMedGoogle Scholar
  8. 8.
    Collet JP, Roffi M, Mueller C, Valgimigli M, Patrono C, Baumgartner H, et al. Questions and answers on antithrombotic therapy: a companion document of the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevationdagger. Eur Heart J. 2015.
  9. 9.
    Garot PMM, Tresukosol D, Pocock SJ, Meredith IT, Abizaid A, Carrié D, Naber C, Iñiguez A, Talwar S, Menown IB, Christiansen EH, Gregson J, Copt S, Hovasse T, Lurz P, Maillard L, Krackhardt F, Ong P, Byrne J, Redwood S, Windhövel U, Greene S, Stoll HP, Urban P, LEADERS FREE Investigators. Two-year outcomes of high bleeding risk patients after polymer-free drug-coated stents. J Am Coll Cardiol. 2017;69(2):162–71.
  10. 10.
    Urban PMI, Abizaid A, Pocock SJ, Carrié D, Naber C, Lipiecki J, Richardt G, Iñiguez A, Brunel P, Valdes-Chavarri M, Garot P, Talwar S, Berland J, Abdellaoui M, Eberli F, Oldroyd K, Zambahari R, Gregson J, Greene S, Stoll HP, Morice MC, LEADERS FREE Investigators. Polymer-free drug-coated coronary stents in patients at high bleeding risk. N Engl J Med. 2015;373(21):2038–47. Scholar
  11. 11.
    Montalescot G, Bolognese L, Dudek D, Goldstein P, Hamm C, Tanguay JF, et al. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med. 2013;369(11):999–1010. Scholar
  12. 12.
    Montalescot G, Collet JP, Ecollan P, Bolognese L, Ten Berg J, Dudek D, et al. Effect of prasugrel pre-treatment strategy in patients undergoing percutaneous coronary intervention for NSTEMI: the ACCOAST-PCI study. J Am Coll Cardiol. 2014;64(24):2563–71. Scholar
  13. 13.
    Wallentin LBR, Budaj A, Cannon CP, Emanuelsson H, Held C, Horrow J, Husted S, James S, Katus H, Mahaffey KW, Scirica BM, Skene A, Steg PG, Storey RF, Harrington RA, Investigators PLATO, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–57.CrossRefPubMedGoogle Scholar
  14. 14.
    Roe MT, Armstrong PW, Fox KA, White HD, Prabhakaran D, Goodman SG, et al. Prasugrel versus clopidogrel for acute coronary syndromes without revascularization. N Engl J Med. 2012;367(14):1297–309. Scholar
  15. 15.
    Catapano AL, Graham I, De Backer G, Wiklund O, Chapman MJ, Drexel H, et al. 2016 ESC/EAS Guidelines for the Management of Dyslipidaemias: The Task Force for the Management of Dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS)Developed with the special contribution of the European Assocciation for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2999–3058. Scholar
  16. 16.
    Mueller CPC, Valgimigli M, Collet JP, Roffi M. Questions and answers on diagnosis and risk assessment: a companion document of the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2015.

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© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Cardiology DivisionUniversity Hospital of GenevaGenevaSwitzerland

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