**13. Percutaneous coronary intervention vs. coronary artery bypass surgery**

The main advantages of PCI in the setting of NSTEMI are faster revascularization of the culprit lesion, a lower risk of stroke and the absence of deleterious effects of cardiopulmonary bypass on the ischemic myocardium, on the other hand, CABG may more frequently offer complete revascularization in advanced multivessel CAD. The decision to perform PCI or CABG was left to the discretion of the investigator. A post hoc analysis of NSTE-ACS patients with multivessel CAD included in the ACUITY trial showed that 78% underwent PCI while the remaining patients were treated surgically [176]. There were no differences in mortality at 1 month and 1 year between the two modalities. PCI treated patients experienced lower rates of stroke, MI, major bleeds and renal injury, but had significantly higher rates of unplanned revascularization than CABG during the periprocedural period and at 1 year [177–179].

• A P2Y12 receptor inhibitor should be continued for up to 12 months. For patients with

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• Oral beta-blockers should be continued indefinitely, especially in patients with reduced left

• All patients with NSTEMI should start high-intensity statin therapy (moderate-intensity if not a candidate for high-intensity statin) in hospital regardless of cholesterol levels, and if there are no contraindications [182]. Two trials demonstrated superior outcomes in patients treated with atorvastatin within 12 h of receiving PCI, and it may provide benefit when given early in NSTEMI [183, 184]. A high-intensity statin is defined as a daily dose that lowers LDL-C by approximately >50%, while a moderate-intensity statin daily dose lowers LDL-C by approximately 30–50%. Statin therapy is particularly important in patients who have hyperlipidemia, diabetes, prior MI, or CAD. Statins inhibit the rate-limiting step in cholesterol synthesis. They may also reduce vascular inflammation, improve endothelial function, and decrease thrombus formation in addition to lowering LDL [185]. The addition of ezetimibe

to the statin regimen may also be considered to achieve lower LDL targets [186].

• ACE inhibitors should be started in all patients with left ventricular systolic dysfunction (ejection fraction <40%), heart failure, HTN, diabetes, stable chronic kidney disease [1, 15]. They are started after 24 h. The goal BP is at least <140/90 mmHg (including patients with

• Aldosterone antagonists should be used in all patients with left ventricular dysfunction (ejection fraction ≤40%), a history of diabetes mellitus, or evidence of congestive heart failure. Aldosterone blockade should not be used in patients with serum creatinine >2.5 mg/dL in men or > 2.0 mg/dL in women, as well as in patients with hyperkalemia

Patients who have experienced NSTEMI have a high risk of morbidity and death from a future event. The rate of sudden death in patients who have had an MI is 4–6 times the rate in the general population [189]. Life-threatening ventricular arrhythmias (sustained VT or VF) occurring after 48 h from the index acute coronary syndrome portend a poor prognosis, and are most frequently associated with left ventricular dysfunction. The benefit of implantable cardioverter-defibrillators, for both primary and secondary prevention, in patients with significant left ventricular dysfunction has been well demonstrated [190, 191]. Implantation for primary prevention should be considered at a minimum of 40 days following hospital

Data from the era prior to medical therapy and revascularization suggest that the risk of cardiovascular death following an MI in the absence of treatment is approximately 5% per year, with a death rate after hospital discharge in the first year of about 10%. Pharmacotherapy, lifestyle changes, and cardiac rehabilitation are well demonstrated to be beneficial and together

aspirin allergy, long-term P2Y12 receptor inhibitor use is suggested [1, 181].

ventricular function.

CKD or diabetes) [187].

(potassium >5.0 mEq/L) [188].

discharge based on current recommendations [192].

are additive in reducing mortality [193].

**16. Prognosis**

While the majority of patients with single-vessel CAD should undergo ad hoc PCI of the culprit lesion, the revascularization strategy in an individual NSTE-ACS patient with multivessel CAD should be discussed in the context of a Heart Team and be based on the clinical status as well as the severity and distribution of the CAD and the lesion characteristics. The SYNTAX score was found to be useful in the prediction of death, MI and revascularization among NSTE-ACS patients undergoing PCI and may help guide the choice between revascularization strategies [180].
