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NSTEMI — ABIM Board MCQ

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HardCardiovascularNSTEMIABIM Board

A 64-year-old man with type 2 diabetes mellitus and prior PCI presents with 2 hours of substernal chest pressure. ECG shows new 1-mm horizontal ST-segment depressions in leads V4–V6, and serial high-sensitivity troponin concentrations are elevated and rising. He receives aspirin, anticoagulation, nitrates, and high-intensity statin therapy. His pain resolves, and he has no heart failure, sustained arrhythmia, or hemodynamic instability. His GRACE risk score is 152. Which of the following is the most appropriate management strategy?

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Correct answer: B — Invasive coronary angiography during the current hospitalization

This patient has a high-risk NSTEMI, demonstrated by a dynamic troponin elevation, ischemic ST-segment depression, diabetes, prior coronary disease, and a GRACE score greater than 140. He should undergo invasive coronary angiography during the current hospitalization, with revascularization when anatomically appropriate. Immediate angiography within 2 hours is reserved for refractory or recurrent ischemia, cardiogenic shock, acute heart failure, or hemodynamic or electrical instability, none of which is present. Stress testing and outpatient coronary CT angiography are inappropriate because NSTEMI is already established and the patient is high risk. Fibrinolysis is not indicated for NSTE-ACS, and medical therapy without planned angiography would inadequately address his risk of recurrent ischemic events.

Reference: Rao SV, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes, Top Things to Know, recommendation 4. 2025. https://professional.heart.org/en/science-news/2025-guideline-for-the-management-of-patients-with-acute-coronary-syndromes/top-things-to-know