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High-risk NSTEMI — ABIM Board MCQ

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HardCardiovascularHigh-risk NSTEMIABIM Board

A 59-year-old has NSTEMI with rising troponin and recurrent chest pain despite aspirin, anticoagulation, nitrates and high-intensity statin therapy. Blood pressure is 102/66 mm Hg and creatinine is normal. Which next management is most appropriate?

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Correct answer: D — Proceed with urgent invasive angiography and indicated revascularization

The best answer is “Proceed with urgent invasive angiography and indicated revascularization”. Recurrent ischemia despite medical therapy makes an invasive strategy urgent in NSTE-ACS. Angiography identifies anatomy and permits revascularization when appropriate. Outpatient testing and observation delay definitive care, fibrinolysis is not routine therapy for NSTEMI with ST depression, and withdrawing antithrombotic treatment would increase ischemic risk without a procedural reason.

Reference: 2025 ACC/AHA Guideline for Acute Coronary Syndromes: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001309