When should a patient with ACS be referred for catheterization and potential PCI?

• A. STEMI or high-risk NSTEMI with ongoing ischemia or high-risk features
• B. NSTEMI with no ongoing ischemia
• C. Stable angina with no ischemia
• D. Chest pain with normal ECG

Answer: (A)

In acute coronary syndromes, the goal is to restore blood flow to the affected area as quickly as possible when there is ongoing ischemia. For STEMI, the blockage is usually complete, and the artery should be opened with catheter-directed therapy as a priority (PCI) as soon as possible to minimize heart muscle damage. For NSTEMI, the artery is not completely occluded, so an invasive strategy isn’t always emergent, but it’s strongly indicated when there is ongoing chest pain or other high-risk features—such as persistent or recurring ischemia, hemodynamic instability, heart failure, life-threatening arrhythmias, or a high risk score—to promptly identify and treat a culprit lesion.

The best choice reflects that urgent catheterization and PCI are indicated for STEMI or for high-risk NSTEMI patients with ongoing ischemia or high-risk features. NSTEMI without ongoing ischemia and stable angina without ischemia, or chest pain with a normal ECG, do not require immediate invasive intervention and are managed more conservatively or with noninvasive risk stratification unless new high-risk features develop.