Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Escalate
Activate immediate invasive management for STEMI and for NSTE-ACS with haemodynamic instability, recurrent or refractory pain, life-threatening arrhythmia or acute heart failure; stabilisation and transfer should occur in parallel.
Synopsis
Use invasive angiography and haemodynamic catheterisation when results will change treatment, while reducing access, bleeding, kidney and radiation harm.
Coronary angiography defines lumen anatomy but does not show plaque biology or prove that an intermediate stenosis causes ischaemia.
Use FFR or a validated non-hyperaemic pressure ratio to assess intermediate lesions before revascularisation when functional significance is uncertain.
Radial access usually reduces access-site bleeding and permits earlier mobilisation, but anatomy and procedure may require femoral access.
Key red flags
Coronary occlusion
Acute occlusion with an ACS presentation requires immediate reperfusion strategy and antithrombotic management.
Investigation priorities
01
Invasive coronary angiographyFirst step
Define coronary anatomy and enable revascularisation in appropriate ACS or chronic coronary syndromes.
Management branches
Preferred routeChronic coronary syndrome
Severe refractory symptoms, high event risk or high pre/post-test likelihood
Confirm the indication, optimise guideline-directed therapy and review non-invasive anatomy or ischaemia.
Obtain informed consent covering diagnostic angiography, possible PCI, CABG alternative and material risks.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.