Synopsis
Choose the urgent or elective revascularisation route, explain PCI versus CABG trade-offs and manage the immediate antithrombotic and follow-up priorities.
- Primary PCI is the preferred STEMI reperfusion strategy when it can be delivered within the NICE time window; if it cannot, assess promptly for fibrinolysis and the pharmaco-invasive pathway.
- For NSTEMI/unstable angina, the timing of angiography follows clinical instability and calculated risk; unstable patients need immediate invasive assessment.
- In stable angina, revascularisation is primarily for symptoms not controlled by optimal medical therapy; prognostic benefit depends on anatomy and clinical context.
Key red flags
Persistent ST elevation or equivalent with compatible acute ischaemia requires immediate PPCI network activation and a documented symptom/ECG timeline.
Investigation priorities
Define acute ischaemic territory and detect dynamic change or post-procedure occlusion.
Management branches
STEMI within the reperfusion window
- Activate the regional primary-PCI pathway immediately and give ACS antithrombotic treatment unless contraindicated.
- Offer coronary angiography with primary PCI when this can be delivered within 120 minutes of when fibrinolysis could have been given under NICE NG185.
Angina despite optimal medical therapy or prognostically important anatomy
Key medicines
AspirinFor long-term post-revascularisation prevention, typically 75 mg orally once daily after the acute loading dose.
TicagrelorACS: 180 mg oral loading dose then 90 mg twice daily, generally with low-dose aspirin, for the planned course up to 12 months unless adjusted.