see also: [[ACS]], [[Chest pain]], [[Troponin]] #incomplete Reference: [Heart foundation 2025 guideline](https://www.heartfoundation.org.au/for-professionals/acs-guideline) > Correct phrase is NSTEACS ## Management of NSTEACS ### Timing of invasive management of NSTEACS Studies on the timing of invasive coronary angiography in NSTEACS, comparing early intervention (e.g. within 24 hours) with delayed intervention (e.g. 2–3 days), found **no overall benefit** in mortality, MI or stroke when applied to all participants without considering individual risk. Risk stratification should guide timing decisions NSTEACS. For **unstable or very high-risk individuals**, immediate angiography (within two hours) is recommended based on poor outcomes without intervention, although this is supported by expert opinion rather than robust evidence. In people at high risk (e.g. [GRACE score](https://www.mdcalc.com/calc/1099/grace-acs-risk-mortality-calculator) >140), early intervention reduced death, MI and stroke at 6 months compared to delayed strategies (14% vs 21%), without increasing major bleeding. Mortality benefits were also observed in those with elevated biomarkers, diabetes, GRACE score >140, or aged ≥75 years, but evidence for specific risk-treatment interactions is limited. Data using hs-cTn-based GRACE scores remain unavailable. ![[Pasted image 20250513084039.png]] ### Anticoagulation Anticoagulation is recommended for people with ACS, whether managed with fibrinolytic therapy, primary PCI or a NSTEACS strategy. - In fibrinolysis, the GUSTO trial showed the lowest mortality among people with STEMI who received tPA and IV heparin . ASSENT-3 demonstrated fewer ischaemic events with tenecteplase plus enoxaparin (30 mg IV bolus followed by 1 mg/kg subcutaneously twice daily) compared with IV heparin. In NSTEACS, Early trials showed that UFH reduces MACE without increasing bleeding, forming the basis for anticoagulation in higher-risk ACS. Although low molecular weight heparin (LMWH) on background therapy with aspirin can also reduce MACE, a larger trial showed there was **no difference in the ischaemic endpoint of death and MI but significantly increased bleeding** (commonly related to femoral access) with LMWH in settings of peoples on DAPT, early angiography and frequent GPI use [393]. Contemporary meta-analyses suggest no ischaemic advantage of bivalirudin over UFH, especially with radial access [394]. Finally, fondaparinux halves major bleeding compared with LMWH in people on DAPT without compromising efficacy (there were high rates of angiography in these trials).