1	Intervention for acute coronary syndrom without ST elevation,the earlier,the better Shubin Qiao,M.D Cardiovascular Institute &Fuwai hospital, Chinese Academy of Medical Sciences
2	Clinical character 65 male Essential hypertension, Hyperlipidemia Previous PCI at RCA 8 months ago Chest pain for 16 hours ST(V_2-5) depressing even with comprehensive medication Troponin (+)
3	Previous PCI 8 months ago
4	PCI at RCA 8 months ago
5	PCI at RCA 8 months ago
6	Angiography finding this time
7	PCI procedure
8	Final result
9	Implication PCI for NSTE ACS is the best choice especially for those with ischemic evidence under comprehensive medication Previous PCI can not prevent recurrent ACS by vulnerable plaque rupture LV function is well preserved in NSTE ACS patients,especially for anterior wall ischenmia.
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11	Trials of Invasive versus Conservative Management of UA/NSTEMI
12	Invasive Management of UA/NSTEMI Meta-analysis: ¯ Death/MI at 17 mo. F/U
13	Invasive Rx in ACS: Early and Late Mortality
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15	FRISC-II Mortality at One-Year Invasive Vs. Conservative Management Strategies
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18	TACTICS-TIMI-18: Primary Endpoint: Death, MI, Rehospitalization for ACS at 6 Months
19	Cumulative risk of death, MI or refractory angina
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23	Wide Variations in Timing of Interventions in Invasive Arm of Major Trials
24	ISAR COOL- Limitations Very small single center study Only 36 primary outcome events in entire trial No difference in mortality No measure of baseline CKMB obscuring the diagnosis of MI in Early Angiography group in patients with baseline MI
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27	Risk indicators of use for selection of patients for early invasive treatment in ACS Age(>65 years） Coronary risk factors-diabetes mellitus,hyperlipidemia,hypertension,smoking Renal dysfunction- reduced GFR(<95mL/min, even higher risk at <60mL/min） Previous myocardial infarction, previous angina pectoris Cardiac dysfunction-elevated NT-proBNP (>240,even higher risk at >2000ng/L) History of chest pain at rest or during last 24 h or recurrences despite treatment Myocardial ischemia-ST segment depression (³0.1mV,even higher risk at ³0.2mV) Coronary thrombosis-elevated troponin (-T ³ 0.01,even higher risk at ³0.5) Inflammation-elevation of CRP(>10mg/ L) Severe coronary artery lesion at coronary angiography
28	ACC/AHA Guidelines Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemic therapy Elevated troponin T or I New or presumably new ST-segment depression Recurrent angina/ischemia with CHF symptoms, an S₃ gallop, pulmonary edema, worsening rales, or new or worsening MR High-risk findings on nonivasive stress testing Depressed LV systolic function( e.g., EF<0.40 on noninvasive study) Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG
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30	Unresolved issues The optimal period of pretreatment or stablization before angiography and revascularization The extent of revascularization (culprit lesion vs. complete revascularization)
31	"An International Randomized Trial of" An International Randomized Trial of Early Versus Delayed Invasive Strategies in Patients with Non-ST Segment Elevation Acute Coronary Syndromes
32	TIMACS: Timing of Intervention Study Objective: To compare the relative efficacy, safety and cost effectiveness of early versus late (standard delayed) angiography and intervention Addresses the currently unresolved question: “When is the most appropriate time to take patients to the cath lab?”.
33	Conclusion Early invasive stratigy should be used in selected (high risk)patients with non-st elevating ACS Risk stratification is helpful Intervention for some patients with NSTE ACS should be used the earlier ,the better