From the Guidelines
Patients with ST depression or T wave changes and active cardiac chest pain should undergo PCI within 24 hours as part of an early invasive strategy, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes 1. This approach is based on the presence of high-risk criteria, including dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischemia, which is a key indicator for early intervention.
- Key factors that support an early invasive strategy include:
- Diagnosis of NSTEMI suggested by the diagnostic algorithm
- Dynamic or presumably new contiguous ST/T-segment changes
- Transient ST-segment elevation
- GRACE risk score >140
- The benefits of an early invasive strategy, as outlined in the 2020 ESC guidelines 1, include reducing the risk of progression to myocardial infarction and improving outcomes by restoring coronary blood flow.
- Prior to PCI, patients should receive appropriate medical therapy, including dual antiplatelet therapy and anticoagulation, to reduce the risk of further ischemic events.
- The timing of the invasive strategy is critical, with very high-risk patients (those with hemodynamic instability, recurrent chest pain refractory to medical treatment, life-threatening arrhythmias, or cardiac arrest) requiring immediate PCI (within 2 hours), as recommended by the guidelines 1.
- In contrast, patients considered at low risk may undergo a selective invasive strategy after appropriate ischemia testing or detection of obstructive CAD by CCTA, highlighting the importance of individualized management based on patient risk profile.
From the Research
Patients with ST Depression or T Wave Changes
- Patients with ST depression or T wave changes and active cardiac chest pain should undergo Percutaneous Coronary Intervention (PCI) as soon as possible, especially if they have severe coronary lesions or are at high risk of subsequent cardiac events 2.
- The presence of ST-segment depression is associated with a 100% increase in the occurrence of three-vessel/left main disease and an increased risk of subsequent cardiac events, making early invasive strategy substantially decrease death/myocardial infarction 2.
ECG Patterns and PCI
- Certain ECG patterns, such as ST-segment depression with negative T waves in leads V4-V5, can be a marker of severe coronary artery disease in non-ST elevation acute coronary syndrome, and patients with this pattern may benefit from early PCI 3.
- Patients with ST-segment depression and a negative T wave maximally in leads V4-5 during anginal pain are at high risk of left main, left main equivalent, or severe three-vessel coronary artery disease, and early PCI may be indicated 3.
- Other ECG patterns, such as junctional ST-depression and tall symmetrical T-waves, can also signify proximal LAD occlusion or other severe coronary artery disease, and prompt PCI may be necessary 4, 5.
Clinical Implications
- Early catheterization and PCI are recommended for patients with high-risk ECG patterns, such as those with ST-segment depression and negative T waves, or junctional ST-depression and tall symmetrical T-waves 6, 4, 5.
- Recognition of these ECG patterns by healthcare professionals is crucial to ensure timely reperfusion therapy and improve patient outcomes 4, 5.