In a 76‑year‑old woman with type 2 diabetes mellitus, hypertension, tachycardia, diaphoresis, and ST‑segment depression in leads II, III, aVF, which is the best next step: aspirin, diltiazem, ezetimibe, coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI)?

Percutaneous Coronary Intervention (PCI) is the Best Next Step

This 76-year-old woman is presenting with an acute coronary syndrome (non-ST-elevation myocardial infarction or NSTEMI) based on her symptoms of tachycardia and diaphoresis with ST-segment depression in the inferior leads, and she requires urgent coronary angiography with intent to perform PCI within 48 hours. 1

Clinical Reasoning

This patient meets multiple high-risk criteria for NSTE-ACS that mandate an early invasive strategy:

• Dynamic ST-segment changes (ST-segment depression ≥0.1 mV in leads II, III, aVF) 1
• Diabetes mellitus (A1C of 9%) 1
• Elderly age (76 years) with likely elevated troponins given her presentation 1
• Hemodynamic instability suggested by tachycardia and diaphoresis 1

The European Society of Cardiology guidelines explicitly state that patients with NSTE-ACS demonstrating ST-segment depression ≥0.1 mV should undergo coronary angiography within 48 hours, and a clear benefit from early angiography and PCI has been reported only in high-risk groups like this patient. 1

Why Not the Other Options

Aspirin alone is insufficient as monotherapy in this acute setting, though it should be administered immediately as part of dual antiplatelet therapy before PCI. 2

Diltiazem is contraindicated in this acute presentation—calcium channel blockers have no role in the immediate management of NSTE-ACS and could worsen hemodynamic instability in the setting of possible acute MI. 3

Ezetimibe is a chronic lipid-lowering agent with no role in acute coronary syndrome management and would not address the immediate life-threatening coronary occlusion. 4

CABG is not the immediate next step because:

• The patient requires diagnostic angiography first to define coronary anatomy 1
• CABG is reserved for specific anatomic patterns (left main disease, complex three-vessel disease with high SYNTAX scores, or multivessel disease in diabetics) that cannot be determined without angiography 1, 5
• In NSTE-ACS, deferral of intervention does not improve outcomes, and immediate invasive strategy is superior 1

Management Algorithm

1. Immediate medical therapy: Aspirin, P2Y12 inhibitor (clopidogrel or ticagrelor), anticoagulation (heparin or bivalirudin), and consider glycoprotein IIb/IIIa inhibitors 1, 2

2. Urgent coronary angiography within 48 hours (ideally sooner given her high-risk features) 1

3. PCI of culprit lesion(s) if anatomically suitable 1

4. Consider CABG only if angiography reveals:

   • Unprotected left main disease with high complexity 1, 5
   • Three-vessel disease with high SYNTAX score (>22) in this diabetic patient 1, 5
   • Anatomy unsuitable for PCI 1

Critical Pitfalls to Avoid

Do not delay revascularization in this high-risk patient—the ISAR-COOL trial demonstrated that a "cooling-off" strategy with prolonged medical therapy before catheterization resulted in worse outcomes (11.6% death/MI) compared to immediate invasive strategy (5.9% death/MI). 1

Do not assume CABG is automatically superior because she has diabetes—while CABG shows mortality benefit over PCI in diabetics with multivessel disease at long-term follow-up, the immediate priority is diagnostic angiography and treatment of the acute culprit lesion. 1, 5

Recognize that her diabetes and age increase procedural risk but do not contraindicate PCI—elderly patients and diabetics benefit significantly from early invasive strategy in NSTE-ACS despite higher baseline risk. 1