Compared with a delayed invasive strategy (within 24 to 72 h), an early invasive strategy (within the initial 24 h) in patients with NSTEMI reduces recurrent/refractory ischemia, length of stay, and costs. However, there is no definitive evidence that it has an incremental benefit in reducing MI or death. Patients who are unstable (refractory angina/ischemia, new or worsening heart failure, mitral regurgitation, hemodynamic instability, sustained ventricular fibrillation or ventricular tachycardia) need an urgent/immediate invasive strategy within 2 h, and are excluded from the denominator and numerator. Clinical Recommendation(s) 2014 AHA/ACC Guideline for the Management of Patients With Non ST-Elevation Acute Coronary Syndromes11 1. An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in initially stabilized patients with NSTE- ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Table 8).161,163,179 183 (Class I, Level of Evidence: B) 2. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with: a. (eg, hepatic, renal, pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Class III, Level of Evidence: C) b. Acute chest pain and a low likelihood of ACS (Class III, Level of Evidence: B) who are troponin-negative, especially women.178 (Class: III, Level of Evidence: C) 3. Older patients with NSTE-ACS should be treated with GDMT, an early invasive strategy, and revascularization as appropriate.184 188 (Class I, Level of Evidence: A) 4. Patients with prior CABG and NSTE-ACS should receive antiplatelet and anticoagulant therapy according to GDMT and should be strongly considered for early invasive strategy because of their increased risk.143,145,177,178,189,190 (Class I, Level of Evidence: B) 5. 