4.4.4. Early Invasive and Ischemia-Guided Strategies: Recommendations Class I 1. An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indi- cated in patients (men and women ) with NSTE-ACS who have refractory angina or hemodynamic or elec- trical instability (without serious comorbidities or contraindications to such procedures).42,44,138,338 (Level of Evidence: A) 2. An early invasive strategy (diagnostic angiography with intent to perform revascularization if appropri- ate based on coronary anatomy) is indicated in ini- tially stabilized patients with NSTE-ACS (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Table 8).42,44,138,333,334,338,339 (Level of Evidence: B) See Section 7.7 for additional information on women. Amsterdam et al 2014 AHA/ACC NSTE-ACS Guideline e369 Class IIa 1. It is reasonable to choose an early invasive strategy (within 24 hours of admission) over a delayed inva- sive strategy (within 25 to 72 hours) for initially sta- bilized high-risk patients with NSTE-ACS. For those not at high/intermediate risk, a delayed invasive ap- proach is reasonable.139 (Level of Evidence: B) Class IIb 1. In initially stabilized patients, an ischemia-guid- ed strategy may be considered for patients with Figure 3. Algorithm for Management of Patients With Definite or Likely NSTE-ACS.* *See corresponding full-sentence recommendations and their explanatory footnotes. In patients who have been treated with fondaparinux (as upfront therapy) who are undergoing PCI, an additional anticoagulant with anti-IIa activity should be administered at the time of PCI because of the risk of catheter thrombosis. ASA indicates aspirin; CABG, coronary artery bypass graft; cath, catheter; COR, Class of Recommendation; DAPT, dual antiplatelet therapy; GPI, glycoprotein IIb/IIIa inhibitor; LOE, Level of Evidence; NSTE-ACS, non ST-elevation acute coronary syndrome; PCI, percutaneous coronary intervention; pts, patients; and UFH, unfractionated heparin. 