Meets any of these criteria for ACC/AHA C lesion Diffuse ( 2 cm length) Excessive tortuosity of proximal segment Extremely angulated segments, 90 Inability to protect major side branches Degenerated vein grafts with friable lesions Occluded for 3 mo ACC indicates American College of Cardiology; AHA, American Heart Association; and SCAI, Society for Cardiovascular Angiography and Interven- tions. Reprinted with permission from Krone et al.879 Appendix 4E. General Considerations in Deciding Between Early Invasive Strategy and Initial Conservative Strategy Early Invasive Strategy Generally Preferred Initial Conservative Strategy Generally Preferred or Reasonable Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy Elevated cardiac biomarkers (TnT or TnI) New or presumably new ST-segment depression Signs or symptoms of heart failure Hemodynamic instability High-risk score (eg, GRACE, TIMI) Sustained ventricular tachycardia PCI within 6 mo Prior CABG Diabetes mellitus Mild to moderate renal dysfunction Reduced LV function (LVEF 40%) Low-risk score (eg, GRACE, TIMI) Absence of high-risk features High risk for catheterization-related complications Patient not a candidate for revascularization (with either PCI or CABG) Patient prefers conservative therapy CABG indicates coronary artery bypass graft surgery; GRACE, Global Registry of Acute Coronary Events; LV, left ventricular; LVEF, left ventricular ejection fraction; PCI, percutaneous coronary intervention; TIMI, Thrombolysis In Myocardial Infarction; TnI, troponin I; and TnT, troponin T. Appendix 4F. Agents for Procedural Sedation and Analgesia Drug Clinical Effects Dose Onset Duration Comments Midazolam Sedation, anxiolysis. No analgesia. Initial 0.5 to 1 mg IV, then titrated. 2 to 3 min 45 to 60 min Reduce dose when used in combination with opioids. May produce paradoxical excitement. Reversible with flumazenil. Fentanyl Analgesia 50 mcg IV. May repeat every 3 min, titrate to effect. 3 to 5 min 30 to 60 min Reduce dosing when combined with benzodiazepines. Reversible with naloxone. 