This patient should undergo coronary artery bypass graft (CABG) surgery. In patients with a non–ST-elevation acute coronary syndrome (unstable angina or non–ST-elevation myocardial infarction), the TIMI risk score is used to determine whether a conservative strategy or an early invasive strategy is warranted. This patient has several TIMI risk factors, including aspirin use in the past week, ST-segment deviation, elevated biomarkers, more than three traditional coronary artery disease (CAD) risk factors, and documented CAD with greater than or equal to 50% diameter stenosis; therefore, an early invasive strategy is warranted. In this patient, an oral P2Y₁₂ inhibitor (clopidogrel, prasugrel, ticagrelor) was not administered, but if this had been given, the surgery should be delayed 5 days to allow discontinuation and excretion of the antiplatelet medication.

Intra-aortic balloon pump placement may be considered for patients with recurrent cardiac ischemia and poor left ventricular function. However, although this patient had recurrent chest pain during hospitalization, his symptoms improved with intravenous nitroglycerin and medical therapy, and he has remained hemodynamically stable. Therefore, intra-aortic balloon pump placement is not indicated.

Because this patient has multivessel disease and a reduced left ventricular ejection fraction, he should undergo CABG rather than percutaneous coronary intervention.

In patients with left main coronary artery stenosis, depressed left ventricular function, and an acute coronary syndrome, the optimal treatment strategy includes revascularization rather than medical therapy.