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European Heart Journal 2003 24(17):1544-1553; doi:10.1016/S0195-668X(03)00211-2
Copyright © 2003 by the European Society of Cardiology.
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Review

Current management of non-ST-segment-elevation acute coronary syndrome: reconciling the results of randomized controlled trials1

Abhiram Prasad, Verghese Mathew, David R Holmes, Jr. and Bernard J Gersh*

Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA

* Address for reprints: Bernard J. Gersh, MD, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA

Received 16 October 2002; revised 8 January 2003; accepted 20 March 2003

Abstract

Aims Patients presenting with non-ST-segment-elevation acute coronary syndrome represent a heterogeneous group with regard to the severity of coronary atherosclerosis and prognosis. The conventional approach to their treatment has involved admission to the hospital for pharmacologic stabilization, subsequent mobilization, and management by either a conservative or an invasive strategy. The choice of one approach over another is guided largely by local practice patterns and the availability of invasive facilities.

Methods and results However, recent randomized trials comparing the strategies have demonstrated a superiority of the invasive strategy, particularly in patients at higher risk. Furthermore, randomized trials have provided information on refining risk stratification. On the basis of these data, we outline criteria for assessing risk and recommend that stratification be conducted at presentation using clinical features, the electrocardiogram, and biomarkers.

Conclusion Higher-risk patients should be admitted for pharmacologic stabilization and assessed by coronary angiography within 48h with the aim of early revascularization, provided the risk of periprocedural complications is not prohibitive. Glycoprotein IIb/IIIa receptor inhibitors are indicated, particularly in patients requiring percutaneous coronary intervention. The conservative strategy remains appropriate for patients admitted to hospitals without invasive facilities. Patients not at highrisk may be observed in a facility with cardiac monitoring such as a chest pain unit and undergo subsequent stress testing. The adoption of such an early risk stratification and revascularization-based approach is likely to result in a reduction in recurrent myocardial infarction and ischaemia, duration of hospitalization, repeat hospitalization, and mortality.

Key Words: Myocardial infarction • Unstable angina • Risk

List of Abbreviations: ACS, acute coronary syndrome • ESSENCE, Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-wave Coronary Event • FRAXIS, Fraxiparin in Ischemic Syndromes • FRIC, Fragmin in Unstable Coronary Artery Disease • FRISC, Fragmin During Instability in Coronary Artery Disease • FRISC II, Fragmin and Fast Revascularization During Instability in Coronary Artery Disease • GUSTO IIb, Global Use of Strategies to Open Occluded Coronary Arteries IIb • LMWH, low molecular weight heparin • MATE, Medicine Versus Angiography in Thrombolytic Exclusion trial • NQMI, non-Q-wave myocardial infarction; • NSTEMI, non-ST-segment elevation myocardial infarction • OASIS, Organisation to Assess Strategies for Ischaemic Syndromes • PRISM, Platelet Receptor Inhibition for Ischemia Syndrome Management • PRISM-PLUS, Platelet Receptor Inhibition for Ischemia Syndrome Management in Patients Limited by Unstable Signs and Symptoms • PURSUIT, Platelet IIb/IIa in Unstable Angina Receptor Suppression Using Integrilin Therapy • TACTICS, Treat Angina With Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy • TIMI, Thrombolysis in Myocardial Ischemia • VANQWISH, Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital


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