[Aggressive diagnostic and therapeutic approach for acute coronary syndrome]

The purpose of this article is to propose an "aggressive strategy" in the treatment of patients with acute coronary syndrome (ACS), especially unstable angina. The indication and timing of emergent coronary angiography in patients with ACS remains to be validated. The results of TIMI III B trial, a randomized, controlled trial about this issue, show that an early invasive strategy reduced the average length of initial hospitalization and the incidence of rehospitalization within 6 weeks. However, the same kind of clinical trial named VANQWISH reported that no benefit was obtained from such an aggressive strategy. It is of paramount importance to note that these 2 studies were performed in the era of plain old balloon angioplasty. Now we can use many kinds of coronary stent which impart both excellent radial strength and flexibility. Recent studies have demonstrated that culprit lesions of ACS can be treated at the same success rate as those of stable effort angina. In our hospital, use of coronary stents in patients with ACS dramatically reduced the recurrence of ACS and the incidence of angiographic restenosis with the same initial procedure success rate. Since the mid-nineties, the radial artery has been used as a vascular access site of coronary intervention. The major advantage of this technique is lesser access site-related complications and increased patient comfort, which reduced hospital stay and cost. Recently it was demonstrated that ad-hoc transradial intervention can be applied in patients with unstable angina or even those with acute myocardial infarction by trained angioplasters. Thus, we would like to conclude that the best strategy in the management of ACS is to perform emergent coronary angiography from the radial artery as soon as possible after admission, and to do ad-hoc intervention using coronary stents suitable for the lesion anatomy.