Coronary Revascularization in Patients with Acute Coronary Syndromes

Non-Q wave myocardial infarction and unstable angina remain major causes of morbidity and mortality in patients with atherosclerotic coronary artery disease. Judicious use of cardiac catheterization and coronary revascularization may further improve the prognosis of patients with these acute coronary syndromes (ACS). Patients with ACS at high risk for further cardiac events include those patients with electrocardiographic ST-segment depression, left bundle branch block, and, to a lesser extent, T-wave inversion, and those patients with recurrent pain, cardiac enzyme elevation, or exercise-induced ischemia after hospitalization. While these patient subgroups may benefit from early cardiac catheterization and revascularization, the role of routine coronary revascularization is less well established. Whereas one study has demonstrated reduced recurrent hospitalizations in patients treated with routine invasiveive strategy, another has suggested that outcomes are not different with the two approaches. Pending the results of a third ongoing study Ñ the Thrombolysis in Myocardial Infarction (TIMI)-18 trial Ñ a judicious approach to revascularization in patients presenting with ACS is warranted.