["Cure" and "tactics" interventional strategies in unstable angina/non-Q infarction]

Early risk stratification and an invasive approach (coronary angiography and reperfusion if indicated) have recently emerged as the treatment of choice in non-ST elevation acute coronary syndromes. An aggressive pharmacologic therapy, i.e. glycoprotein IIb/IIIa antagonists, is also more effective in case of risk assessment at the time of the admission of the patient in the coronary care unit. Recent data have assessed the advantages of abciximab over tirofiban in unstable patients submitted to percutaneous coronary intervention (PCI), whereas non-anticorpal molecules (tirofiban, integrilin) are indicated for the medical treatment of high-risk patients in order to reduce myocardial necrosis during the acute phase. A good platelet inhibition with the oral tienopiridine derivative clopidogrel, resulted in a lower incidence of major cardiovascular events at follow-up both in patients treated conservatively as well as in patients submitted to PCI (CURE and PCI-CURE trials). The early risk of myocardial necrosis before coronary revascularization was also reduced by clopidogrel in patients submitted to PCI, an effect already demonstrated with tirofiban and integrilin ("small molecules like" effect). A new therapeutic scheme including, at the time of admission, oral clopidogrel for platelet inhibition, an early risk assessment and the subsequent use of abciximab in the cath lab, if indicated is proposed for the treatment of unstable angina. The advantages associated with the proposed treatment have to be validated by ad hoc studies.