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

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.

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.

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.