[Coronary revascularization in acute coronary syndrome: which technique? which patients? how and when?]

During the last decades, the prognosis of non-ST-elevation acute coronary syndromes has greatly improved. This improvement mainly depends on a better understanding of their pathophysiological background that allowed a remarkable evolution of their diagnostic and therapeutic management. Likewise, invasive strategies have evolved accordingly. Initially, patients with non-ST-elevation acute coronary syndromes had a very conservative approach and coronary revascularization was strongly discouraged during the acute phase. Afterward, as pharmacological therapies and revascularization techniques improved, interventional strategies gradually switched to a careful "delayed invasive approach". Recently, several studies, taking full advantage from the most effective treatments, have demonstrated that an early aggressive strategy (coronary revascularization within 48 hours of symptom onset) could reduce the incidence of cardiac events in patients with non-ST-elevation acute coronary syndromes at medium-to-high risk. These findings made this "early aggressive" strategy very attractive. However, in the real world such a strategy is rarely an option due to several logistical constraints and very often the selection of the therapeutic strategy depends more on resource availability than on patients' risk profile. Therefore, Italian cardiologists should pursue integrated healthcare models in order to overcome such limitations. They should develop critical pathways able to target adequately the patient risk and improve interventional networks where even subjects admitted to peripheral hospitals could benefit from a timely revascularization procedure according to their risk profile. This could reduce treatment disparities and could counteract the vicious circle that tends to privilege interventions in low-risk subjects instead of high-risk patients, like the elderly, women or diabetics.