[Acute coronary syndromes without ST segment elevation]

Coronary artery disease accounts for most deaths in Western communities. Especially acute coronary syndromes--with or without ST segment elevation in the ECG--are potentially life-threatening events. The tremendous number of more than 400,000 acute coronary syndromes per year in Germany demonstrates the necessity of guidelines for diagnosis and treatment approaches. During the diagnostic process the patients' individual risk is repeatedly assessed. The ultimate treatment regimen is based on this risk stratification and includes five major therapeutic tools: anti-ischemic agents, anticoagulants, antiplatelet drugs, coronary revascularization, and long-term patient management. Several anticoagulants, which act at different levels of the coagulation cascade, have been investigated in the NSTE-ACS (non-ST elevation acute coronary syndrome). Most anticoagulants have been shown to be capable of reducing the risk of death and myocardial infarction, however, at the cost of bleeding complications. Antiplatelet agents are necessary for both, the acute event and the subsequent maintenance therapy. The recommended treatment regimen includes aspirin in combination with a thienopyridine. During the acute phase of the acute coronary syndrome, glycoprotein IIb/IIIa inhibitors have been shown to reduce cardiovascular events. Revascularization for NSTE-ACS is performed to relieve angina and ongoing myocardial ischemia, and to prevent the progression to myocardial infarction or death. The indications for myocardial revascularization and the preferred approach (percutaneous coronary intervention or coronary artery bypass grafting) depend on the extent and severity of the lesions as identified by coronary angiography, the patient's condition and comorbidity. The long-term management after an acute coronary syndrome implies lifestyle measures and drug treatment in order to control risk factors impacting on the patients' outcome.