Revascularization of patients with unstable coronary artery disease: the case for early intervention

In unstable angina, there are data to suggest a substantial risk of recurrent ischemia, infarction, and death when early angiography and/or revascularization have been deferred. Conversely, it has been suggested that early angiography and revascularization are more dangerous than deferred procedures. Critical review of the literature, however, suggests that there is no specific risk inherent in early intervention, but rather that patients who cannot wait are at higher risk anyway. The most valuable data on the comparison of an "early invasive" and a "conservative" strategy in unstable angina come from the Thrombolysis in Myocardial Ischemia (TIMI) IIIB study. The results show no major difference in outcome between groups (despite a high intervention rate in the conservative group), but a shorter hospital stay, lower drug use, and fewer rehospitalizations in the group treated according to the early invasive strategy. These results have been interpreted as favoring early intervention, due to the potential for a shorter hospital stay (a major determinant of cost in many countries) because of the possibility of achieving complete diagnosis and treatment within several days of admission, with good results. In addition, since the inception of the TIMI IIIB study, there have been major improvements in the field of angioplasty, such as the increased use of stents and the availability of safe and effective glycoprotein (GP) IIb-IIIa inhibitors. Thus, the pathophysiology, the excellent results of early intervention, and the recent improvements in angioplasty and its medical and pharmacologic environment, provide a strong rationale for early intervention.