Utilization of Early Invasive Management Strategies for High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes

Abstract

In the past decade, several advances have occurred in the management of non–ST-segment elevation acute coronary syndromes (NSTE ACS). Pharmacotherapies, such as intravenous platelet glycoprotein (Gp) IIb/IIIa inhibitors, low-molecular-weight heparin, and clopidogrel, have demonstrated incremental benefits for patients with NSTE ACS.^1-4 Complementary to advances in antithrombotic and antiplatelet therapies, catheterization-based strategies for revascularization have also improved.⁵ Randomized clinical trial data collectively support the use of an early invasive approach with prompt cardiac catheterization compared with an initial conservative approach that reserves cardiac catheterization for patients who develop recurrent ischemia despite medical therapy.^6,7 The Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)-Thrombolysis in Myocardial Infarction (TIMI)-18 trial found that catheterization within the first 48 hours after presentation was superior to an initial strategy of medical management, particularly in high-risk patients with elevated troponin levels or ST-segment depression.⁶ Similarly, The Fast Revascularization during Instability in Coronary artery disease (FRISC II) trial demonstrated a significant reduction in long-term mortality with early invasive management for NSTE ACS.⁸