Invasive approach to acute coronary syndrome without sustained ST segment elevation

In the TIMI IIIB trial (1), nearly all the patients had a coronary angiogram in the invasive arm followed by 61% PCI. In contrast, 64% of conservative patients had a coronary angiogram followed by 49% PCI. In this setting, invasive strategy did not show a clinical benefit. However, these results reflect the usual 1994 practice. Moreover, it is difficult to consider this conservative arm as truly conservative. In the VANQWISH trial (2), patients assigned to a conservative strategy had a lower cumulative rate of death and MI at follow-up. These results might be due to a very high in hospital mortality rate in the CABG patients, in the invasive arm. Furthermore, the invasive arm had a low initial revascularisation rate of only 44% without usual stents or Gp IIb/IIIa inhibitor.

In contrast, the FRISC II (3) trial showed the positive impact of an invasive strategy. Only 10% of patients in the conservative arm had a coronary angiogram as compared to 97% in the invasive one. The invasive approach was associated with a significant decrease in death and myocardial infarction during the 6 months follow-up. TACTICS TIMI 18 confirmed the positive result of FRISC II showing that the invasive strategy was superior to the medical strategy of stabilisation of patients admitted for ACS. This demonstrated the beneficial strategy of invasive treatment in association with stents and GpIIb/IIIa inhibitors.

The current question concerns the best timing between admission in unit care and the cath-lab. The VINO study (4) purposed to fulfill this lack. A very early invasive approach including PCI on the day of admission was superior to a strategy of medical stabilisation in patients with non ST segment elevation MI. Moreover, Neumann et al (5) aimed to determine whether immediate PCI was superior to delayed PCI in patients suffering from ACS. Deferral of PCI to passivate the culprit lesion was associated with a worse 30 day outcome as compared with immediate PCI.

Hence, invasive management of ACS patients is accepted as beneficial, and recent studies have demonstrated evidence for early management. Yet to date, the best pharmacological environment of PCI (i.e., aspirin, thienopyridines, low molecular weight heparin and Gp IIb/IIIa inhibitors) needs to be determined.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.