Prof. Antoine Lafont,
Dr. Camille Brasselet
In the setting of acute coronary syndrome (ACS) without sustained ST segment elevation, invasive management of high-risk evolutive patients (i.e., ischemic, hemodynamic, rhythmic instability) is accepted and validated. Nevertheless, there is still a debate about the management on non high risk evolutive patients, particularly regarding the delay between the onset of the symptoms and revascularisation.
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.
1- Anderson HV, Cannon CP, Stone Phet al. One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction. J Am Coll Cardiol 1995;26:1643-50 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=7594098
2- Boden WE, O'Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med 1998;338:1785-92 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9632444
3- Wallentin L, Lagerqvist B, Husted S, et al. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. FRISC II Investigators. Fast Revascularisation during Instability in Coronary artery disease. Lancet 2000;356(9223):9-16 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10892758
4- Spacek R, Widimsky P, Straka Z, et al. Value of first day angiography/angioplasty in evolving Non-ST segment elevation myocardial infarction: an open multicenter randomized trial. The VINO Study. Eur Heart J 2002;23(3):230-8 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11792138 5- Neumann FJ, Kastrati A, Pogatsa-Murray G, et al. Evaluation of prolonged antithrombotic pretreatment ("cooling-off" strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. JAMA 2003;290(12):1593-9 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14506118
Dr C. Brasselet and Dr A. Lafont, Paris, France Vice-Chairman of the ESC Working Group on Interventional Cardiology and Coronary Pathophysiology
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