“Ischemia-guided” versus “early invasive” strategies in the management of acute coronary syndrome/non–ST-segment elevation myocardial infarction: The interventionalist’s perspective

Conventional therapy for non–ST-segment elevation acute coronary syndrome (ACS) has traditionally employed an “ischemia-guided” strategy. In this approach, diagnostic cardiac catheterization and revascularization are only used in patients with objective evidence of myocardial ischemia as identified by recurrent symptoms or provocative stress testing. More recent studies, however, have demonstrated improved clinical outcomes with the use of an “early invasive” approach, employing routine coronary angiography early in the patient’s hospital course, followed by percutaneous intervention or bypass surgery where appropriate. Improved clinical outcomes associated with an “early invasive” strategy may have evolved as a consequence of recent advances in both adjunctive pharmacotherapy and revascularization technique. In particular, use of glycoprotein IIb/IIIa inhibitors and/or low-molecular-weight heparin before catheterization have been shown to reduce clinical events in patients with ACS, and may reduce the risk of an invasive approach by plaque passivation before interventional therapy. Perhaps more importantly, the combined use of glycoprotein IIb/IIIa inhibitors and intracoronary stenting may reduce the potential early hazard of an invasive approach by specifically decreasing the incidence of death and nonfatal myocardial infarction associated with percutaneous intervention. In spite of the benefits of this synergistic combination of pharmacology and mechanical revascularization, risk stratification remains important in identifying high-risk individuals most likely to benefit from an “early invasive” approach. In addition, angiography with possible percutaneous coronary intervention of “culprit” lesions should always be used in combination with aggressive medical therapy to treat the widespread coronary atherosclerosis commonly seen in patients with ACS.