Management of non ST-segment elevation acute coronary syndromes—continuing the search for the bad guys

See doi:10.1016/S1095-668X(02)00525-0for the article to which this editorial refers. Patients with non ST-segment elevation (STE) acute coronary syndromes (ACS) are subject to a significant risk of adverse cardiac events. The recognition that up to 50% of these patients will experience recurrent ischaemia and 10% will die or reinfarct within 30 days despite optimum medical management has prompted investigation into better pharmacological therapy and the role of invasive procedures.1–3 However, the timing of intervention is controversial and two different protocols, an ‘early invasive strategy’ and an ‘early conservative strategy’, have been assessed. The first randomized trials either failed to show an advantage with early intervention (TIMI IIIB)3 or suggested that this approach could potentially be harmful (VANQWISH) compared to an early conservative strategy.4 In the OASIS registry, a large multicentre prospective observational study of an unselected population with non-STE ACS, admission to centres with cardiac catheterization theatres increased the likelihood of revascularization when compared to admission to centres without such facilities.2 However, there was no significant difference in cardiac outcomes at follow-up. Although these studies would argue against a systematic early invasive strategy, the findings have to be interpreted with caution. The high crossover rate to invasive therapy in TIMI IIIB and VANQWISH is an important confounding factor which reduces the statistical power. Although a greater contrast in revascularization rates was achieved in the OASIS registry, the findings are limited by the non-randomized protocol. More fundamentally, since the publication of these early trials significant advances in adjunctive pharmacological therapy with the advent of glycoprotein IIb/IIIa receptor blockers and clopidogrel, as well as surgical and percutaneous techniques with the development of stents and arterial conduits, have improved outcomes following revascularization. These limitations were addressed in FRISC II, where contrasting revascularization rates of 78 and 43% at 1 …