HOME SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES CARDIOSOURCE SEARCH HELP FEEDBACK		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boden, W. E. Search for Related Content PubMed Articles by Boden, W. E.

"Routine invasive" versus "selective invasive" approaches to non–ST-segment elevation acute coronary syndromes management in the post-stent/platelet inhibition era

William E. Boden, MD, FACC^*,*,1

^* Division of Cardiology and the Henry Low Heart Center at Hartford Hospital, Hartford, Connecticut, USA
Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA

Manuscript received May 31, 2002; accepted December 11, 2002.

^* Reprint requests and correspondence: William E. Boden, Hartford Hospital, 80 Seymour St., Jefferson Building 722, Hartford, Connecticut 06102, USA.
wboden{at}harthosp.org

Is a "routine invasive" or "selective invasive" strategy the best approach for patients with non–ST-segment elevation acute coronary syndrome (ACS)? A "selective invasive" strategy incorporates ischemia-guided use of aggressive medical therapy followed by angiography and revascularization for angina or stress-induced myocardial ischemia. The "routine invasive" strategy (cardiac catheterization followed by percutaneous coronary intervention within 24 to 48 h of symptom-onset) is frequently employed, but no randomized, controlled trials have demonstrated improved clinical outcomes. Recently, the second Fragmin and fast Revascularization during InStability in Coronary artery disease (FRISC-II) and the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction (TACTICS TIMI-18) trials found significant reductions in death, recurrent myocardial infarction, or hospitalization for biomarker-positive ACS. Also, the third Randomized Intervention Trial of unstable Angina (RITA-3) recently reported a halving of refractory angina and reduction in the use of antianginal medication with early intervention. Early trials failed to demonstrate the superiority of the "routine invasive" approach, presumably because of fewer revascularizations, unavailability of stents, and more recent use of glycoprotein IIb/IIIa inhibitors and low-molecular-weight heparins. The FRISC-II, TACTICS TIMI-18, and RITA-3 studies indicate that higher-risk patients benefit from early revascularization, but that aggressive antiplatelet, antithrombin, and anti-ischemic therapy are also important. While all three trials support an "early invasive" approach in intermediate- and high-risk patients, other trials support a more "conservative" approach in those without electrocardiographic changes or enzyme elevations. Optimal management should incorporate both strategies.

Abbreviations and Acronyms   ACS = acute coronary syndrome(s)   CABG = coronary artery bypass graft   CK-MB = creatine kinase-myocardial band   GP = glycoprotein   LMWH = low-molecular-weight heparin   NSTEMI = non–ST-segment elevation myocardial infarction   PCI = percutaneous coronary intervention   RR = risk ratio   UA = unstable angina   UFH = unfractionated heparin

This article has been cited by other articles:

				R. J. de Winter, F. Windhausen, J. H. Cornel, P. H.J.M. Dunselman, C. L. Janus, P. E.F. Bendermacher, H. R. Michels, G. T. Sanders, J. G.P. Tijssen, F. W.A. Verheugt, et al. Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes N. Engl. J. Med., September 15, 2005; 353(11): 1095 - 1104. [Abstract] [Full Text] [PDF]

				Authors/Task Force Members, S. Silber, P. Albertsson, F. F. Aviles, P. G. Camici, A. Colombo, C. Hamm, E. Jorgensen, J. Marco, J.-E. Nordrehaug, et al. Guidelines for Percutaneous Coronary Interventions: The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology Eur. Heart J., April 2, 2005; 26(8): 804 - 847. [Full Text] [PDF]

				R. A. Elkoustaf and W. E. Boden Is there a gender paradox in the early invasive strategy for non ST-segment elevation acute coronary syndromes? Eur. Heart J., September 2, 2004; 25(18): 1559 - 1561. [Full Text] [PDF]