Acute Coronary Syndromes. New Diagnostic Strategies and Treatment

Abstract

Within its continuing education program, Revista Espanola de Cardiologia launches a new series of Update articles. In recent years, these series have dealt with a range of topics in cardiology. Now, we believe the time has come to update our knowledge of acute coronary syndromes (ACS). Recent changes in the field have led to the publication of new guidelines on both acute ST-segment elevation myocardial infarction and non–ST-segment elevation ACS. The present Update deals with those issues that have changed most, or aroused most controversy, in ACS. In the first article, we review the epidemiological data that are currently most relevant and sketch a view of the future. In the diagnosis and prognosis of ACS, various biomarkers have been studied but none—except troponin—has been introduced into clinical practice. In another article, we will analyze the value of the different troponin biomarkers, along with their potential future applications. The invasive strategy in non–ST-segment elevation ACS will be discussed in another paper, at a time when an invasive strategy with possible drawbacks in some subgroups of patients—particularly those with lower levels of risk—is systematically used. In Spain, regional primary angioplasty programs are being implemented but run into difficulties when faced with the problems of performing reperfusion within an adequate time window. In this context, we will study how to improve these programs and the potential role of fibrinolysis as a reperfusion strategy in acute myocardial infarction. Subsequently, we will look at the clinical reality of damage from reperfusion—much in evidence in experimental models but less so in clinical scenarios—and possible means of protecting the myocardium. New antithrombotic drugs have been introduced in the treatment of ACS. These drugs are more effective, but they are also more expensive and entail a greater bleeding risk. How to use these drugs safely and their cost-efficiency will be analyzed in another article. Clinical practice guidelines generally report recommendations derived from major randomized trials. However, in the ‘‘real world’’, we treat patients who would be excluded from these trials and yet we apply guideline recommendations to them. We will devote one article to ACS treatment in these ‘‘special’’ patients represented by populations of advanced age and/or with comorbidities. There have been significant developments in imaging tests