Abstract
BackgroundA major change has occurred in the last few years in the therapeutic approach to patients presenting with all forms of acute coronary syndromes. Whether or not these patients present initially to tertiary cardiac care centers, they are now routinely referred for early coronary angiography and increasingly undergo percutaneous revascularization. This practice is driven primarily by the angiographic image and technical feasibility. Concomitantly, there has been a decline in expectant or ischemia-guided medical management based on specific clinical presentation, response to initial treatment, and results of noninvasive stratification. This 'tertiarization' of acute coronary care has been fuelled by the increasing sophistication of the cardiac armamentarium, the peer-reviewed publication of clinical studies purporting to show the superiority of invasive cardiac interventions, and predominantly supporting (non-peer-reviewed) editorials, newsletters, and opinion pieces.DiscussionThis review presents another perspective, based on a critical reexamination of the evidence. The topics addressed are: reperfusion treatment of ST-elevation myocardial infarction; the indications for invasive intervention following thrombolysis; the role of invasive management in non-ST-elevation myocardial infarction and unstable angina; and cost-effectiveness and real world considerations. A few cases encountered in recent practice in community and tertiary hospitals are presented for illustrative purposes The numerous and far-reaching scientific, economic, and philosophical implications that are a consequence of this marked change in clinical practice as well as healthcare, decisional and conflict of interest issues are explored.SummaryThe weight of evidence does not support the contemporary unfocused broad use of invasive interventional procedures across the spectrum of acute coronary clinical presentations. Excessive and unselective recourse to these procedures has deleterious implications for the organization of cardiac health care and undesirable economic, scientific and intellectual consequences. It is suggested that there is need for a new equilibrium based on more refined clinical risk stratification in the treatment of patients who present with acute coronary syndromes.
Highlights
A major change has occurred in the last few years in the therapeutic approach to patients presenting with all forms of acute coronary syndromes
It is suggested that there is need for a new equilibrium based on more refined clinical risk stratification in the treatment of patients who present with acute coronary syndromes
Over the past few years, a major change has occurred in the approach to patients presenting with acute coronary syndromes (ACS), from predominantly expectant medical management, based on specific clinical presentation, response to initial treatment, evolution, and results of noninvasive risk stratification, towards rapid and increasingly systematic coronary angiography
Summary
Choice of initial reperfusion therapy in ST-elevation myocardial infarction (STEMI) Case 1 A 75-year-old woman presented at a regional hospital with a 2hour history of increasing chest discomfort. Inadequate myocardial perfusion despite reestablished epicardial artery flow, a phenomenon that is ischemic-time-dependent (26), in addition to a low potential for myocardial salvage after a few hours of persistent ischemia, may account for absence of consistent and marked benefit of 'rescue' angioplasty in recent studies [33,34,35] In our experience, another group frequently referred for cardiac catheterization and PCI is post-MI patients who perform a very adequate exercise test, indicative of low risk, without ischemic symptoms, but whose ECG shows ST-depression, compatible with residual myocardial ischemia. If ACS becomes a tertiary disease, will recruitment of cardiovascular specialists to secondary hospitals not risk being jeopardized? Might this development not result in suboptimal treatment of cardiovascular disease in nontertiary settings [65] ? questions about the continuity of care following the acute coronary episode have not been adequately addressed
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
