Current Device Strategies in the Management of Acute Coronary Syndromes

Abstract

Early head-to-head trials suggested no advantage of an early invasive approach to an early conservative approach in patients with acute coronary syndromes (ACS) (1–3). In part, the limitations to conventional percutaneous transluminal coronary intervention (PTCA) were due to dissection and attendant abrupt vessel closure, as well as frequent adverse clinical events: 5% incidence of myocardial infarction (MI), 2–3% risk of emergent coronary artery bypass graft (CABG) surgery, and 30–50% rate of late restenosis. Since these early trials, significant advances have been made in the understanding of the underlying pathologic processes that have historically limited PTCA. For example, a great deal of attention has focused on the development of new device strategies that diminish the degree of endothelial trauma and arterial wall inflammation. Major advances in adjuvant medications, including the judicious use of potent antiplatelet (thienopyridines and glycoprotein [Gp] IIb/IIIa antagonists) agents have dramatically decreased the rates of both early and late complications. Technological advances include stents (medicating and coated), directional coronary atherectomy, rotational atherectomy, laser atherectomy, cutting balloons, brachytherapy, and intravascular ultrasound. Together, the advances in medications and technology have greatly improved outcomes and have lead to the re-examination of the conclusion that medical therapy is preferred (4). The dramatic increase in available techniques has driven interventional cardiologists to take a lesion-specific approach to therapy, and in this context, the term percutaneous coronary intervention (PCI) has been adopted to reflect conventional PTCA and its alternatives. This chapter will summarize: (i) current techniques employed in PCI; (ii) coronary stents, including the techniques to treat in-stent restenosis; (iii) new pharmacologic approaches to ACS; and (iv) future directions in device strategies for the management of ACS.