The Management of Non-ST Segment Elevation Acute Coronary Syndromes. The Acceptance of Diversity Could Be Crucial

Abstract

Current classification of acute coronary syndromes (ACS) enables us to distinguish between 2 groups of patients clearly defined in terms of approaches to therapy: patients with ST segment elevation ACS are reperfused as early as possible and patients with non-ST segment elevation ACS (NSTE ACS) receive antithrombotic and antiischemic therapy. However, coronary heart disease is really a “continuum” from stable angina to Q wave acute myocardial infarction (AMI), passing thru unstable angina and non-Q wave AMI, which are 2 components of NSTE ACS. The fundamental physiologic reality of NSTE ACS is the rupture of plaque and formation of non-occlusive thrombus. Additional pathophysiologic factors can condition symptoms. Inflammation, vasoconstriction of epicardial artery(ies) or small vessel, the degree of baseline coronary stenosis and myocardial oxygen consumption are known to contribute to clinical condition 1 to a greater or lesser extent. In fact, Braunwald classifies 9 groups based on clinical presentation (secondary, primary or post-infarction) and severity (recent onset or progressive; rest with episodes in the last 48 hours or not) that could be further subdivided according to electrocardiogram (ECG) readings and troponin levels. 2 Patients with NSTE ACS are characterized by a wide variety of clinical conditions and multiple pat