Avoidance of routine revascularization in the management of patients with non-ST-segment elevation acute coronary syndromes

A debate continues over whether a routine invasive or a conservative strategy is the best treatment approach for patients with non–ST-segment elevation acute coronary syndrome. The fundamental question underlying this debate is whether risk stratification should be an anatomy-driven or an ischemia-driven process. An early routine invasive or “drive-through” strategy, which consists of cardiac catheterization followed by percutaneous coronary intervention within 24 hours of the onset of angina, has not been shown to result in improved outcomes. In fact, investigators in the Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital (VANQWISH) trial found that aggressively treated patients had significantly worse outcomes during the first year of follow-up than did those treated with a conservative strategy. In this overview, a conservative (ischemia-guided) strategy with aggressive medical therapy is recommended for patients with non–ST-segment elevation acute coronary syndrome. This conservative treatment includes intensive antiplatelet, antithrombotic, and anti-ischemic therapy combined with careful clinical assessment and provocative testing. Patients undergo catheterization and revascularization only if spontaneous angina occurs or there is objective evidence of stress-induced myocardial ischemia. In the future, it may be revealed that only patients at high risk have real benefit from early aggressive therapy, but the same approach may result in harm to patients at low risk. Tailoring therapy to the level of risk is essential to optimizing efficacy and clinical outcomes.