New evidence was presented this week at the American College of Cardiology Scientific Sessions in Atlanta strongly suggesting that even patients with the less severe forms of Acute Coronary Syndrome (ACS) do better with immediate invasive therapy.
Those "less severe" forms of ACS include unstable angina and Non-ST Segment Elevation Myocardial infarction (NSTEMI). All forms of ACS are usually caused by a ruptured plaque in a coronary artery. So all forms of ACS are treated as medical emergencies.
In any kind of ACS, it is important to rapidly stabilize the cardiac ischemia being produced by the plaque rupture, then to take steps to stabilize the plaque. Furthermore, in both unstable angina and NSTEMI, it is important to decide whether to schedule early cardiac catheterization (generally, with the idea of placing a stent), or to attempt to use non-invasive management.
Generally, patients with unstable angina or NSTEMI are rapidly assessed and classified as being either at "high risk" or "low risk." Those at high risk clearly do better with immediate invasive management, but whether those at low risk also do better with immediate invasive management has been unsettled.
This week, investigators from Scotland, reporting at the ACC meetings, say that a meta-analysis of several major clinical trials examining this question now show "conclusively" that all patients with unstable angina and NSTEMI - both low risk and high risk - have a significantly better long-term outcome if they are treated with immediate invasive management. Specifically, five years after treatment, those who had immediate invasive therapy had a lower risk of cardiovascular death and heart attack. The greatest benefit, however, was seen in patients classified at being at high risk.
For what it's worth, Bill Clinton received immediate invasive management when he was in the hospital with ACS last month.
