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Introduction
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Introduction
Cardiovascular diseases are currently the leading cause of death in
industrialized countries and are expected to become so in emerging countries
by 2020 (Murray & Lopez, 1997).
Registry data consistently show that NSTE-ACS (Non ST elevation-Acute
coronary syndrome) is more frequent than STE-ACS (ST elevation- Acute
coronary syndrome) (Yeh et al., 2010) the annual incidence is about 3 per
1000 inhabitants, but varies between countries (Fox et al., 2010).
Hospital mortality is higher in patients with STEMI (ST elevation
myocardial infarction) than among those with NSTE-ACS (7% vs. 3.5%,
respectively), but at 6 months the mortality rates are very similar in both
conditions (12% and 13% respectively) (Yeh et al., 2010).
Long-term follow-up showed that death rates were higher among patients
with NSTE-ACS than with STE-ACS, with a two-fold difference at 4 years
(Terkelsen, Lassen et al., 2005). This difference in mid- and long-term
evolution may be due to different patient profiles, since NSTE-ACS patients
tend to be older, with more co-morbidities, especially diabetes and renal
failure (Bassand, Christian, et al., 2007).
The lessons from epidemiological observations are that treatment
strategies for NSTE-ACS not only need to address the acute phase but with
the same intensity impact on longer term management.
The optimal timing of angiography and revascularization in NSTE-ACS has
been studied extensively. However patients at very high risk, i.e. those with
refractory angina, severe heart failure, life-threatening ventricular
arrhythmias, or haemodynamic instability, were generally not included in
RCTs (randomized controlled trials), in order not to withhold potentially
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Introduction
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life- saving treatment. Such patients may have evolving MI and should be
taken to an immediate (2h) invasive evaluation, regardless of ECG or
biomarker findings (Bassand, Christian, et al., 2007).
A more recent meta-analysis of eight RCTS showed a significant
reduction in death, MI, or re-hospitalization with ACS for the invasive
strategy at 1 year (O`Donghue, Boden et al., 2008).
There has been a debate about whether early angiography followed by
revascularization is associated with an early hazard
(Mehta, Cannon et al., 2005.)
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