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Introduction Literature Literature 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 -1- Introduction Literature Literature 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.) -2-