Volume 193 - Issue 9
Acute coronary syndromes: consensus recommendations for translating knowledge into action
Author: Peter L Thompson
Med J Aust 2010; 193 (9): 550-553. || doi: 10.5694/j.1326-5377.2010.tb04047.x
Published online: 1 November 2010
Published online: 1 November 2010
In reply: Forge quotes the recommendation from the United States guidelines to consider conservative treatment after initial stabilisation of non-ST-elevation myocardial infarction.1 This may not the best option for patients in Australian regional hospital conditions. This pathway delivers less optimal outcomes1,2 and should only be considered if a seamless switch to an invasive approach can be made. The primary recommendation from the US guidelines for patients whose conditions are initially stabilised is that “an early invasive strategy . . . is indicated”.1
The benefit of an early invasive approach has been confirmed in the most recent meta-analysis comparing routine with selective invasive approaches.2 Over 5 years, the routine invasive approach achieved a relative reduction in deaths or myocardial infarctions of 19%, and an absolute reduction of 11.1% among highest-risk patients, 3.8% among intermediate-risk patients and 2% among lowest-risk patients. The results of the ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) trial3 showed no heterogeneity from the results of the other trials.
Identifying patients at risk of complications and most likely to benefit from early intervention remains an ongoing challenge. Increasing experience has confirmed the value of an elevated troponin level as a predictor of increased risk, but also the need to apply some wisdom in interpreting it, with even more challenges with high-sensitivity troponin assays becoming available.4
For patients presenting to a regional hospital with non-ST-elevation acute coronary syndromes, the available evidence favours careful risk stratification and early transfer to an invasive facility for high-risk patients.
References
- Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. Circulation 2007; 116: e148-e304. 0_CBBJJHJD
- Fox KA, Clayton TC, Damman P, et al; FIR Collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: a meta-analysis of individual patient data. J Am Coll Cardiol 2010; 55: 2435-2445. 0_CBBHDAGF
- de Winter RJ, Windhausen F, Cornel JH, et al; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353: 1095-1104. 0_CBBDHHIC
- Thygesen K, Mair J, Katus H, et al; the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J 2010; 31: 2197-2204. 0_CBBBACJH