Skip to main content

Advertisement

Log in

Routine Invasive Versus Conservative Management in Non-ST-elevation Acute Coronary Syndromes

  • Published:
Journal of Cardiovascular Translational Research Aims and scope Submit manuscript

Abstract

Coronary angiography as part of the management of non-ST-segment-elevation acute coronary syndrome (ACS) patients has several advantages but also carries some risks if done routinely. The advantage of a planned early invasive approach in moderate to high-risk patients appears to be clear and is recommended by guidelines. This is often not mirrored by real world practice; however, only about 50% to 70% of ACS patients do undergo a diagnostic catheterization. In addition, the optimal timing of an angiography or intervention in relation to contemporary antithrombotic regimens remains unclear. In this paper, the current evidence for routine invasive management as well as the timing of catheterization in non-ST-ACS is reviewed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. De Luca, G., van’t Hof, A. W., de Boer, M. J., et al. (2004). Time-to-treatment significantly affects the extent of ST-segment resolution and myocardial blush in patients with acute myocardial infarction treated by primary angioplasty. European Heart Journal, 25, 1009–1013.

    Article  PubMed  Google Scholar 

  2. Boden, W. E., O'Rourke, R. A., Crawford, M. H., et al. (1998). Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. The New England Journal of Medicine, 338, 1785–1792.

    Article  PubMed  CAS  Google Scholar 

  3. (1999). Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Fragmin and fast revascularisation during instability in coronary artery disease investigators. Lancet, 354, 708–715.

  4. Poole-Wilson, P. A., Pocock, S. J., Fox, K. A., et al. (2006). Interventional versus conservative treatment in acute non-ST elevation coronary syndrome: time course of patient management and disease events over 1 year in the RITA 3 trial. Heart, 92, 1473–1479.

    Article  PubMed  CAS  Google Scholar 

  5. Lagerqvist, B., Husted, S., Kontny, F., Stahle, E., Swahn, E., & Wallentin, L. (2006). 5-year outcomes in the FRISC-II randomised trial of an invasive versus a non-invasive strategy in non-ST-elevation acute coronary syndrome: a follow-up study. Lancet, 368, 998–1004.

    Article  PubMed  Google Scholar 

  6. Fox, K. A., Poole-Wilson, P., Clayton, T. C., et al. (2005). 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet, 366, 914–920.

    Article  PubMed  CAS  Google Scholar 

  7. Cannon, C. P., Weintraub, W. S., Demopoulos, L. A., et al. (2001). Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. The New England Journal of Medicine, 344, 1879.

    Article  PubMed  CAS  Google Scholar 

  8. McCullough, P. A., Gibson, C. M., Dibattiste, P. M., et al. (2004). Timing of angiography and revascularization in acute coronary syndromes: an analysis of the TACTICS-TIMI-18 trial. Journal of Interventional Cardiology, 17, 81–86.

    Article  PubMed  Google Scholar 

  9. de Winter, R. J., Windhausen, F., Cornel, J. H., et al. (2005). Early invasive versus selectively invasive management for acute coronary syndromes. The New England Journal of Medicine, 353, 1095–1104.

    Article  PubMed  Google Scholar 

  10. Damman, P., Hirsch, A., Windhausen, F., Tijssen, J. G., & de Winter, R. J. (2009). 5-year clinical outcomes in the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) trial a randomized comparison of an early invasive versus selective invasive management in patients with non-ST-elevation acute coronary syndrome. Journal of the American College of Cardiology, 55, 858–864.

    Article  Google Scholar 

  11. Bavry, A. A., Kumbhani, D. J., Rassi, A. N., Bhatt, D. L., & Askari, A. T. (2006). Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials. Journal of the American College of Cardiology, 48, 1319–1325.

    Article  PubMed  Google Scholar 

  12. Fox, K. A., Clayton, T. C., Damman, P., et al. (2010). 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. Journal of the American College of Cardiology, 55, 2435–2445.

    Article  PubMed  Google Scholar 

  13. Mehta, S. R., Cannon, C. P., Fox, K. A., et al. (2005). Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. Journal of the American Medical Association, 293, 2908–2917.

    Article  PubMed  CAS  Google Scholar 

  14. Fox, K. A., Goodman, S. G., Klein, W., Brieger, D., Steg, P. G., Dabbous, O., et al. (2002). Management of acute coronary syndromes. Variations in practice and outcome; findings from the Global Registry of Acute Coronary Events (GRACE). European Heart Journal, 23, 1177.

    Article  PubMed  CAS  Google Scholar 

  15. Fox, K. A., Steg, P. G., Eagle, K. A., et al. (2007). Decline in rates of death and heart failure in acute coronary syndromes, 1999–2006. Journal of the American Medical Association, 297, 1892–1900.

    Article  PubMed  CAS  Google Scholar 

  16. Hasdai, D., Behar, S., Wallentin, L., et al. (2002). A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). European Heart Journal, 23, 1190.

    Article  PubMed  CAS  Google Scholar 

  17. Bhatt, D. L., Roe, M. T., Peterson, E. D., et al. (2004). Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Journal of the American Medical Association, 292, 2096–2104.

    Article  PubMed  CAS  Google Scholar 

  18. Cohen, M. G., Filby, S. J., Roe, M. T., et al. (2009). The paradoxical use of cardiac catheterization in patients with non-ST-elevation acute coronary syndromes: lessons from the Can Rapid Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines (CRUSADE) Quality Improvement Initiative. American Heart Journal, 158, 263–270.

    Article  PubMed  Google Scholar 

  19. Hochman, J. S., Sleeper, L. A., Webb, J. G., et al. (1999). Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should we emergently revascularize occluded coronaries for cardiogenic shock. The New England Journal of Medicine, 341, 625–634.

    Article  PubMed  CAS  Google Scholar 

  20. Holmes, D. R., Jr., Berger, P. B., Hochman, J. S., et al. (1999). Cardiogenic shock in patients with acute ischemic syndromes with and without ST-segment elevation. Circulation, 100, 2067–2073.

    PubMed  Google Scholar 

  21. Jacobs, A. K., French, J. K., Col, J., et al. (2000). Cardiogenic shock with non-ST-segment elevation myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock? Journal of the American College of Cardiology, 36, 1091–1096.

    Article  PubMed  CAS  Google Scholar 

  22. Wright, R. S., Anderson, J. L., Adams, C. D., et al. (2011). ACCF/AHA focused update of the Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 123, 2022–2060.

    Article  PubMed  Google Scholar 

  23. Hamm, C.W., Bassand, J.P., Agewall, S., et al.(2011). ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: the Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J, in press.

  24. Bassand, J. P., Hamm, C. W., Ardissino, D., et al. (2007). Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. European Heart Journal, 28, 1598–1660.

    Article  PubMed  CAS  Google Scholar 

  25. Bertrand, M. E., Simoons, M. L., Fox, K. A., et al. (2002). Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 23, 1809.

    Article  PubMed  Google Scholar 

  26. Tricoci, P., Lokhnygina, Y., Berdan, L. G., et al. (2007). Time to coronary angiography and outcomes among patients with high-risk non ST-segment elevation acute coronary syndromes: results from the SYNERGY trial. Circulation, 116, 2669–2677.

    Article  PubMed  Google Scholar 

  27. Ryan, J. W., Peterson, E. D., Chen, A. Y., et al. (2005). Optimal timing of intervention in non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE (can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) registry. Circulation, 112, 3049–3057.

    Article  PubMed  Google Scholar 

  28. Sorajja, P., Gersh, B. J., Cox, D. A., et al. (2010). Impact of delay to angioplasty in patients with acute coronary syndromes undergoing invasive management: analysis from the ACUITY (acute catheterization and urgent intervention triage strategy) trial. Journal of the American College of Cardiology, 55, 1416–1424.

    Article  PubMed  CAS  Google Scholar 

  29. Montalescot, G., Dabbous, O. H., Lim, M. J., Flather, M. D., & Mehta, R. H. (2005). Relation of timing of cardiac catheterization to outcomes in patients with non-ST-segment elevation myocardial infarction or unstable angina pectoris enrolled in the multinational global registry of acute coronary events. The American Journal of Cardiology, 95, 1397–1403.

    Article  PubMed  Google Scholar 

  30. Swanson, N., Montalescot, G., Eagle, K. A., et al. (2009). Delay to angiography and outcomes following presentation with high-risk, non-ST-elevation acute coronary syndromes: results from the Global Registry of Acute Coronary Events. Heart, 95, 211–215.

    Article  PubMed  CAS  Google Scholar 

  31. Hirsch, A., Windhausen, F., Tijssen, J. G., et al. (2009). Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias. European Heart Journal, 30, 645–654.

    Article  PubMed  Google Scholar 

  32. Neumann, F. J., Kastrati, A., Pogatsa-Murray, G., et al. (2003). Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial. Journal of the American Medical Association, 290, 1593–1599.

    Article  PubMed  CAS  Google Scholar 

  33. Montalescot, G., Cayla, G., Collet, J. P., et al. (2009). Immediate vs. delayed intervention for acute coronary syndromes: a randomized clinical trial. Journal of the American Medical Association, 302, 947–954.

    Article  PubMed  CAS  Google Scholar 

  34. Mehta, S. R., Granger, C. B., Boden, W. E., et al. (2009). Early versus delayed invasive intervention in acute coronary syndromes. The New England Journal of Medicine, 360, 2165–2175.

    Article  PubMed  CAS  Google Scholar 

  35. van't Hof, A. W., de Vries, S. T., Dambrink, J. H., et al. (2003). A comparison of two invasive strategies in patients with non-ST elevation acute coronary syndromes: results of the early or late intervention in unstable angina (ELISA) pilot study. 2b/3a upstream therapy and acute coronary syndromes. European Heart Journal, 24, 1401–1405.

    Article  Google Scholar 

  36. Katritsis, D. G., Siontis, G. C., Kastrati, A., van’t Hof, A. W., Neumann, F. J., Siontis, K. C., et al. (2011). Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. European Heart Journal, 32, 32–40.

    Article  PubMed  Google Scholar 

  37. Chan, M. Y., Mahaffey, K. W., Sun, L. J., et al. (2008). Prevalence, predictors, and impact of conservative medical management for patients with non-ST-segment elevation acute coronary syndromes who have angiographically documented significant coronary disease. JACC. Cardiovascular Interventions, 1, 369–378.

    Article  PubMed  Google Scholar 

  38. Chan, M. Y., Sun, J. L., Newby, L. K., et al. (2009). Long-term mortality of patients undergoing cardiac catheterization for ST-elevation and non-ST-elevation myocardial infarction. Circulation, 119, 3110–3117.

    Article  PubMed  Google Scholar 

  39. Steg, P. G., Kerner, A., Van de Werf, F., et al. (2008). Impact of in-hospital revascularization on survival in patients with non-ST-elevation acute coronary syndrome and congestive heart failure. Circulation, 118, 1163–1171.

    Article  PubMed  Google Scholar 

  40. Riezebos, R. K., Ronner, E., Ter Bals, E., et al. (2009). Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes. Heart, 95, 807–812.

    Article  PubMed  CAS  Google Scholar 

  41. Wijns, W., Kolh, P., Danchin, N., et al. (2010). Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal, 31, 2501–2555.

    Article  PubMed  Google Scholar 

  42. Riezebos, R. K., Tijssen, J. G., Verheugt, F. W., & Laarman, G. J. (2011). Percutaneous coronary intervention for non ST-elevation acute coronary syndromes: which, when and how? The American Journal of Cardiology, 107, 509–515.

    Article  PubMed  Google Scholar 

  43. Bonaca, M., Scirica, B., Sabatine, M., et al. (2010). Prospective evaluation of the prognostic implications of improved assay performance with a sensitive assay for cardiac troponin I. Journal of the American College of Cardiology, 55, 2118–2124.

    Article  PubMed  CAS  Google Scholar 

  44. Corsten, M. F., Dennert, R., Jochems, S., et al. (2010). Circulating MicroRNA-208b and MicroRNA-499 reflect myocardial damage in cardiovascular disease. Circulation. Cardiovascular Genetics, 3, 499–506.

    Article  PubMed  Google Scholar 

  45. D'Alessandra, Y., Devanna, P., Limana, F., et al. (2010). Circulating microRNAs are new and sensitive biomarkers of myocardial infarction. European Heart Journal, 31, 2765–2773.

    Article  PubMed  Google Scholar 

  46. (1999). Long-term low-molecular-mass heparin in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet, 354, 701–707.

  47. Fox, K. A., Poole-Wilson, P. A., Henderson, R. A., et al. (2002). Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized intervention trial of unstable angina. Lancet, 360, 743–751.

    Article  PubMed  CAS  Google Scholar 

Download references

Acknowledgements

PS is a Clinical Investigator for the Fund for Scientific Research-Flanders.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Peter R. Sinnaeve.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sinnaeve, P.R. Routine Invasive Versus Conservative Management in Non-ST-elevation Acute Coronary Syndromes. J. of Cardiovasc. Trans. Res. 5, 22–29 (2012). https://doi.org/10.1007/s12265-011-9328-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12265-011-9328-5

Keywords

Navigation