Early invasive and early conservative strategies — As a consequence of the uncertainties in predicting the prognosis in patients without one of the indications for immediate coronary arteriography and revascularization described below, two major strategies were adopted: conservative and early invasive. (See Indications for immediate angiographybelow) The early invasive strategy of coronary angiography followed by revascularization, if appropriate, is aimed at improving long-term prognosis. It involves prompt catheterization of all patients with UA or NSTEMI after the initiation of medical therapy, usually within 4 to 24 hours of admission. Most of the clinical trials have demonstrated a reduction in the incidence of death or nonfatal MI with an early invasive strategy, especially in high-risk patients. The American College of Cardiology Foundation/AHA UA/STEMI guidelines and their focused updates make a distinction between an early and a delayed invasive approach, with the latter being defined as diagnostic angiography after 24 hours and being acceptable in stable low to intermediate risk patients [ 3,4 ]. The conservative strategy begins with rapidly intensifying medical therapy. Patients who become asymptomatic on this regimen are given several days to cool off, during which time intravenous medications are discontinued. If the patient remains symptom-free, stress testing is performed, most often with some form of myocardial imaging (nuclear or echocardiography). Persistence of symptoms, symptom recurrence, or a positive stress test should lead to prompt cardiac catheterization.
Posted on: Mon, 03 Feb 2014 20:10:01 +0000
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