Early Invasive Versus Conservative Management for Non-ST-Segment Elevation Acute Coronary Syndromes

There is debate about routine early invasive treatment compared with conservative treatment in non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Current guidelines recommend an early invasive approach in high-risk patients with acute coronary syndromes without ST-segment elevation. Over the past 10 years, there have been nine trials which randomized approximately 10,000 NSTE-ACS patients into an early invasive or conservative treatment strategy. In these trials, early invasive treatment was not associated with a reduction in mortality after 1 year of follow-up. However, early invasive treatment was associated with a borderline statistically significant reduction in the composite endpoint of death or nonfatal myocardial infarction compared to conservative treatment. In addition, rehospitalization and refractory angina were less frequent in the early invasive strategy groups. Although the optimal timing of angiography and subsequent revascularization, if appropriate, remains controversial, we believe that for patients with NSTE-ACS, an early invasive strategy should be strongly considered during initial hospitalization in high-risk patients and in cases of medical therapy failure to reduce angina symptoms and rehospitalization, without increased risk of death or myocardial infarction. [Tzu Chi Med J 2008;20(1):19–24]