Ischaemic heart disease: management of non-ST-elevation acute coronary syndrome

Patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) are at increased risk of adverse cardiovascular outcomes, particularly within the first few days of presentation. All patients should be risk stratified with an established risk scoring system (e.g. GRACE) to identify those who will benefit from evidence-based treatments. Patients with a confirmed diagnosis of NSTE-ACS should be considered for anti-ischaemic and anti-platelet therapy, anticoagulation, and invasive investigation and revascularization. All patients should be offered aspirin and an anticoagulant unless contra-indicated by bleeding risk. Fondaparinux (a synthetic pentasaccharide anticoagulant) reduces the risk of bleeding and is associated with long-term mortality benefit when compared with enoxaparin, and should be used routinely unless coronary angiography is planned within 24 h. An ADP-receptor antagonist (e.g. clopidogrel) should be offered to all patients with a predicted six-month mortality >1.5%. Glycoprotein IIb/IIIa receptor inhibitors reduce the risk of ischaemic events but increase the risk of bleeding and clinical judgement remains important in determining when these agents should be used. A routine early invasive strategy (coronary angiography and revascularization in those with suitable coronary anatomy) improves outcome in patients at high risk, and should be offered to all patients with a predicted six-month mortality >3% and no contraindications (such as active bleeding or comorbidity).