Optimal treatment of patients with acute coronary syndromes and non–ST-elevation myocardial infarction, ,

Non–ST-elevation myocardial infarction is usually indistinguishable from unstable angina at the initial presentation. The diagnosis is made subsequently when cardiac enzymes are found to be elevated either at admission or within 18 hours. Our understanding of the pathophysiology of acute coronary syndromes has advanced dramatically, and coupled with this understanding has been the introduction of new antiplatelet and antithrombotic treatments. The best way to integrate these treatments into percutaneous revascularization procedures has not yet been defined. In general, patients with non–ST-elevation myocardial infarction should be treated in the same way as those with unstable angina. Patients should be risk profiled at admission and subsequently according to clinical features, electrocardiographic findings, results of laboratory tests including measurement of troponins, and response to therapy. They should also be monitored carefully for signs of ischemia. Patients at low risk with a normal electrocardiogram and normal troponin T or I levels should be assessed for early discharge and outpatient assessment with exercise or pharmacological testing for inducible ischemia. Patients at intermediate risk should be treated with aspirin, unfractionated or low-molecular-weight heparin and, if unfractionated heparin is chosen, an adjunctive IIb/IIIa receptor antagonist. Patients at high risk should be treated with the same therapies and considered for expeditious angiography and revascularization as appropriate. A long-term secondary prevention strategy should be implemented. (Am Heart J 1999;138:S105-S114.)