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- ACS, acute coronary syndrome
- ARTS, arterial revascularization therapies study
- AWESOME, angina with extremely serious operative mortality evaluation
- CABG, coronary artery bypass grafting
- ERACI-II, Argentine randomised study: coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease
- FRISC-II, Fragmin and fast revascularization during instability in coronary artery disease
- NSTEMI, non-ST segment elevation myocardial infarction
- OPCABG, “Off-pump” CABG
- PCI, percutaneous coronary intervention
- PRAIS-UK, prospective registry of acute ischaemic syndromes in the UK
- RAVEL, randomised comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization
- RITA-3, third randomized intervention trial of unstable angina
- SIRIUS, prospective randomised evaluation of the sirolimus-eluting stent in patients with de novo coronary artery lesions
- SoS, stent or surgery trial
- STEMI, ST segment elevation myocardial infarction
- TACTICS-TIMI 18, treat angina with Aggrastat and determine cost of therapy with an invasive or conservative strategy-thrombolysis in myocardial infarction
Recent advances in both percutaneous coronary intervention and coronary artery bypass grafting emphasise the need for new randomised trials addressing acute coronary syndromes specifically, including a high proportion of patients with truly representative disease
We are in the midst of a steady increase in the number of patients presenting to hospitals with acute coronary syndromes (ACS). This group includes patients with ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI) and unstable angina (chest pain without electrocardiographic changes or an enzyme rise). The optimal treatment of STEMI (currently thought to be primary percutaneous coronary intervention (PCI) or systemic thrombolysis) will not be discussed further here. For NSTEMI and unstable angina, the consensus of rapidly evolving guidelines is that management should be based upon a system of risk stratification, incorporating an assessment of chest pain, ECG changes and cardiac markers.1 For patients in the high risk group, recent trials show that an early invasive strategy (coronary angiography followed by revascularisation when appropriate) is superior to a conservative one, in terms of recurrent ischaemic episodes, if not lives saved.2–4 We are now left with the question of which mode of revascularisation should be selected for individual patients.
NEW PCI VERSUS NEW CABG
Conventional surgical revascularisation, as performed routinely, achieves a combined average risk of < 3% and the prospect of an excellent long term outcome.5 This operative risk may be further reduced, particularly in high risk patients, by avoiding cardiopulmonary bypass, using “off-pump” CABG (OPCABG),6,7 while total arterial revascularisation may further improve long term outcome.8 On the other hand, conventional stents have minimised the periprocedural risk of PCI to < 2%, while drug eluting stents have recently been shown to reduce restenosis rates to single figures in selected lesions.9,10
TRIAL EVIDENCE
What evidence is there to guide …
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