Resumen de Ischaemic heart disease: management of non-ST-elevation acute coronary syndrome
Non-ST segment elevation acute coronary syndrome (NSTE-ACS) is a clinical diagnosis based on history, electrocardiogram and serum biomarker concentration. A diagnosis of myocardial infarction requires the detection of a rise and/or fall of cardiac biomarker concentration with at least one value above the upper reference limit, and at least one feature of myocardial ischaemia such as typical symptoms or electrocardiographic abnormality. High-sensitivity assays allow earlier detection of lower concentrations of troponin but specificity has decreased and raised serum troponin is now detected in conditions other than acute coronary syndrome.
Patients with NSTE-ACS are at increased risk of adverse cardiovascular outcomes, and should be risk stratified with an established risk scoring system (e.g. GRACE) to identify those likely to benefit from evidence-based treatments. Patients with NSTE-ACS should be offered aspirin and an anticoagulant unless these are contraindicated by bleeding risk. An ADP-receptor antagonist should be offered to all patients with a predicted 6-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 invasive strategy (coronary angiography and revascularization in those with suitable coronary anatomy) improves outcome in patients at high risk and is recommended for all patients with a predicted 6-month mortality >3% and no contraindications (such as active bleeding or comorbidity). All patients with a confirmed diagnosis of NSTE-ACS should be offered high-intensity statin therapy.
