Secondary prevention of acute coronary syndromes: are we disregarding the guidelines?

Heart diseases are the leading cause of death and morbidity in western countries and among them acute coronary artery diseases result to be the major contributor. During the last few decades a lot of energy has been mostly applied to the acute phase of non-ST-elevation acute coronary syndromes (ACS), where cardiac events concentrate. In fact a timely risk stratification along with an early aggressive invasive strategy and very powerful antithrombotic treatment have profoundly improved the in-hospital prognosis of such patients. Such a strong emphasis on the acute phase of ACS could have limited the interest in the equally important post-discharge therapies. However, several studies have demonstrated that different preventive treatments (aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, statins and clopidogrel) could substantially reduce the long-term mortality and morbidity of such patients. Therefore, current guidelines emphasize the role of aggressive secondary preventive treatments after ACS. However, a strong discrepancy between the indications of the guidelines and their application in the real world arises day by day. Such a discrepancy could be due to errors of omission or therapeutic paradoxes. Since patients with ACS are a subgroup of subjects where secondary preventive measures could be useful and cost-effective, cardiologists should not limit their attention to the acute phase of the disease but should eagerly concentrate their efforts on an aggressive secondary preventive treatment as well. Pursuing such a task could extend and magnify the benefits obtained with acute treatment of ACS and significantly improve the outcomes of such patients. Therefore, the role of the Scientific Societies is to improve the application of guidelines and the utilization of all evidence-based treatments even in such post-discharge phase.