Update on the management of acute coronary syndromes

At present there is debate as to whether an invasive or a conservative strategy should form the basis of an optimal management strategy for unstable angina/non-Q wave myocardial infarction (UA/NOMI). However, these approaches are complementary, not necessarily mutually exclusive. On the basis of current evidence, all patients should receive optimized medical therapy, with surgical interventions targeted at high-risk patients, to improve both clinical outcomes and cost effectiveness. While standard antithrombotic combinations have improved short-term outcomes, they do not fully eliminate the risk of recurrent ischemic episodes. The recent introduction of direct thrombin inhibitors, platelet fibrinogen receptor antagonists and low-molecular-weight heparins (LMWHs) has offered an opportunity to develop more aggressive antithrombotic regimens. Enoxaparin, an LMWH, has demonstrated improved efficacy compared with standard heparin in both the acute and chronic phases of UA/NQMI, without an increase in major com-plications caused by bleeding. Further studies are justified to investigate the potential of combined antithrombotic regimens containing enoxaparin as an alternative to heparin in conservative strategies and as adjuncts to interventional procedures. Recommendations for the management of UA/NOMI should be continually reviewed in response to the impact of novel treatment modalities, Copyright (C) 2000 S. Karger AG, Basel.