[Acute coronary syndromes without ST-segment elevation. From randomized clinical trials, to consensus guidelines, to clinical practice in Italy: need to close the circle].
Recent therapeutic advances in the treatment of acute ischemic heart disease have been proven by randomized clinical trials and approved by formal practice guidelines. This rigorous approach has led to a sizable reduction in mortality and morbidity across the spectrum of acute coronary syndromes (ACS). However, contemporary registries of non-ST-elevation ACS set up by the cardiological community in Italy, as well as in the rest of Europe and in America, have shown only limited compliance to the general indication of treating high-risk patients by an early invasive approach protected by the use of glycoprotein IIb/IIIa receptor blockers. This partial failure in the process of improving patient care may be attributed to several reasons, including the suspect that practice guidelines may be biased by conflict of interest, concern about the applicability of the results of clinical trials to the real world, unrealistic expectations about treatment effects and, finally, logistic and economic obstacles including the availability of cath-labs and the high cost of platelet receptor blockers. Although the practice guidelines may provide a cultural support for translating the results of clinical research into patient care, and national and local cardiological associations can help in increasing awareness of the real benefits of an early aggressive approach in high-risk patients, the health care managers should remove bureaucratic obstacles and reallocate resources from treatments of unproven benefit to those that have been clearly shown to reduce mortality and the risk of reinfarction in ACS patients.
Savonitto
Stefano
S
I Divisione di Cardiologia, Dipartimento Cardio-Toraco-Vascolare A. De Gasperis, Ospedale Niguarda Ca' Granda, Milano. stefano.savonitto@fastwebnet.it
Klugmann
Silvio
S
D000208:Acute Disease; D006328:Cardiac Catheterization; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003131:Combined Modality Therapy; D003327:Coronary Disease / Q000188:drug therapy / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy*; D019317:Evidence-Based Medicine; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D007558:Italy / Q000453:epidemiology; D009204:Myocardial Revascularization; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D012042:Registries; D040242:Risk Reduction Behavior
D002317:Cardiovascular Agents; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex