title: [Patients with non-ST-elevation acute coronary syndrome managed without coronary revascularization: an undertreated population].
abstract: Non-ST-elevation acute coronary syndromes (NSTE-ACS) represent one of the most common clinical presentations of ischemic heart disease. Patients with NSTE-ACS are a heterogeneous population, with different clinical features and prognosis. A significant proportion of this population is medically managed, without any revascularization. In the Italian EYESHOT and French FAST-MI registries, patients managed with a conservative strategy were 40% and 35%, respectively. NSTE-ACS patients not undergoing coronary revascularization are at higher risk of adverse cardiovascular events and have a worse prognosis, including short- and long-term mortality, compared with those receiving revascularization. Patients with NSTE-ACS medically managed consist of three different subgroups: those not undergoing coronary angiography, those receiving coronary angiography and without significant coronary artery disease, and those with significant coronary artery disease at angiography but not receiving revascularization. Patients presenting with NSTE-ACS for whom a conservative strategy without coronary angiography is planned should be selected very carefully and coronary angiography should not be denied because of the lack of on-site cath-lab facilities. In addition, advanced age alone, in the absence of severe comorbidities or frailty, should not be considered as a reason for denying coronary angiography and, in general, optimal treatment. Given that evidence-based data are lacking, a careful balance between benefits and risks is needed in the decision to perform or not coronary angiography and/or revascularization in patients with important comorbidities, or frailty, or advanced age. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance.NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharmacological treatment. Dual antiplatelet therapy is recommended for 12 months also in medically managed patients, after careful balance of ischemic and bleeding risk. Indeed, in this group of patients it is mandatory to optimize pharmacological treatment, including antiplatelet therapy, in order to improve clinical outcome. In NSTE-ACS not undergoing revascularization, the proportion of patients discharged with dual antiplatelet therapy should be increased in comparison to current clinical practice, and the use of ticagrelor instead of clopidogrel should be considered in selected patients.
authors.affiliation: U.O. Cardiologia, Azienda Ospedaliero-Universitaria di Parma.
authors.forename: Alberto
authors.initials: A
authors.lastname: Menozzi
authors.affiliation: Divisione di Cardiologia, Ospedale San Giovanni Evangelista, Tivoli (RM).
authors.forename: Leonardo
authors.initials: L
authors.lastname: De Luca
authors.affiliation: U.O. Cardiologia, Ospedale Ca' Foncello, Treviso.
authors.forename: Zoran
authors.initials: Z
authors.lastname: Olivari
authors.affiliation: U.O. Cardiologia, ASST Papa Giovanni XXIII, Bergamo.
authors.forename: Roberta
authors.initials: R
authors.lastname: Rossini
authors.affiliation: S.C. Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia.
authors.forename: Marco
authors.initials: M
authors.lastname: Ferlini
authors.affiliation: U.O. Cardiologia, Azienda Ospedaliero-Universitaria di Parma.
authors.forename: Daniela
authors.initials: D
authors.lastname: Lina
authors.affiliation: U.O Cardiologia, Ospedale S. Antonio Abate, Trapani.
authors.forename: Maurizio Giuseppe
authors.initials: MG
authors.lastname: Abrignani
authors.affiliation: U.O. Cardiologia, Ospedale Ferrarotto, Catania.
authors.forename: Piera
authors.initials: P
authors.lastname: Capranzano
authors.affiliation: U.O. Cardiologia, AOU Careggi, Firenze.
authors.forename: Nazario
authors.initials: N
authors.lastname: Carrabba
authors.affiliation: U.O. Cardiologia, Ospedale Morgagni-Pierantoni, Forlì.
authors.forename: Marcello
authors.initials: M
authors.lastname: Galvani
authors.affiliation: U.O. Cardiologia Interventistica, Anthea Hospital, Bari.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Marchese
authors.affiliation: U.O. Cardiologia, Ospedale S. Andrea, La Spezia.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Mazzotta
authors.affiliation: U.O. Cardiologia, Ospedale Mazzoni, Ascoli Piceno.
authors.forename: Luciano
authors.initials: L
authors.lastname: Moretti
authors.affiliation: Cardiologia Ospedaliera, Azienda Ospedaliero-Universitaria Policlinico di Bari.
authors.forename: Nicola
authors.initials: N
authors.lastname: Signore
authors.affiliation: U.O. Cardiologia 1, A.O. San Camillo-Forlanini, Roma.
authors.forename: Massimo
authors.initials: M
authors.lastname: Uguccioni
authors.affiliation: S.C. Cardiologia, Fondazione IRCCS Policlinico San Matteo, Pavia.
authors.forename: Stefano
authors.initials: S
authors.lastname: De Servi
mesh_terms: D054058:Acute Coronary Syndrome / Q000503:physiopathology / Q000628:therapy*; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D017202:Myocardial Ischemia / Q000503:physiopathology / Q000628:therapy*; D000072658:Non-ST Elevated Myocardial Infarction / Q000503:physiopathology / Q000628:therapy*; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D018570:Risk Assessment; D012307:Risk Factors
chemical_list: D010975:Platelet Aggregation Inhibitors