Newer Antithrombotic Strategies in the Initial Management of Non–ST-Segment Elevation Acute Coronary Syndromes

Abstract

OBJECTIVE: To review the place in therapy of currently available antithrombotic agents in the non–ST-segment elevation acute coronary syndromes, that is, unstable angina and non–Q-wave myocardial infarction (MI). Recommendations are made based on currently available data. DATA SOURCE: English-language clinical studies, position statements, and review articles pertaining to the management of unstable angina and non–Q-wave MI with currently available products. STUDY SELECTION: Selection of prospective clinical studies was limited to those focusing on the management of the non–ST-segment elevation acute coronary syndromes, unstable angina, and non–Q-wave MI. DATA SYNTHESIS: It has yet to be determined which combination of agents (dalteparin, enoxaparin, lepirudin, clopidogrel, ticlopidine, abciximab, eptifibatide, tirofiban) and procedural strategies most significantly reduces mortality and serious events in these patients. The relevant pathophysiology, diagnostic criteria, and risk-stratifying procedures are reviewed in context with information from clinical studies regarding currently available agents for the management of non–ST-segment elevation acute coronary syndromes. CONCLUSIONS: A large number of new therapeutic classes and agents are available for the treatment of unstable angina and non–Q-wave MI. Although the diagnoses of unstable angina or non–Q-wave MI identify risk, treatment decisions are often based on the presence or absence of ST-segment elevations. Limited prospective evidence delineates the proper utilization of resources to best manage these patients. Efforts should be aimed at identifying particular patients who will best benefit from recently available therapies.