Risk Stratification and Therapeutic Decision Making in Acute Coronary Syndromes

Abstract

Management of acute coronary syndromes has advanced considerably during recent years, similar to the evolution in treatment of acute myocardial infarction (MI) in the 1980s. Then, fibrinolytic and aspirin therapy were shown to reduce mortality substantially.¹ Although these therapies first were applied to all patients with suspected MI,¹ those with ST-segment elevation or left bundle-branch block were shown to derive most, if not all, of the benefit.² Accelerated tissue-type plasminogen activator (tPA) then was found to be superior to streptokinase in the Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries (GUSTO-I) trial, with a relative 14% reduction in 30-day mortality.³ Mortality models suggested that tPA treatment independently predicted better outcomes, consistent across patient subgroups regardless of absolute risk.⁴ Without a heterogeneous treatment effect, the interpretation was that almost all patients with MI would benefit from tPA treatment.