Acute coronary syndromes: extending medical intervention for five days before proceeding to revascularization.

Intensive medical therapy before percutaneous coronary intervention appears to improve results in patients with unstable angina and non-ST-segment elevation myocardial infarction (MI). In this review of treatment strategies for patients with acute coronary syndromes, an "aggressive conservative" approach based on that used in the FRagmin and Fast Revascularisation during InStability in Coronary artery disease (FRISC II) trial is recommended. In FRISC II, an early (but not emergent) invasive therapeutic procedure undertaken within 7 days of starting open-label dalteparin lowered the risk of death and MI in moderate- and high-risk patients and resulted in better and more rapid symptom relief and fewer hospital readmissions than the noninvasive approach. The early treatment period represents a critical juncture in the spectrum of care for patients with unstable angina and affords physicians the best opportunity to educate them about the importance of risk factor modification. Informed consent is also an important issue, particularly in the event of ad hoc coronary intervention. The optimal treatment plan must include considerations of length of hospitalization, medication requirements, and the potential for symptom recurrence or need for hospital readmission. Finally, tailoring therapy for individual patients and establishing appropriate timing of procedures will help ensure the best possible outcome.