The Interventional Approach to the Acute
Coronary Syndromes
February 2002
In this month's issue of the Journal of Invasive Cardiology, a new section dedicated to the invasive and interventional management of acute coronary syndromes (ACS) is being launched. This is an exciting opportunity for our community to share the latest observations in pathogenesis, treatment strategies and leading edge pharmacologic adjuncts useful in the therapy of patients with acute chest pain.
It is a dream role for me to serve as Section Editor because of my dual interests in interventional cardiology and management of acute ischemia. My goal is to develop a different kind of educational forum that provides a unique perspective, including both review articles by experts and original articles by innovators. Of special interest are articles which emphasize ideas and observations that challenge the mainstream and ask questions with less of a traditional slant than cardiology journals with a broader audience. As interventionists, we tend to think about the patient with an acute coronary syndrome differently than the CCU specialist and non-invasive generalist, and this section will reflect that approach.
The evolution of the interventional approach to acute chest pain syndromes over the past 20 years is a fascinating story that parallels the changes in cardiology itself. Despite a strong bias against angioplasty and a clear preference for a medical approach in the 1980s by the non-cath lab-based cardiology leadership, study after study demonstrated that intervention was the better route.
In retrospect, it is amazing that these studies were carried out successfully because they required larger patient numbers enrolled at more centers by highly trained specialists than any previous undertakings. That those initial studies were so suggestive of the potential of intervention in ACS is further evidence of the good skills and good sense of the physicians who participated in them.
As the techniques and equipment used in percutaneous revascularization improved, so did the outcomes, until the conservative voices eventually gave way. We still debate which patients should go to the cath lab — but now 70–90% undergo angiography before hospital discharge, not the other way around. This advance is easy to overlook because it happened over a relatively brief period of time, preceded by many pioneers who recognized the promise and were courageous enough to speak out against the established thought of the time.
The first in this series is a paper from the group at the Rush Heart Institute which evaluates the angiographic appearance of culprit stenosis in vein grafts compared to native coronary vessels. This observational study highlights the often overlooked fact that the pathogenesis of ACS is different in vein grafts than native coronaries. This simple observation has important management and therapeutic implications.
In the future months, we intend to take a fresh look at the entire field of acute coronary syndromes. For example, there will be core curriculum articles reviewing the biologic nature of the atherosclerotic plaque and culprit stenoses, an article reviewing the existent risk stratification schemes, and a paper on contemporary use of anti-platelet agents. The authors of all accepted papers are outstanding clinical investigators who have made critical observations in the field. I hope the readership of the Journal will enjoy reading and discussing these articles and conclude that they address the main issues and controversies, as well as the opportunities, that now comprise this area of interest.
