In reply: Forge quotes the recommendation from the United States guidelines to consider conservative treatment after initial stabilisation of non-ST-elevation myocardial infarction.1 This may not the best option for patients in Australian regional hospital conditions. This pathway delivers less optimal outcomes1,2 and should only be considered if a seamless switch to an invasive approach can be made. The primary recommendation from the US guidelines for patients whose conditions are initially stabilised is that “an early invasive strategy . . . is indicated”.1
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- 1 Western Australia Heart Research Institute, Sir Charles Gairdner Hospital, Perth, WA.
- 2 Coronary Care Manual, second edition, Elsevier, Sydney, NSW.
- 1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. Circulation 2007; 116: e148-e304.
- 2. Fox KA, Clayton TC, Damman P, et al; FIR Collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: a meta-analysis of individual patient data. J Am Coll Cardiol 2010; 55: 2435-2445.
- 3. de Winter RJ, Windhausen F, Cornel JH, et al; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators. Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005; 353: 1095-1104.
- 4. Thygesen K, Mair J, Katus H, et al; the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Recommendations for the use of cardiac troponin measurement in acute cardiac care. Eur Heart J 2010; 31: 2197-2204.