Acute coronary syndromes, role of angioplasty in the stent-era

Pharmacological treatment frequently stabilizes symptoms of patients with a cute myocardial ischemia. However, significant quiescent residual stenosis normally persists and leads to rethrombosis. Since rethrombosis produces re ischemia and has a deleterious impact on initial and long-term prognosis in these patients, definitive normalisation of local flow assured through dea ctivation treatments and complete passivation of quiescent residual stenosi s in an inert plaque should be a main priority in modern treatment of acute coronary ischemia. Considering the negative influence of significant stenosis on rethrombosis, and that the normalization has a clear antithrombotic effect of flow, rout ine elimination of residual stenosis by means of angioplasty should prevent rethrombosis and its side effects. Nevertheless, according to trials carri ed out previous to the most relevant progresses in the field of interventio nal cardiology, the advantage of this strategy over the conservative treatm ent has not been clearly demonstrated. Coronary stenting produces a real normalisation of now and lumen which prev ents local thrombosis. In concordance with these facts, recent evidence ind icates a substancial clinical benefit of stenting in very thrombogenic acut e settings, such as primary angioplasty or refractory acute coronary angina . Presumably, routine stenting also benefits initial and long-term prognosis of other subsets of unstable patients, especially those with thrombolysed m yocardial infarction and stabilized patients with acute ischemia without ST -segment elevation. To demonstrate this new trials are needed to compare th e efficacy of conservative and interventional approaches that incorporate t he advances of each strategys. Until new data are available on these studie s, the treatment of acute coronary ischemia should be tailored to each pati ent and no out-dated recommendation should be given or accepted.