Targeting treatment for optimal outcome

Rapid assessment of patients presenting with acute chest pain is essential, in order to distinguish between those who have a life-threatening conditio n, such as myocardial infarction or unstable angina, and the substantial pr oportion who do not have an acute coronary syndrome. It is thus of vital im portance that reliable techniques are available to facilitate rapid risk st ratification, as an aid to both clinical diagnosis and management strategy decisions. Assessments based on clinical findings, electrocardiographic mon itoring, symptom-limited exercise testing, and biochemical marker measureme nts, used either singly or in various combinations, can fulfill this role. The present paper reviews some of the recent data that demonstrate the valu e of these techniques. Very few studies allow conclusions to be drawn about optimal treatment stra tegies in relation to groups stratified according to prognostic markers, an d the question of whether intense medical treatment or early invasive inter vention is most beneficial is one that clinical trials have yet to address adequately. In the recently completed Fragmin and Fast Revascularization du ring InStability in Coronary artery disease (FRISC II) study, comparisons w ere made of clinical outcomes achieved with early invasive versus noninvasi ve (i.e., medical) management strategies, and with short-term versus prolon ged anticoagulation with dalteparin sodium (Fragmin(R)), in patients with u nstable coronary artery disease. All study participants underwent symptom-l imited exercise testing and provided blood samples for measurements of bioc hemical markers; continuous electrocardiography monitoring and echocardiogr aphy were also performed in a high proportion of patients. Data from the FR ISC II trial thus shed further light on the issue of risk stratification an d its use to determine optimal treatment strategies.