Unstable angina - Acute coronary syndrome without ST-segment elevations. Antithrombotic treatment

Results of recent trials of antithrombotic therapy and appearance of ESC an d ACC/AHA guidelines on the treatment of non-ST-elevation acute coronary sy ndromes (ACS) present a significant challenge to russian cardiologists. Eco nomic situation and some characteristics of patient care (e.g. low rate of invasive procedures) precludes mechanistic application of achievements of W estern cardiology. Nevertheless attitude to low molecular heparins and mode rn antiplatelet drugs should be formulated. Correct dosing of unfractionate d heparin is theoretically possible and can lead to improved efficacy but i s completely unrealistic in every day practice in Russia. So introduction o f low molecular weight heparins (LMWH) can solve the problem of proper and wide spread use of antithrombins in this country. As rates of invasive proc edures performed in patients with ACS are low it is difficult to extrapolat e to Russia data obtained in studies where large proportion of end points ( myocardial infarctions, bleedings) were associated with invasive interventi ons. Therefore data on equality of low molecular and unfractionated heparin s are more important than slight advantages of enoxaparin observed in ESSEN CE and TIMI-11B. So there is no real ground for preference of one LMWH over another in this country. Before any evidence based data are obtained rathe r expensive thienopyridins are very rarely indicated in patients with ACS. It should be taken into consideration that loading doses can substantially accelerate onset of action of these agents. High efficacy of GP IIb/IIIa an tagonists has been unequivocally proven only for their use in conjunction w ith percutaneous coronary interventions. Failure of abciximab in GUSTO IV A CS has given our health administrators a chance to postpone search of a way to overcome a cost barrier for dissemination of this potentially life-savi ng drug group somewhat beyond narrow circle of elite medicine. Another chal lenge is the necessity to introduce in every day practice standardized and relatively inexpensive methods of measurement of cardiac troponins. The lat ter have become a sine qua non of modern management of ACS because of inval uable meaning for risk stratification and determination of aggressiveness o f therapy and thus improvement of cost-efficacy of treatment.