New aspects in the treatment of acute coronary syndromes without ST-elevation: ICTUS and ISAR-COOL in perspective

For treatment of patients with high-risk acute coronary syndromes, current guidelines recommend early coronary angiography and coronary revascularization, when feasible, irrespective of the primary success of medical treatment. Moreover, the results of a randomized trial (ISAR-COOL) suggested performing revascularization as early as possible. The concept of systematic coronary angiography and revascularization in high-risk acute coronary syndromes has been challenged recently by another randomized study (ICTUS) demonstrating an excess of myocardial infarction during 1-year follow-up with a routine-invasive strategy when compared with a selectively invasive strategy. This review intends to put the new trial results in perspective with evidence from previous studies.