Do interventions provide additional benefit to drug treatment of acute coronary syndromes? A call for a reserved, watchful approach

Introduction: Balloon angioplasty has revolutionized clinical cardiology since its first use in coronary patients by Andreas Grünzig in 1977.1 Initially limited to single, concentric, and proximal lesions, its clinical applicability rapidly expanded to more complex stenoses and total occlusions. With equipment improvement and growing investigator experience, even the most vulnerable lesions found in patients with unstable angina or acute myocardial infarction, were soon recognized as potential targets for percutaneous interventions.2-6 The overwhelming and unquestioned success of coronary angioplasty is most prominently demonstrated by the estimated more than 1,000,000 procedures that will be performed worldwide during 1999. There is little doubt that, in patients with severe coronary lesions and exercise-induced angina, coronary angioplasty with minimal invasiveness can widen the vessel lumen and initiate coronary remodeling. This will lead, in many cases, to a durable relief from angina symptoms, as reviewed elsewhere.7 However, though vigorously advocated by interventional cardiologists, the benefit of percutaneous revascularization procedures in patients with acute coronary syndromes is less clear. This is even reflected in the AHCPR Clinical Practice Guidelines,8 in which both conservative medical management and early invasive therapies are regarded as suitable alternatives in most patients. This chapter will address the question of whether and when coronary angioplasty will add to the benefits of conservative drug treatment