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 condition, such as myocardial infarction or unstable angina, and the substantial proportion who do not have an acute coronary syndrome. It is thus of vital importance that reliable techniques are available to facilitate rapid risk stratification, as an aid to both clinical diagnosis and management strategy decisions. Assessments based on clinical findings, electrocardiographic monitoring, symptom-limited exercise testing, and biochemical marker measurements, used either singly or in various combinations, can fulfill this role. The present paper reviews some of the recent data that demonstrate the value of these techniques. Very few studies allow conclusions to be drawn about optimal treatment strategies in relation to groups stratified according to prognostic markers, and the question of whether intense medical treatment or early invasive intervention is most beneficial is one that clinical trials have yet to address adequately. In the recently completed Fragmin and Fast Revascularization during InStability in Coronary artery disease (FRISC II) study, comparisons were made of clinical outcomes achieved with early invasive versus noninvasive (i.e., medical) management strategies, and with short-term versus prolonged anticoagulation with dalteparin sodium (Fragmin), in patients with unstable coronary artery disease. All study participants underwent symptom-limited exercise testing and provided blood sample for measurements of biochemical markers; continuous electrocardiography monitoring and echocardiography were also performed in a high proportion of patients. Data from the FRISC II trial thus shed further light on the issue of risk stratification and its use to determine optimal treatment strategies.