Routine invasive versus conservative management strategies in acute coronary syndrome: time for a "hybrid" approach.

The acute coronary syndrome is most often caused by plaque rupture and can result in a variety of clinical conditions. There are two general strategies (early invasive versus conservative) currently employed in the treatment of unstable angina or non-ST elevation myocardial infarction. Pooled data from recent clinical trials have demonstrated that high-risk patients benefit from a routine or early invasive approach while certain low-risk subgroups have similar outcomes with a conservative approach. Most patients in the USA are treated aggressively given advances in technology and the relative ease of interventional therapy. The routine invasive approach, however, remains controversial and has important limitations that are not well identified in trials. Furthermore, data from trials are difficult to interpret given their relevance to contemporary practice in today's cost conscious, health care environment. The decision to pursue an invasive or conservative approach should be based upon an individual patient's risk profile, and the level of medical therapy should be based on the underlying pathophysiology. The best strategy incorporates aggressive anti-atherosclerotic therapy with early risk stratification and invasive therapy when appropriate-the so-called hybrid approach. Identifying plaque rupture helps identify patients that would benefit from potent antiplatelet, antithrombotic, and anti-inflammatory therapies, and further insight into the natural history of coronary artery disease coupled with continued advances in diagnostic and interventional approaches will hopefully help guide long-term primary and secondary management.