Acute coronary syndromes: introducing new therapies into established guidelines.
Quantitative (or semiquantitative) risk stratification is becoming a more accurate and feasible way to define both overall risk and likelihood of benefit from more potent and invasive therapies. LMWH appears to be at least as good, and likely modestly better than, unfractionated heparin, and when used for patients undergoing revascularization, it should be continued until revascularization. GP IIb/IIIa inhibitors are highly effective for coronary intervention, as well as for "up-front" use in high-risk ACS patients in an environment in which intervention is commonly used. In spite of the new guidelines, a clear delineation to the practitioner of which treatments are proven effective, in which patients, and in what combinations, remains challenging. Best estimates are that only 50% to 75% of ideal patients are currently receiving proven therapies. Better methods are needed to fully integrate proven effective treatments into practice.
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