Patients with non-ST segment elevation acute coronary syndromes managed without coronary revascularization: A population needing treatment improvement Alberto Menozzi a, ⁎, Stefano De Servi b , Roberta Rossini c , Marco Ferlini d , Daniela Lina a , Maurizio Giuseppe Abrignani e , Piera Capranzano f , Nazario Carrabba g , Marcello Galvani h , Alfredo Marchese i , Gianfranco Mazzotta j , Luciano Moretti k , Nicola Signore l , Massimo Uguccioni m , Zoran Olivari n , Leonardo De Luca o a Division of Cardiology, Azienda Ospedaliero-Universitaria, Parma, Italy b Division of Cardiology, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy c Division of Cardiology, ASST Papa Giovanni XXIII, Bergamo, Italy d Division of Cardiology, Policlinico San Matteo, Pavia, Italy e Division of Cardiology, Ospedale S. Antonio Abate, Trapani, Italy f Division of Cardiology, Ospedale Ferrarotto, Catania, Italy g Division of Cardiology, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy h Division of Cardiology, Ospedale Morgagni-Pierantoni, Forlì, Italy i Interventional Cardiology Unit, Anthea Hospital, Bari, Italy j Division of Cardiology, Ospedale S. Andrea, La Spezia, Italy k Division of Cardiology, Ospedale Mazzoni, Ascoli Piceno, Italy l Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico di Bari, Italy m Division of Cardiology, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy n Division of Cardiology, Ospedale Ca’ Foncello, Treviso, Italy o Division of Cardiology, San Giovanni Evangelista Hospital, Tivoli, Rome, Italy abstract article info Article history: Received 12 February 2017 Received in revised form 7 May 2017 Accepted 16 May 2017 NSTE-ACS patients are a heterogeneous population, with different clinical features and prognosis. A large propor- tion of them is medically managed, without any revascularization. In the EYSHOT and FAST-MI registries such pa- tients were 40% and 35%, respectively. These patients are at higher risk of adverse cardiovascular events and have a worse prognosis compared with those receiving revascularization. Medically managed NSTE-ACS patients consist of different subgroups: those not undergoing coronary angiogra- phy, those without significant coronary artery disease, and those with coronary stenoses not referred to revascularization. Patients with NSTE-ACS for whom a conservative strategy without coronary angiogram is planned must be very carefully selected. In patients with comorbidities, frailty, or advanced age, a careful balance between benefits and risks is needed to choice the management strategy (perform or not coronary angiography and/or revascularization), as evidence-based medicine data are lacking in the setting of frailty and comorbidities. In this decisional process, it should be also taken into consideration the role of coronary anatomy in risk stratification and treatment guidance. NSTE-ACS patients managed without revascularization less frequently receive guideline-recommended pharma- cological treatment. Dual antiplatelet therapy (DAPT) is recommended for 12 months also in medically managed patients, after careful balancing of ischemic and bleeding risk. In these patients it is mandatory to optimize phar- macological treatment, including antiplatelet therapy, to improve outcome. In NSTE-ACS medically managed, the proportion of patients discharged with DAPT should be increased in comparison with current practice, and the use of ticagrelor in place of clopidogrel should be considered in selected patients. © 2017 Elsevier B.V. All rights reserved. Keywords: NSTE-ACS DAPT Ticagrelor Conservative management Coronary revascularization International Journal of Cardiology 245 (2017) 35–42 Abbreviations: NSTE-ACS, acute coronary syndrome/syndromes without persistent ST-segment elevation; ACS, acute coronary syndrome; PCI, percutaneous coronary intervention; CABG, coronary artery by-pass grafting; DAPT, dual antiplatelet therapy; NO, nitric oxide. ⁎ Corresponding author at: Division of Cardiology, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43125, Parma, Italy. E-mail address: almenozzi@ao.pr.it (A. Menozzi). http://dx.doi.org/10.1016/j.ijcard.2017.05.066 0167-5273/© 2017 Elsevier B.V. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard