Los estudios publicados desde 1999 que compararon una estrategia invasiva moderna (con disponibilidad de stent y nuevos antitrombóticos) y conservadora (invasive selectiva) en los pacientes con síndrome coronario agudo sin elevación del ST han demostrado que la estrategia invasive disminuye, a largo plazo, la incidencia de muerte o infarto y mejora la evolución clínica en los pacientes de alto riesgo, aunque durante la hospitalización aumenta levemente las complicaciones isquémicas. El momento de realizar la coronariografía es controvertido, aunque la mayoría de las guías recomiendan que se haga en las primeras 48 h. Los pacientes que más se benefician son los que presentan cambios en el ST, elevación de troponinas o diabetes. Los de bajo riesgo con ambas estrategias tienen resultados similares. El beneficio de la estrategia invasiva se atribuye a la revascularización mecánica, pero también al uso de los nuevos antitrombóticos (clopidogrel e inhibidores de la glucoproteína IIb/IIIa). La utilización de clopidogrel está recomendada por la mayoría de las guías, aunque el momento de su aplicación es objeto de controversia y los datos más recientes indican que parece preferible la heparina no fraccionada si se planifica una estrategia invasiva. La administración precoz de inhibidores de la glucoproteína IIb /IIIa (tirofibán o eptifibatida) está indicada. En los casos en que la coronariografía se realiza tempranamente (menos de 2,5-6 h), el uso de abciximab o eptifibatida en el laboratorio de hemodinámica, una vez conocida la anatomía coronaria, parece una estrategia razonable.
Palabras clave
Síndrome coronario agudo sin elevación del ST
Angina inestable
Infarto de miocardio sin Q
Estrategia invasiva
Angioplastia
Intervencionismo coronario percutáneo
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