What has recently changed in the management of non-ST-segment elevation acute coronary syndrome?
Sanjit S. Jolly: We have been taking patients as an invasive approach for some time and I think what has happened is our markers have become more sensitive. We initially had started off with creatine kinase MB subunit (CK-MB), then we went to troponin, now we have gone to high-sensitivity troponin, so the proportion of patients that are getting diagnosed with non-ST-segment elevation acute coronary syndrome is higher. The proportion that we diagnose as unstable angina or chest pain of other etiologies is less, so more patients are coming to the catheterization laboratory.
I think the second important thing is that we now have more potent antiplatelet therapies. For years we had used clopidogrel; we now have agents such as ticagrelor and prasugrel, which are potent P2Y12 inhibitors. They clearly reduce the risk of stent thrombosis and recurrent ischemic events in these patients, and not only that; the flip side is they also increase bleeding. For the most part we are using these agents, but we also have to revisit and evaluate the bleeding risk of individual patients and then make decisions where we are not going to use these agents.
Those are the major advances: improved diagnostic techniques and improved antiplatelet therapies.