The management of acute coronary syndrome (ACS) has benefitted from the widespread use of evidence-based, protocol-driven management. This is particularly the case in the management of myocardial infarction (MI) with ST elevation (STEMI) where prompt recognition and reperfusion, preferably via percutaneous coronary intervention (PCI) is now a well-established standard of care. The management of ACS without ST elevation (NSTEACS) presents a greater challenge in determining optimal therapy for what is potentially a more nuanced and heterogeneous clinical situation. Uncertainty can occur in relation to risk stratification, the optimal timing and strategy for PCI and in the use of bare metal (BMS) versus drug-eluting (DES) stent.

A new study by Remkes et al1 published in Open Heart seeks to address the latter. The question is a relevant one and there have been no randomised trials of DES versus BMS looking specifically at the NSTEACS population. Despite seeming to have a milder form of acute coronary disease, with relative rather than total occlusion of a coronary artery, patients with NSTEACS have similar rates of mortality, readmission and revascularisation as patients with STEMI.2 This demonstrates that this population tends to be older, with more complex coronary disease, more coronary risk factors and greater comorbidity.

Remkes et al have provided some high-quality data …