[Which patients with acute coronary syndrome without ST segment elevation should be handled invasively/interventionally when?]. / Welche Patienten mit akutem Koronarsyndrom ohne ST-Hebung sollen wann invasiv/interventionell behandelt werden?

Until recently the therapeutic approach in patients with acute coronary syndrome without ST-segment elevation focused on medical stabilization. Usually cardiac catheterization and revascularisation were performed later only if the stabilized patient had provoked ischemia. Since angioplasty became safer with the introduction of coronary stents, and since new potent antithrombotic agents (i.e. tienopyridines or glycoprotein-receptorIIb/IIIa-antagonists) have been developed, early angioplasty has become much more effective. Moreover major progress has been made in risk-stratification, which allow an individual therapeutic strategy for each patient according to his risk-status. We discuss the most important randomised clinical trials comparing a conservative versus an invasive strategy and introduce a new algorithm for risk-stratification und therapy in acute coronary syndromes without ST-elevation.

[Case of the month. Problems in diagnosis of acute coronary syndrome]. / Fall des Monats. Probleme in der Diagnostik des akuten Koronarsyndroms.

Three cases of patients with suspected acute coronary syndrome are presented. The importance of the clinical evaluation is stressed in relation to ECG changes and determinations of new necrosis markers.

[Cardiogenic shock]. / Der kardiogene Schock.

Cardiogenic shock (CS), defined as forward failure combined with systolic blood pressure < 90 mm Hg and reduced organ perfusion despite adequate volume loading, still has a grim prognosis with mortality rates of 80-100% if the causes are left untreated. The most frequent conditions underlying CS are acute myocardial infarction, acute and severe aortic or mitral incompetence, rapidly progressive dilatative cardiomyopathy and hypertrophic obstructive cardiomyopathy. Whereas correct conservative management by drugs and pacing may be life saving in the latter, the other conditions require early invasive management. Indications for cardiac surgery and circulatory assistance are given for mechanical complications leading to CS. In CS complicating myocardial infarction, comprehensive management with early invasive revascularization and intraaortic balloon pumping may result in improved survival compared with the disappointing outcome of medical treatment, including fibrinolysis. This strategy can be offered to the majority of infarct patients in CS, who are primarily admitted to hospitals not equipped for interventional cardiology or cardiac surgery. Between-hospital transfer of these patients for PTCA (or surgery) and advanced intensive care has been shown to be feasible and safe.