The management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: early invasive strategy for all?

It is unquestionable that early invasive reperfusion therapy in the setting of ST-segment elevation myocardial infarction (STEMI) has significantly reduced infarct-related mortality and morbidity [1]. Scientific and social dissemination campaigns have created a certain awareness both in the public domain and among physicians with slogans such as ‘the sooner the better’ and ‘time is muscle’, when faced with such acute situations. The early diagnosis of ischaemia plays an equally important role in improving outcome after myocardial infarction (MI). Cardiac troponins (cTn) play a central role in detecting myocardial damage and are regarded as a cornerstone in the diagnosis of an acute coronary event resulting from atherosclerotic plaque instability [2]. On intracoronary imaging studies and post-mortem observation, acute coronary syndrome without persistent ST-segment elevation (i. e. non-STEMI, NSTEMI-ACS) is often seen to be related to ‘milder’ forms of plaque instability such as erosion and ulceration-based instability [3–5]. The high-sensitive cTn assays have put the definition of MI into a new perspective [2]. Early detection is preferable in any type of injury or disease, but the question of whether earlier intervention will also result in favourable outcome at an acceptable cost remains. In this issue of the Netherlands Heart Journal, Damman and colleagues give the Dutch ACS Working Group perspective on the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting with