Non-ST-segment elevation acute coronary syndromes: an algorithm for decision.

We have read with great interest the report of the Task Force concerning the guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes (NST-ACS). We would like to compliment the Task Force members for this excellent work, updating the previous ESC guidelines concerning that matter. In particular, the recent chapters on management of elderly patients, renal insufficiency, bleeding complications, anaemia, transfusions are new and of particular importance for the cardiological community. However, we feel a bit puzzled by the lack of a clear message concerning the recommendations on anticoagulation. Indeed, Table 11 reports six possible anticoagulation regimen without any clear recommendation regarding the drug of choice to be given as soon as the diagnostic of NST-ACS has become a working hypothesis. Taking into account the literature, the recommendations of the ESC, and also the recently published recommendations of ACC/AHA, we propose a simplified analysis (Figure 1) that may help the clinicians to choose the best anticoagulation strategy adapted to their own practice. We have used the following rules to digest the complex data on the subject: