Current Cardiology Reports

, Volume 3, Issue 4, pp 289–296

Guidelines for the acute coronary syndromes

  • Elliot Rapaport


Traditional measures employed in the immediate management of patients presenting with an acute coronary syndrome have markedly reduced the risk of early death or myocardial infarction. Further incremental benefit is seen with the substitution of enoxaparin for unfractionated heparin, and in the use of glycoprotein IIb/IIIa inhibitors during percutaneous coronary intervention. However, the evidence for benefit from the glycoprotwin IIb/IIIa inhibitors with medical management alone is unconvincing. Newer data also suggest an aggressive approach to the high-risk patient offers a better ultimate outcome than a conservative one.


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References and Recommended Reading

  1. 1.
    Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care 1: Part 7: The era of reperfusion. Circulation 2000, 102:1172–1203.Google Scholar
  2. 2.
    Braunwald E, Antman EM, Beasley JW, et al.: ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. Circulation 2000, 102:1193–1209. Excellent report.PubMedGoogle Scholar
  3. 3.
    Task Force of the European Society of Cardiology: Management of acute coronary syndromes without persistent ST segment elevation: recommendations of the Task force of the European Society of Cardiology. Eur Heart J 2000, 21:1406–1432.CrossRefGoogle Scholar
  4. 4.
    Antman EM, Fox KM: Guidelines for the diagnosis and management of unstable angina and non-Q-wave myocardial infarction: proposed revisions. Am Heart J 2000, 139:461–475.PubMedCrossRefGoogle Scholar
  5. 5.
    Gazes PC, Mobley E, Mims Jr., et al.: Preinfarctional (unstable) angina—a prospective study—ten year follow-up: prognostic significance of electrocardiographic changes. Circulation 1973, XLVIII:331–337.Google Scholar
  6. 6.
    Calvin JE, Klein LW, Vandenberg EJ, et al.: Validated risk stratification model accurately predicts low risk in patients with unstable angina. J Am Coll Cardiol 2000, 36:1803–1808.PubMedCrossRefGoogle Scholar
  7. 7.
    Antman EM, Cohen M, Bernink PJLM, et al.: The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA 2000, 384(7):835–842.CrossRefGoogle Scholar
  8. 8.
    TIMI IIIb Investigators: Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial: Thrombolysis in Myocardial Ischemia. Circulation 1994, 89:1545–1556.Google Scholar
  9. 9.
    Boden WE, O’Rourke RA, Crawford MH, et al.: Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy: Veterans Affairs Non- Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med 1998, 338:1785–1792.PubMedCrossRefGoogle Scholar
  10. 10.
    FRISC II Investigators: Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomized multicentre study. Coronary Artery Disease Investigators. Lancet 1999, 354:708–715.CrossRefGoogle Scholar
  11. 11.
    Moore J: TACTICS-TIMI 18: early invasive strategy superior. Cardiology Today 2000, 3:38.Google Scholar
  12. 12.
    COHORT: The influence of statin therapy at discharge and performance of early revascularization on 1-year mortality. Cardiology Today. Trial Roundup Handbook 2001, (January):17.Google Scholar
  13. 13.
    Lewis HD, Davis JW, Archibald DG, et al.: Protective effects of aspirin against acute myocardial infarction and death in men with unstable angina: results of a Veterans Administration Cooperative Study. N Engl J Med. 1983, 309:396–403.PubMedCrossRefGoogle Scholar
  14. 14.
    Cairns JA, Singer J, Gent M, et al.: One year mortality outcomes of all coronary and intensive care unit patients with acute myocardial infarction, unstable angina or other chest pain in Hamilton, Ontario, a city of 375,000 people. Can J Cardiol 1989, 5:239–246.PubMedGoogle Scholar
  15. 15.
    RISC Group: Risk of myocardial infarction and death during treatment with low dose aspirin and intravenous heparin in men with unstable coronary artery disease: The RISC group. Lancet 1990, 336:827–830.CrossRefGoogle Scholar
  16. 16.
    Balsano F, Rizzon P, Violi F, et al.: Antiplatelet treatment with ticlopidine in unstable angina: a controlled multicenter clinical trial. The Studio della Ticlopidine nell’Angina Instabile Group. Circulation 1990, 82:17–26.PubMedGoogle Scholar
  17. 17.
    Herbert JM, Dol F, Bernat A, et al.: The antiaggregating and antithrombotic activity of clopidogrel is potentiated by aspirin in several experimental models in the rabbit. Thrombosis Haemost 1998, 80:512–518.Google Scholar
  18. 18.
    CURE Study Investigators: The clopidogrel in unstable angina to prevent recurrent events (CURE) trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease. Eur Heart J 2000, 2:2033–2041.Google Scholar
  19. 19.
    Topol EJ: The future of antiplatelet therapy: Optimizing management in patients with acute coronary syndrome. Clin Cardiol 2000, 23:V123-V128. Of interest to clinicians.CrossRefGoogle Scholar
  20. 20.
    Oler A, Whooley MA, Oler J, Grady D: Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina: a meta-analysis. JAMA 1996, 276:811–815.PubMedCrossRefGoogle Scholar
  21. 21.
    Antman EM: TIMI 11B. Enoxaparin versus unfractionated heparin for unstable angina or non-Q-wave myocardial infarction: a double-blind, placebo-controlled, parallelgroup, multicenter trial. Rationale study design and methods. Thrombolysis in Myocardial Infarction (TIMI) 11B Trial Investigators. Am Heart J 1998, 135:S353–360.PubMedGoogle Scholar
  22. 22.
    Cohen M, Demers C, Gurfinkel EP, et al.: Low-molecularweight heparins in non-ST segment elevation ischemia: The ESSENCE trial. Efficacy and Safety of Subcutaneous Enoxaparin versus intravenous unfractionated heparin, in Non-Q wave Coronary Events. Am J Cardiol 1998, 82:19L-24L.PubMedCrossRefGoogle Scholar
  23. 23.
    The FRAX.I.S. Study Group: Comparison of two treatment durations (6 days and 14 days) of a low molecular weight heparin with a 6-day treatment of unfractionated heparin in the initial management of unstable angina or non-Q-wave myocardial infarction: FRAX.I.S. (FRAxiparine in Ischaemic Syndrome). Eur Heart J 1999, 20,21:1553–1562.CrossRefGoogle Scholar
  24. 24.
    Turpie AGG: Clinical trials of low molecular weight heparins. Eur Heart J 1999, 1(Suppl):R18-R27.Google Scholar
  25. 25.
    OASIS-2 Investigators: Effects of recombinant hirudin (lepirudin) compared with heparin on death, myocardial infarction refractory angina, and revascularization procedures in patients with acute myocardial ischaemia without ST elevation; a randomized trial. Lancet 1999, 353:429–438.CrossRefGoogle Scholar
  26. 26.
    Boersna E, Akkerhuis M, Theroux P, et al.: Platelet glycoprotein IIb/IIIa receptor inhibition in non-ST-elevation acute coronary syndromes: early benefit during medical treatment only, with additional protection during percutaneous coronary intervention. Circulation 1999, 100:2045–2048.Google Scholar
  27. 27.
    Jancin B: Coronary syndrome guidelines outdated by GUSTO-IV results. Int Med News 200:5.Google Scholar
  28. 28.
    Widimsky P: VINO (Validation of Immediate angioplasty in non-Q wave myocardial infarction. An open randomized multicenter study): randomized trial comparing clinical outcome in 110 patients with non-Q wave myocardial infarction treated either by immediate angiography with appropriate revascularization or by conservative therapy. Presented at the XXII Congress of the European Society of Cardiology. August 26–30, 2000. Amsterdam, Netherlands.Google Scholar
  29. 29.
    Califf RM: Accelerated-dose eptifibatide in nonemergency coronary stent implantation: an update of results from the ESPRIT trial. Medical Education Reports, Interviews and Testimony 2000, 1:1.Google Scholar
  30. 30.
    Progress in Clinical Trials. Clin Cardiol 2001, 24:85–88.Google Scholar
  31. 31.
    Ferguson JJ: Combining low-molecular-weight heparin and glycoprotein IIb/IIIa antagonists for the treatment of acute coronary syndromes: The NICE 3 story. J Invas Cardiol 2000, 12(Suppl):E10-E13. Key study with interesting results.Google Scholar
  32. 32.
    Kereiakes DJ, Young J, Broderick TM, et al.: Therapeutic adjuncts for immediate transfer to the catheterization laboratory in patients with acute coronary syndromes. Am J Cardiol 2000, 86(Suppl):10M-17M.PubMedCrossRefGoogle Scholar
  33. 33.
    Aronow HD, Roe MT, Lauer MS, et al.: Early and striking mortality reduction after acute coronary syndromes following lipid lowering therapy [abstract]. JACC 2000, 411A.Google Scholar

Copyright information

© Current Science Inc. 2001

Authors and Affiliations

  • Elliot Rapaport
    • 1
  1. 1.Cardiology Division, San Francisco General HospitalUniversity of California San FranciscoSan FranciscoUSA

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