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Management of Acute Coronary Syndrome

  • Arman Qamar
  • Benjamin M. SciricaEmail author
Chapter
  • 4 Downloads

Abstract

Coronary artery disease (CAD) is the leading cause of death in the world. Acute coronary syndrome (ACS) is a frequent life threatening manifestation of CAD, that is typically caused by a rupture or erosion of an atherosclerotic plaque precipitating the acute total, or near total, coronary obstruction by thrombus. Chest discomfort at rest or at low exertion is the most frequent presenting symptom. A resting 12-lead ECG is the first diagnostic tool in the assessment of patients with suspected ACS. Acute coronary syndromes include ST-segment elevation myocardial infarction (STEMI), non-ST-elevation MI (NSTEMI) and unstable angina. In the absence of contraindications, all patients with ACS should receive aspirin, a second antiplatelet agent, an anticoagulant, beta-adrenergic blockers and high dose statins. Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in STEMI. Early risk stratification is critical in the management of patients with non-ST-elevation ACS. Patients at high risk of adverse events should be treated with early versus delayed invasive strategy.

Keywords

Acute coronary syndrome Chest pain STEMI NSTEMI Unstable angina Primary PCI 

References

  1. 1.
    O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78–140.CrossRefGoogle Scholar
  2. 2.
    Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, et al. 2014 AHA/ACC guideline for the management of patients with Non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;64(24):2645.CrossRefGoogle Scholar
  3. 3.
    Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119–77.CrossRefGoogle Scholar
  4. 4.
    Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267–315.CrossRefGoogle Scholar
  5. 5.
    Morrow DA, Antman EM, Parsons L, de Lemos JA, Cannon CP, Giugliano RP, McCabe CH, Barron HV, Braunwald E. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. JAMA. 2001;286(11):1356.CrossRefGoogle Scholar
  6. 6.
    Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284(7):835.CrossRefGoogle Scholar
  7. 7.
    Granger CB, Goldberg RJ, Dabbous O, Pieper KS, Eagle KA, Cannon CP, Van De Werf F, Avezum A, Goodman SG, Flather MD, Fox KA, Global Registry of Acute Coronary Events Investigators. Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003;163(19):2345–53.CrossRefGoogle Scholar
  8. 8.
    Moradkhan R, Sinoway LI. Revisiting the role of oxygen therapy in cardiac patients. J Am Coll Cardiol. 2010;56:1013–6.CrossRefGoogle Scholar
  9. 9.
    Stub D, Smith K, Bernard S, Nehme Z, Stephenson M, Bray JE, Cameron P, Barger B, Ellims AH, Taylor AJ, Meredith IT, Kaye DM. AVOID Investigators. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131(24):2143–50.CrossRefGoogle Scholar
  10. 10.
    Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2012;125:1058–72.CrossRefGoogle Scholar
  11. 11.
    Gislason GH, Jacobsen S, Rasmussen JN, et al. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal anti-inflammatory drugs after acute myocardial infarction. Circulation. 2006;113:2906–13.CrossRefGoogle Scholar
  12. 12.
    Ryden L, Ariniego R, Arnman K, et al. A double-blind trial of metoprolol in acute myocardial infarction. Effects on ventricular tachyarrythmias. N Engl J Med. 1983;308:614–8.CrossRefGoogle Scholar
  13. 13.
    Cannon CP, Braunwald E, McCabe CH, et al. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495–504.CrossRefGoogle Scholar
  14. 14.
    Cannon CP, Blazing MA, Giugliano RP, McCagg A, for the IMPROVE-IT Investigators, et al. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387–97.CrossRefGoogle Scholar
  15. 15.
    Sabatine MS, Giugliano RP, Keech AC, et al. Evolocumab and clinical outcomes in patients with cardiovascular disease. N Engl J Med. 2017;376(18):1713–22.CrossRefGoogle Scholar
  16. 16.
    Schwartz GG, Steg PG, Szarek M, et al. Alirocumab and cardiovascular outcomes after acute coronary syndrome. N Engl J Med. 2018;379(22):2097–107.CrossRefGoogle Scholar
  17. 17.
    Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361:1045–57.CrossRefGoogle Scholar
  18. 18.
    Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, Neumann FJ, Ardissino D, De Servi S, Murphy SA, Riesmeyer J, Weerakkody G, Gibson CM, Antman EM, TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–15.CrossRefGoogle Scholar
  19. 19.
    Yusuf S, Zhao F, Mehta SR, et al. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345:494–502.CrossRefGoogle Scholar
  20. 20.
    Anderson JL, Karagounis LA, Califf RM. Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction. Am J Cardiol. 1996;78(1):1.CrossRefGoogle Scholar
  21. 21.
    Morrow DA, Cannon CP, Rifai N, Frey MJ, Vicari R, Lakkis N, Robertson DH, Hille DA, De Lucca PT, Di Battiste PM, Demopoulos LA, Weintraub WS, Braunwald E, TACTICS-TIMI 18 Investigators. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA. 2001;286(19):2405–12.CrossRefGoogle Scholar
  22. 22.
    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(4):1545–56.Google Scholar
  23. 23.
    The TIMI Study Group. Comparison of invasive and conservative strategies after treatment with intravenous tissue plasminogen activator in acute myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) phase II trial. N Engl J Med. 1989;320(10):618–27.CrossRefGoogle Scholar
  24. 24.
    Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, Morrison LJ, Langer A, Dzavik V, Mehta SR, Lazzam C, Schwartz B, Casanova A, Goodman SG, TRANSFER-AMI Trial Investigators. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360(26):2705–18.CrossRefGoogle Scholar
  25. 25.
    Qamar A, Bhatt DL. Culprit-only vs. complete revascularization during ST-segment elevation myocardial infarction. Prog Cardiovasc Dis. 2015;58(3):260–6.CrossRefGoogle Scholar
  26. 26.
    Thiele H, Akin I, Sandri M, et al. PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med. 2017;377(25):2419–32.CrossRefGoogle Scholar
  27. 27.
    Jolly SS, Cairns JA, Yusuf S, Meeks B, TOTAL Investigators, et al. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372(15):1389–98.CrossRefGoogle Scholar
  28. 28.
    Mauri L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, DAPT Study Investigators, et al. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med. 2014;371(23):2155–66.CrossRefGoogle Scholar
  29. 29.
    Bonaca MP, Bhatt DL, Cohen M, Steg PG, PEGASUS-TIMI 54 Steering Committee and Investigators, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015;372(19):1791–800.CrossRefGoogle Scholar
  30. 30.
    Lopes RD, Heizer G, Aronson R, Vora AN, Massaro T, Mehran R, Goodman SG, Windecker S, Darius H, Li J, Averkov O, Bahit MC, Berwanger O, Budaj A, Hijazi Z, Parkhomenko A, Sinnaeve P, Storey RF, Thiele H, Vinereanu D, Granger CB, Alexander JH, AUGUSTUS Investigators. Antithrombotic therapy after acute coronary syndrome or PCI in atrial fibrillation. N Engl J Med. 2019;380(16):1509–24.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

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