Abstract
Acute coronary syndromes include a wide spectrum of clinical coronary disease states, from unstable angina with no observable electrocardiogram changes to ST-segment elevation myocardial infarction. If not recognized and treated immediately, they may prove fatal in some cases. Percutaneous coronary intervention has emerged as a primary treatment for the majority of these patients, often on an urgent or emergency basis. Most of the interventions are ad hoc immediately following a diagnostic coronary angiogram. Understanding the details of these procedures is very important. Furthermore, knowledge of ancillary pharmacotherapy, anticoagulants, antiplatelet agents, and thrombolytics is vital in managing these patients. At times, these patients present with cardiac arrest or cardiogenic shock, which complicates management further. Intra-aortic balloon pump and Impella® devices can be used for hemodynamic support in these situations. In this chapter, we discuss the approaches for managing acute coronary syndromes, with emphasis on revascularization strategies and essential ancillary topics associated with revascularization. We also discuss the management of patients presenting with cardiogenic shock and after cardiac arrest.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation. 2014;130:e344–426.
O'Gara PT, Kushner FG, Ascheim DD, 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. Circulation. 2013;127:e362–425.
Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of myocardial infarction. J Am Coll Cardiol. 2012;60:1581–98.
Armstrong PW, Committee WS. A comparison of pharmacologic therapy with/without timely coronary intervention vs. primary percutaneous intervention early after ST-elevation myocardial infarction: the WEST (which early ST-elevation myocardial infarction therapy) study. Eur Heart J. 2006;27:1530–8.
Armstrong PW, Gershlick AH, Goldstein P, et al. Fibrinolysis or primary PCI in ST-segment elevation myocardial infarction. N Engl J Med. 2013;368:1379–87.
Borgia F, Goodman SG, Halvorsen S, et al. Early routine percutaneous coronary intervention after fibrinolysis vs. standard therapy in ST-segment elevation myocardial infarction: a meta-analysis. Eur Heart J. 2010;31:2156–69.
Cantor WJ, Fitchett D, Borgundvaag B, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med. 2009;360:2705–18.
Fernandez-Aviles F, Alonso JJ, Pena G, et al. Primary angioplasty vs. early routine post-fibrinolysis angioplasty for acute myocardial infarction with ST-segment elevation: the GRACIA-2 non-inferiority, randomized, controlled trial. Eur Heart J. 2007;28:949–60.
Scheller B, Hennen B, Hammer B, et al. Beneficial effects of immediate stenting after thrombolysis in acute myocardial infarction. J Am Coll Cardiol. 2003;42:634–41.
Massberg S, Schulz C, Gawaz M. Role of platelets in the pathophysiology of acute coronary syndrome. Semin Vasc Med. 2003;3:147–62.
Patrono C, Bachmann F, Baigent C, et al. Expert consensus document on the use of antiplatelet agents. Rev Esp Cardiol. 2004;57:963–80.
Fihn SD, Gardin JM, Abrams J, et al. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, preventive cardiovascular nurses association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126:e354–471.
Levine GN, Bates ER, Bittl JA, et al. 2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. J Thorac Cardiovasc Surg. 2016;152:1243–75.
Task Force Members, Montalescot G, Sechtem U, et al. 2013 ESC guidelines on the management of stable coronary artery disease: the task force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34:2949–3003.
Tantry US, Mahla E, Gurbel PA. Aspirin resistance. Prog Cardiovasc Dis. 2009;52:141–52.
Committee CS. A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE steering committee. Lancet. 1996;348:1329–39.
Steinhubl SR, Berger PB, Mann JT 3rd, et al. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA. 2002;288:2411–20.
Sabatine MS, Cannon CP, Gibson CM, et al. Effect of clopidogrel pretreatment before percutaneous coronary intervention in patients with ST-elevation myocardial infarction treated with fibrinolytics: the PCI-CLARITY study. JAMA. 2005;294:1224–32.
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.
Mehta SR, Yusuf S, Peters RJ, et al. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet. 2001;358:527–33.
Price MJ, Berger PB, Teirstein PS, et al. Standard- vs high-dose clopidogrel based on platelet function testing after percutaneous coronary intervention: the GRAVITAS randomized trial. JAMA. 2011;305:1097–105.
FDA. FDA Drug Safety Communication: Reduced effectiveness of Plavix (clopidogrel) in patients who are poor metabolizers of the drug. 2010. https://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm203888.htm
FDA. FDA reminder to avoid concomitant use of Plavix (clopidogrel) and omeprazole. 2009. https://www.fda.gov/Drugs/DrugSafety/ucm231161.htm
Bhatt DL, Cryer BL, Contant CF, et al. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med. 2010;363:1909–17.
Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357:2001–15.
Montalescot G, Bolognese L, Dudek D, et al. Pretreatment with prasugrel in non-ST-segment elevation acute coronary syndromes. N Engl J Med. 2013;369:999–1010.
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.
Bonaca MP, Bhatt DL, Cohen M, et al. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015;372:1791–800.
Bhatt DL, Stone GW, Mahaffey KW, et al. Effect of platelet inhibition with cangrelor during PCI on ischemic events. N Engl J Med. 2013;368:1303–13.
Lefkovits J, Plow EF, Topol EJ. Platelet glycoprotein IIb/IIIa receptors in cardiovascular medicine. N Engl J Med. 1995;332:1553–9.
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;37:267–315.
Task Force on the management of STEMI of the ESC, Steg PG, James SK, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569–619.
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;276:811–5.
Petersen JL, Mahaffey KW, Hasselblad V, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-segment elevation acute coronary syndromes: a systematic overview. JAMA. 2004;292:89–96.
Verdoia M, Schaffer A, Barbieri L, Suryapranata H, De Luca G. Bivalirudin as compared to unfractionated heparin in patients undergoing percutaneous coronary revascularization: a meta-analysis of 22 randomized trials. Thromb Res. 2015;135:902–15.
Mina GS, Gobrial GF, Modi K, Dominic P. Combined use of bivalirudin and radial access in acute coronary syndromes is not superior to the use of either one separately: meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2016;9:1523–31.
Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators, Yusuf S, Mehta SR, et al. Comparison of fondaparinux and enoxaparin in acute coronary syndromes. N Engl J Med. 2006;354:1464–76.
Mega JL, Braunwald E, Wiviott SD, et al. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med. 2012;366:9–19.
Karjalainen PP, Vikman S, Niemela M, et al. Safety of percutaneous coronary intervention during uninterrupted oral anticoagulant treatment. Eur Heart J. 2008;29:1001–10.
ASSENT-2 Investigators, Van De Werf F, et al. Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial. Lancet. 1999;354:716–22.
Rentrop P, Blanke H, Karsch KR, Kreuzer H. Coronary angiographic findings and left ventricular pump function in acute infarction and changes in the chronic stage of infarction (author's transl). Z Kardiol. 1979;68:335–50.
Hochman JS, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006;355:2395–407.
Kastrati A, Mehilli J, Schlotterbeck K, et al. Early administration of reteplase plus abciximab vs abciximab alone in patients with acute myocardial infarction referred for percutaneous coronary intervention: a randomized controlled trial. JAMA. 2004;291:947–54.
ASSENT-4 PCI Investigators. Primary versus tenecteplase-facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (ASSENT-4 PCI): randomised trial. Lancet. 2006;367:569–78.
Ellis SG, Tendera M, de Belder MA, et al. Facilitated PCI in patients with ST-elevation myocardial infarction. N Engl J Med. 2008;358:2205–17.
Keeley EC, Boura JA, Grines CL. Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials. Lancet. 2006;367:579–88.
Levine GN, Bates ER, Blankenship JC, et al. 2015 ACC/AHA/SCAI focused update on primary percutaneous coronary intervention for patients with ST-elevation myocardial infarction: an update of the 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention and the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2016;133:1135–47.
Elgendy IY, Huo T, Bhatt DL, Bavry AA. Is aspiration Thrombectomy beneficial in patients undergoing primary percutaneous coronary intervention? Meta-analysis of randomized trials. Circ Cardiovasc Interv. 2015;8:e002258.
Frobert O, Lagerqvist B, Olivecrona GK, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013;369:1587–97.
Jolly SS, Cairns JA, Yusuf S, et al. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372:1389–98.
Kumbhani DJ, Bavry AA, Desai MY, Bangalore S, Bhatt DL. Role of aspiration and mechanical thrombectomy in patients with acute myocardial infarction undergoing primary angioplasty: an updated meta-analysis of randomized trials. J Am Coll Cardiol. 2013;62:1409–18.
Gick M, Jander N, Bestehorn HP, et al. Randomized evaluation of the effects of filter-based distal protection on myocardial perfusion and infarct size after primary percutaneous catheter intervention in myocardial infarction with and without ST-segment elevation. Circulation. 2005;112:1462–9.
Stone GW, Webb J, Cox DA, et al. Distal microcirculatory protection during percutaneous coronary intervention in acute ST-segment elevation myocardial infarction: a randomized controlled trial. JAMA. 2005;293:1063–72.
Ndrepepa G, Kastrati A. Mechanical strategies to enhance myocardial salvage during primary percutaneous coronary intervention in patients with STEMI. EuroIntervention. 2016;12:319–28.
Delewi R, Hirsch A, Tijssen JG, et al. Impact of intracoronary bone marrow cell therapy on left ventricular function in the setting of ST-segment elevation myocardial infarction: a collaborative meta-analysis. Eur Heart J. 2014;35:989–98.
Zimmet H, Porapakkham P, Porapakkham P, et al. Short- and long-term outcomes of intracoronary and endogenously mobilized bone marrow stem cells in the treatment of ST-segment elevation myocardial infarction: a meta-analysis of randomized control trials. Eur J Heart Fail. 2012;14:91–105.
Armstrong PW, Fu Y, Chang WC, et al. Acute coronary syndromes in the GUSTO-IIb trial: prognostic insights and impact of recurrent ischemia. The GUSTO-IIb investigators. Circulation. 1998;98:1860–8.
Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. JAMA. 2000;284:835–42.
Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004;291:2727–33.
Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114:774–82.
Mehta SR, Jolly SS, Cairns J, et al. Effects of radial versus femoral artery access in patients with acute coronary syndromes with or without ST-segment elevation. J Am Coll Cardiol. 2012;60:2490–9.
Romagnoli E, Biondi-Zoccai G, Sciahbasi A, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (radial versus femoral randomized investigation in ST-elevation acute coronary syndrome) study. J Am Coll Cardiol. 2012;60:2481–9.
Baklanov DV, Kaltenbach LA, Marso SP, et al. The prevalence and outcomes of transradial percutaneous coronary intervention for ST-segment elevation myocardial infarction: analysis from the National Cardiovascular Data Registry (2007 to 2011). J Am Coll Cardiol. 2013;61:420–6.
Karrowni W, Vyas A, Giacomino B, et al. Radial versus femoral access for primary percutaneous interventions in ST-segment elevation myocardial infarction patients: a meta-analysis of randomized controlled trials. JACC Cardiovasc Interv. 2013;6:814–23.
Harada Y, Byrne RA. Bioresorbable drug-eluting stents: no pain, no gain. JACC Cardiovasc Interv. 2016;9:1228–30.
Ellis SG, Kereiakes DJ, Metzger DC, et al. Everolimus-eluting Bioresorbable scaffolds for coronary artery disease. N Engl J Med. 2015;373:1905–15.
Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA. 2006;295:2511–5.
Thiele H, Zeymer U, Neumann FJ, et al. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet. 2013;382:1638–45.
Lettieri C, Savonitto S, De Servi S, et al. Emergency percutaneous coronary intervention in patients with ST-elevation myocardial infarction complicated by out-of-hospital cardiac arrest: early and medium-term outcome. Am Heart J. 2009;157:569–75. e1.
Hazinski MF, Nolan JP, Billi JE, et al. Part 1: executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation. 2010;122:S250–75.
Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132:S465–82.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG, part of Springer Nature
About this chapter
Cite this chapter
Dhoble, A., Anderson, H.V. (2018). Strategies in Acute Coronary Syndrome. In: Lanzer, P. (eds) Textbook of Catheter-Based Cardiovascular Interventions. Springer, Cham. https://doi.org/10.1007/978-3-319-55994-0_55
Download citation
DOI: https://doi.org/10.1007/978-3-319-55994-0_55
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-55993-3
Online ISBN: 978-3-319-55994-0
eBook Packages: MedicineMedicine (R0)