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Management of Acute Coronary Syndrome

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Evidence-Based Critical Care

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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 most typically caused by a rupture or erosion of a atherosclerotic plaque precipitating the acute total, or near total, coronary obstruction by thrombus. Chest discomfort at rest or at low exertion is typically 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.

Many aspects of management of ACS remain uncertain, offering opportunities for future research.

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References

  1. O’Gara PT, Kushner FG, Ascheim DD, Casey Jr DE, 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.

    Article  PubMed  Google Scholar 

  2. Amsterdam EA, Wenger NK, Brindis RG, Casey Jr DE, 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.

    Article  Google Scholar 

  3. Hamm CW, Bassand JP, Agewall S, Bax J, et al. ESC Committee for Practice Guidelines. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999–3054.

    Article  PubMed  Google Scholar 

  4. Steg PG, James SK, Atar D, Badano LP, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). Eur Heart J. 2012;33(20):2569–619.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  8. Moradkhan R, Sinoway LI. Revisting the role of oxygen therapy in cardiac patients. J Am Coll Cardiol. 2010;56:1013–6.

    Article  PubMed  PubMed Central  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  14. 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.

    Article  CAS  PubMed  Google Scholar 

  15. 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.

    Article  CAS  PubMed  Google Scholar 

  16. 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.

    Article  CAS  PubMed  Google Scholar 

  17. 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.

    Article  CAS  PubMed  Google Scholar 

  18. Morrow DA, Cannon CP, Rifai N, Frey MJ, Vicari R, Lakkis N, Robertson DH, Hille DA, DeLucca PT, DiBattiste 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.

    Article  CAS  PubMed  Google Scholar 

  19. 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 

  20. 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.

    Article  Google Scholar 

  21. 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.

    Article  PubMed  Google Scholar 

  22. Qamar A, Bhatt DL. Culprit-only vs. complete revascularization during ST-segment elevation myocardial infarction. Prog Cardiovasc Dis. 2015;58(3):260–6.

    Article  PubMed  Google Scholar 

  23. Jolly SS, Cairns JA, Yusuf S, Meeks B, et al. TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372(15):1389–98.

    Google Scholar 

  24. Cannon CP, Blazing MA, Giugliano RP, McCagg A, et al. for the IMPROVE-IT Investigators. Ezetimibe added to statin therapy after acute coronary syndromes. N Engl J Med. 2015;372:2387–97.

    Google Scholar 

  25. Mauri L, Kereiakes DJ, Yeh RW, Driscoll-Shempp P, et al. DAPT Study Investigators. Twelve or 30 months of dual antiplatelet therapy after drug-eluting stents. N Engl J Med. 2014;371(23):2155–66.

    Google Scholar 

  26. Bonaca MP, Bhatt DL, Cohen M, Steg PG, et al.; PEGASUS-TIMI 54 Steering Committee and Investigators. Long-term use of ticagrelor in patients with prior myocardial infarction. N Engl J Med. 2015;372(19):1791–800.

    Google Scholar 

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Authors and Affiliations

  1. Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Arman Qamar & Benjamin M. Scirica

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  1. Arman Qamar
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  2. Benjamin M. Scirica
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Correspondence to Benjamin M. Scirica .

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Editors and Affiliations

  1. Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, Michigan, USA

    Robert C. Hyzy

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Qamar, A., Scirica, B.M. (2017). Management of Acute Coronary Syndrome. In: Hyzy, R. (eds) Evidence-Based Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-43341-7_12

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  • DOI: https://doi.org/10.1007/978-3-319-43341-7_12

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-43339-4

  • Online ISBN: 978-3-319-43341-7

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