Management of Acute Coronary Syndromes

List of contributors xiii

Foreword xv
Eugene Braunwald

Chapter 1 Pathophysiology of acute coronary syndromes 1
Alisa B. Rosen and Eli V. Gelfand

Introduction 1

Formation of atherosclerotic plaque 2

Plaque instability and the development of ACS 5

Myocardial ischemia 7

Thrombus formation 7

Platelets 7

Secondary hemostasis 9

Dynamic obstruction 10

Progressive mechanical obstruction 10

Inflammation 11

Secondary unstable angina 11

References 11

Chapter 2 Diagnosis of acute coronary syndrome 13
Eli V. Gelfand and Alisa B. Rosen

Introduction 13

Definition of myocardial infarction 13

History 14

Risk factors 17

Physical examination 17

Electrocardiography 19

The pathophysiologic basis of ST segment

changes during ischemia 19

Electrocardiography in ST-elevation MI and identification of the infarct-related artery 20

Electrocardiography in unstable angina and NSTEMI 26

Cardiac biomarkers 26

Noninvasive imaging 29

Echocardiography 29

Myocardial perfusion imaging 30

Coronary computed tomography 30

Cardiovascular magnetic resonance imaging 31

Stress testing for diagnosis of ACS 32

Overall diagnostic pathway for ACS 32

References 34

Chapter 3 Unstable angina and non-ST-elevation myocardial infarction 37
Eli V. Gelfand and Christopher P. Cannon

Introduction 37

Causes of UA/NSTEMI 37

Presentation of UA/NSTEMI 38

General strategies in management of UA/NSTEMI 39

Risk stratification of patients with UA/NSTEMI 40

Initial management of UA/NSTEMI in the emergency department 42

Pharmacologic treatment of ischemia in UA/NSTEMI 43

Beta-blockers 44

Nitrates 44

Calcium channel blockers 45

Angiotensin-converting enzyme inhibitors 45

Morphine 46

Oxygen 46

Invasive versus conservative strategy 46

Antiplatelet therapy in UA/NSTEMI 49

Aspirin 54

Clopidogrel 55

Prasugrel 57

Glycoprotein IIb/IIIa inhibitors 58

Anticoagulant therapy in UA/NSTEMI 61

Unfractionated heparin 61

Enoxaparin 62

Direct thrombin inhibitors 65

Fondaparinux 66

Oral anticoagulation in UA/NSTEMI 67

Fibrinolysis in UA/NSTEMI 68

Early lipid-lowering therapy in patients with UA/NSTEMI 68

Predischarge noninvasive risk stratification after UA/NSTEMI 69

Overall management of UA/NSTEMI 71

References 71

Chapter 4 ST-segment-elevation myocardial infarction 79
Eli V. Gelfand and Christopher P. Cannon

Introduction 79

Global treatment goals in STEMI 79

Prehospital management and triage 80

Transport decisions 82

Management prior to reperfusion 82

Primary reperfusion therapy for STEMI 83

Fibrinolysis 83

Combination fibrinolysis 86

Markers of fibrinolysis effectiveness 86

Complications of fibrinolysis 88

Primary percutaneous coronary intervention 88

Comparison of PCI with fibrinolysis 90

Timing of primary PCI 91

PCI following fibrinolytic therapy 94

Rescue PCI 94

Facilitated PCI 94

Routine PCI after successful fibrinolysis 96

Overall reperfusion strategy 97

Coronary artery bypass grafting for treatment of STEMI 98

Adjunctive pharmacologic treatment of STEMI 98

Antiplatelet agents 98

Anticoagulation therapy 101

Other adjunctive therapy 105

Hospital care following successful reperfusion 110

References 114

Chapter 5 Special considerations in acute coronary syndromes 123
Jason Ryan and Eli V. Gelfand

Secondary unstable angina 123

Acute coronary syndrome in patients with diabetes mellitus 123

General considerations 123

Primary ACS therapy in diabetics 124

Glycemic control in diabetics with ACS 125

Coronary revascularization in diabetics 126

Metabolic syndrome and ACS 127

Chronic kidney disease in ACS 127

Young patients with ACS 130

ACS in the setting of cocaine use 130

ACS in patients with normal coronary arteries or mild CAD 132

Myocarditis 132

Acute transient apical ballooning syndrome 133

Postoperative ACS 134

ACS in a pregnant woman 135

Hyperthyroidism and ACS 136

ACS in patients exposed to radiation 137

Trauma and ACS 137

References 137

Chapter 6 Complications of acute coronary syndrome 141
Jan M. Pattanayak and Eli V. Gelfand

Introduction 141

Pump failure 141

General principle 141

Clinical presentation 142

Prognosis 144

Treatment 144

Right ventricular infarction 148

Introduction 148

Clinical presentation 148

Diagnosis 149

Management 150

Prognosis 152

Mechanical complications of ACS 152

Introduction 152

Left ventricular free wall rupture 152

Ventricular septal rupture 153

Acute mitral regurgitation 154

Left ventricular aneurysm 155

Left ventricular pseudoaneurysm 157

Pericardial complications 157

Arrhythmic complications of ACS 159

Bradyarrhythmias 159

Atrial fibrillation 163

Ventricular tachycardia and fibrillation 163

Complications involving bleeding 164

Complications of percutaneous coronary intervention 165

References 170

Chapter 7 Post-hospitalization care of patients with acute coronary syndrome 173
Jersey Chen and Eli V. Gelfand

Introduction 173

Pharmacologic measures 173

Aspirin 173

Clopidogrel 174

Beta adrenergic blockade 177

Renin–angiotensin–aldosterone inhibitors 179

Lipid-lowering therapy 185

Warfarin 189

Influenza vaccination 192

Medications of limited benefit to patients following ACS 192

Vitamins/antioxidants 192

Estrogen replacement therapy 192

Nonsteroidal anti-inflammatory agents and related compounds 194

Nonpharmacologic measures 195

Antiarrhythmic devices 195

Therapy of comorbidities following ACS 198

Diabetes mellitus 198

Hypertension 199

Depression 199

Lifestyle recommendations following ACS 200

General physical activity and structured cardiac rehabilitation 200

Sexual activity after ACS 201

Smoking cessation 201

Diet/nutrition and weight loss 202

References 204

Appendix 209

Index 217