14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

AcuteCoronarySyndrome
Author:DavidLCoven,MD,PhDChiefEditor:EricHYang,MDmore...
Updated:Sep09,2015

PracticeEssentials
Acutecoronarysyndrome(ACS)referstoaspectrumofclinicalpresentations
rangingfromthoseforSTsegmentelevationmyocardialinfarction(STEMI)to
presentationsfoundinnonSTsegmentelevationmyocardialinfarction(NSTEMI)
orinunstableangina.Itisalmostalwaysassociatedwithruptureofan
atheroscleroticplaqueandpartialorcompletethrombosisoftheinfarctrelated
artery.
Theimagebelowillustratesanalgorithmfortriagingpatientswithchestpain.

Suggestedalgorithmfortriagingpatientswithchestpain.ACS=ACSASA=aspirinEKG=
ECGMI=myocardialinfarctionRx=treatSTEMI=STelevationmyocardialinfarction.
CourtesyofWuetal(1999).

SeeAreYouMissingSubtleMICluesonECGs?TestYourSkills,aCriticalImages
slideshow,tohelpidentifyavarietyofelectrocardiographicabnormalities.

Essentialupdate:ACPreleasesguidelinesonscreeningfor
coronaryheartdisease
In2015,theAmericanCollegeofPhysicians(ACP)releasedguidelineson
screeningforcoronaryheartdisease,includingthefollowing[1]:
Thereisnoevidencethatcardiacscreeningimprovespatientoutcomesin
asymptomatic,lowriskadults.
Potentialharmsofcardiacscreeningincludefalsepositiveresultscausing
patientstoundergopotentiallyunnecessarytestsandprocedures.
Amongadultsatlowrisk,prevalenceofcoronaryheartdiseaseislow,and
cardiacscreeningisoflowpredictivevalue.Therefore,cardiacscreeningisof
lowyield,andtheprobabilitythatpositivefindingswillinfluencetherapeutic
decisionmakingislow.
Cliniciansshouldthereforeemphasizestrategiestoreducecardiovascularrisk
evenfurtheramonglowriskadultsbytreatingmodifiableriskfactors
(smoking,diabetes,bloodpressure,hyperlipidemia,overweight,and
exercise).
Cliniciansshouldnotscreenasymptomatic,lowriskadultsforcardiac
diseaseusingrestingorstresselectrocardiography,stressechocardiography,
orstressmyocardialperfusionimaging.
Cliniciansshouldconductcardiovascularriskassessmentwithaglobalrisk
scorecombiningindividualriskfactormeasurementsintoasingle
quantitativeestimateofrisk.
TheACPrecommendationsdonotapplytosymptomaticpatientsorto
screeningathletesbeforeparticipationinvariousevents.

Signsandsymptoms
AtherosclerosisistheprimarycauseofACS,withmostcasesoccurringfromthe
disruptionofapreviouslynonseverelesion.Complaintsreportedbypatientswith
ACSincludethefollowing:
Palpitations
Pain,whichisusuallydescribedaspressure,squeezing,oraburning
sensationacrosstheprecordiumandmayradiatetotheneck,shoulder,jaw,
back,upperabdomen,oreitherarm
Exertionaldyspneathatresolveswithpainorrest
Diaphoresisfromsympatheticdischarge

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Nauseafromvagalstimulation
Decreasedexercisetolerance
Physicalfindingscanrangefromnormaltoanyofthefollowing:
Hypotension:Indicatesventriculardysfunctionduetomyocardialischemia,
myocardialinfarction(MI),oracutevalvulardysfunction
Hypertension:Mayprecipitateanginaorreflectelevatedcatecholamine
levelsduetoanxietyortoexogenoussympathomimeticstimulation
Diaphoresis
Pulmonaryedemaandothersignsofleftheartfailure
Extracardiacvasculardisease
Jugularvenousdistention
Cool,clammyskinanddiaphoresisinpatientswithcardiogenicshock
Athirdheartsound(S 3)and,frequently,afourthheartsound(S 4)
Asystolicmurmurrelatedtodynamicobstructionoftheleftventricular
outflowtract
Ralesonpulmonaryexamination(suggestiveofleftventriculardysfunctionor
mitralregurgitation)
Potentialcomplicationsincludethefollowing:
Ischemia:Pulmonaryedema
Myocardialinfarction:Ruptureofthepapillarymuscle,leftventricularfree
wall,andventricularseptum
SeeClinicalPresentationformoredetail.

Diagnosis
GuidelinesforthemanagementofnonSTsegmentelevationACSwerereleasedin
2011bytheEuropeanSocietyofCardiology(ESC). [2]Theguidelinesincludethe
useoftheCRUSADEriskscore(CanRapidriskstratificationofUnstableangina
patientsSuppressADverseoutcomeswithEarlyimplementationoftheACC/AHA
guidelines).
Intheemergencysetting,electrocardiography(ECG)isthemostimportant
diagnostictestforangina.ECGchangesthatmaybeseenduringanginalepisodes
includethefollowing:
TransientSTsegmentelevations
DynamicTwavechanges:Inversions,normalizations,orhyperacutechanges
STdepressions:Thesemaybejunctional,downsloping,orhorizontal
Laboratorystudiesthatmaybehelpfulincludethefollowing:
CreatinekinaseisoenzymeMB(CKMB)levels
Cardiactroponinlevels
Myoglobinlevels
Completebloodcount
Basicmetabolicpanel
Diagnosticimagingmodalitiesthatmaybeusefulincludethefollowing:
Chestradiography
Echocardiography
Myocardialperfusionimaging
Cardiacangiography
Computedtomography,includingCTcoronaryangiographyandCTcoronary
arterycalciumscoring
SeeWorkupformoredetail.

Management
Initialtherapyfocusesonthefollowing:
Stabilizingthepatientscondition
Relievingischemicpain
Providingantithrombotictherapy
Pharmacologicantiischemictherapyincludesthefollowing:
Nitrates(forsymptomaticrelief)
Betablockers(eg,metoprolol):Theseareindicatedinallpatientsunless
contraindicated
Pharmacologicantithrombotictherapyincludesthefollowing:
Aspirin
Clopidogrel
Prasugrel
Ticagrelor
GlycoproteinIIb/IIIareceptorantagonists(abciximab,eptifibatide,tirofiban)
Pharmacologicanticoagulanttherapyincludesthefollowing:
Unfractionatedheparin(UFH)
Lowmolecularweightheparin(LMWHdalteparin,nadroparin,enoxaparin)
FactorXainhibitors(rivaroxaban,fondaparinux)
Additionaltherapeuticmeasuresthatmaybeindicatedincludethefollowing:
Thrombolysis
Percutaneouscoronaryintervention(preferredtreatmentforSTelevationMI)
CurrentguidelinesforpatientswithmoderateorhighriskACSincludethe

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following:
Earlyinvasiveapproach
Concomitantantithrombotictherapy,includingaspirinandclopidogrel,as
wellasUFHorLMWH
SeeTreatmentandMedicationformoredetail.
Theimagebelowdepictsa62yearoldwomanwithahistoryofchronicstable
anginaanda"valveproblem."

A62yearoldwomanwithahistoryofchronicstableanginaanda"valveproblem"presentswith
newchestpain.Sheissymptomaticonarrival,complainingofshortnessofbreathand
precordialchesttightness.Herinitialvitalsignsarebloodpressure=140/90mmHgandheart
rate=98.Herelectrocardiogram(ECG)isasshown.Sheisgivennitroglycerinsublingually,
andherpressuredecreasesto80/palpation.Rightventricularischemiashouldbeconsideredin
thispatient.

Background
Acutecoronarysyndrome(ACS)referstoaspectrumofclinicalpresentations
rangingfromthoseforSTsegmentelevationmyocardialinfarction(STEMI)to
presentationsfoundinnonSTsegmentelevationmyocardialinfarction(NSTEMI)
orinunstableangina.Intermsofpathology,ACSisalmostalwaysassociatedwith
ruptureofanatheroscleroticplaqueandpartialorcompletethrombosisofthe
infarctrelatedartery.(SeeEtiology.)
Insomeinstances,however,stablecoronaryarterydisease(CAD)mayresultin
ACSintheabsenceofplaqueruptureandthrombosis,whenphysiologicstress(eg,
trauma,bloodloss,anemia,infection,tachyarrhythmia)increasesdemandsonthe
heart.Thediagnosisofacutemyocardialinfarctioninthissettingrequiresafinding
ofthetypicalriseandfallofbiochemicalmarkersofmyocardialnecrosisinaddition
toatleast1ofthefollowing[3](SeeWorkup.):
Ischemicsymptoms
DevelopmentofpathologicQwaves
IschemicSTsegmentchangesonelectrocardiogram(ECG)orinthesetting
ofacoronaryintervention
Thetermstransmuralandnontransmural(subendocardial)myocardialinfarctionare
nolongerusedbecauseECGfindingsinpatientswiththisconditionarenotclosely
correlatedwithpathologicchangesinthemyocardium.Therefore,atransmural
infarctmayoccurintheabsenceofQwavesonECGs,andmanyQwave
myocardialinfarctionsmaybesubendocardial,asnotedonpathologicexamination.
BecauseelevationoftheSTsegmentduringACSiscorrelatedwithcoronary
occlusionandbecauseitaffectsthechoiceoftherapy(urgentreperfusiontherapy),
ACSrelatedmyocardialinfarctionshouldbedesignatedSTEMIorNSTEMI.(See
Workup.)
Attentiontotheunderlyingmechanismsofischemiaisimportantwhenmanaging
ACS.Asimplepredictorofdemandisratepressureproduct,whichcanbelowered
bybetablockers(eg,metoprololoratenolol)andpain/stressrelievers(eg,
morphine),whilesupplymaybeimprovedbyoxygen,adequatehematocrit,blood
thinners(eg,heparin,IIb/IIIaagentssuchasabciximab,eptifibatide,tirofiban,or
thrombolytics),and/orvasodilators(eg,nitrates,amlodipine).(SeeMedications.)
In2010,theAmericanHeartAssociation(AHA)publishednewguideline
recommendationsforthediagnosisandtreatmentofACS. [4]

Etiology
Acutecoronarysyndrome(ACS)iscausedprimarilybyatherosclerosis.Mostcases
ofACSoccurfromdisruptionofapreviouslynonseverelesion(anatherosclerotic
lesionthatwaspreviouslyhemodynamicallyinsignificantyetvulnerabletorupture).
Thevulnerableplaqueistypifiedbyalargelipidpool,numerousinflammatorycells,
andathin,fibrouscap.
ElevateddemandcanproduceACSinthepresenceofahighgradefixedcoronary
obstruction,duetoincreasedmyocardialoxygenandnutritionrequirements,suchas
thoseresultingfromexertion,emotionalstress,orphysiologicstress(eg,from
dehydration,bloodloss,hypotension,infection,thyrotoxicosis,orsurgery).
ACSwithoutelevationindemandrequiresanewimpairmentinsupply,typicallydue
tothrombosisand/orplaquehemorrhage.
Themajortriggerforcoronarythrombosisisconsideredtobeplaquerupturecaused
bythedissolutionofthefibrouscap,thedissolutionitselfbeingtheresultofthe
releaseofmetalloproteinases(collagenases)fromactivatedinflammatorycells.This
eventisfollowedbyplateletactivationandaggregation,activationofthe
coagulationpathway,andvasoconstriction.Thisprocessculminatesincoronary
intraluminalthrombosisandvariabledegreesofvascularocclusion.Distal
embolizationmayoccur.Theseverityanddurationofcoronaryarterialobstruction,

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thevolumeofmyocardiumaffected,thelevelofdemandontheheart,andthe
abilityoftherestofthehearttocompensatearemajordeterminantsofapatient's
clinicalpresentationandoutcome.(Anemiaandhypoxemiacanprecipitate
myocardialischemiaintheabsenceofseverereductionincoronaryarteryblood
flow.)
Asyndromeconsistingofchestpain,ischemicSTsegmentandTwavechanges,
elevatedlevelsofbiomarkersofmyocyteinjury,andtransientleftventricularapical
ballooning(takotsubosyndrome)hasbeenshowntooccurintheabsenceofclinical
CAD,afteremotionalorphysicalstress.Theetiologyofthissyndromeisnotwell
understoodbutisthoughttorelatetoasurgeofcatecholstresshormonesand/or
highsensitivitytothosehormones.
Baselinebloodglucoselevelsappeartobeanindependentriskfactorforamajor
adversecardiacevent(MACE)inemergencydepartment(ED)patientswith
suspectedACS. [5,6]Inananalysisofdatafrom1708AustralianandNewZealand
patientsinaprospectiveobservationalstudy,investigatorsnotedaMACEoccurred
within30daysofpresentationin15.3%ofpatientswhoseEDadmissionblood
glucoselevelswerebelow7mmol/L(about126mg/dL)however,inthesametime
period,aMACEoccurredintwiceasmanypatients(30.9%)whosebloodglucose
levelswereabove7mmol/L. [6]Aftercontrollingforvariousfactors,patientswhohad
admissionbloodglucoselevelsof7mmol/Lorhigherwereat51%higherriskof
experiencingaMACEcomparedwithpatientswhohadlowerbaselineblood
glucoselevels. [6]OthersignificantpredictorsofMACEincludedmalesex,olderage,
familyhistory,hypertension,dyslipidemia,ischemicfindingsonECG,andpositive
troponintests. [5,6]

Prognosis
SixmonthmortalityratesintheGlobalRegistryofAcuteCoronaryEvents(GRACE)
were13%forpatientswithNSTEMIACSand8%forthosewithunstableangina.
Anelevatedleveloftroponin(atypeofregulatoryproteinfoundinskeletaland
cardiacmuscle)permitsriskstratificationofpatientswithACSandidentifies
patientsathighriskforadversecardiacevents(ie,myocardialinfarction,death)up
to6monthsaftertheindexevent. [7,8](SeeWorkup.)
ThePROVEITTIMItrialfoundthatafterACS,aJshapedorUshapedcurve
associationisobservedbetweenBPandtheriskoffuturecardiovascularevents. [9]
LeLeikoetaldeterminedthatserumcholineandfreeF(2)isoprostanearealso
predictorsofcardiaceventsinACS.Theauthorsevaluatedtheprognosticvalueof
vascularinflammationandoxidativestressbiomarkersinpatientswithACSto
determinetheirroleinpredicting30dayclinicaloutcomes.SerumF(2)isoprostane
hadanoptimalcutofflevelof124.5pg/mL,andserumcholinehadacutofflevelof
30.5mol/L.CholineandF(2)isoprostanehadapositivepredictivevalueof44%
and57%andanegativepredictivevalueof89%and90%,respectively. [10]
Testosteronedeficiencyiscommoninpatientswithcoronarydiseaseandhasa
significantnegativeimpactonmortality.Furtherstudyisneededtoassessthe
effectoftreatmentonsurvival. [11]
AstudybySanchisetalsuggestsrenaldysfunction,dementia,peripheralartery
disease,previousheartfailure,andpreviousmyocardialinfarctionarethecomorbid
conditionsthatpredictmortalityinNSTEMIACS. [12]Inpatientswithcomorbid
conditions,thehighestriskperiodwasinthefirstweeksafterNSTEMIACS.In
hospitalmanagementofpatientswithcomorbidconditionsmeritsfurther
investigation.
PatientswithendstagerenaldiseaseoftendevelopACS,andlittleisknownabout
thenaturalhistoryofACSinpatientsreceivingdialysis.Gurmetalexaminedthe
presentation,management,andoutcomesofpatientswithACSwhoreceived
dialysisbeforepresentationforanACS.ThesepatientswereenrolledintheGlobal
RegistryofAcuteCoronaryEvents(GRACE)at123hospitalsin14countriesfrom
19992007.
NSTEMIACSwasthemostcommoninpatientsreceivingdialysis,occurringin50%
ofpatients(290of579)versus33%(17,955of54,610)ofthosenotreceiving
dialysisTheinhospitalmortalityrateswerehigheramongpatientsreceivingdialysis
(12%vs4.8%p<0.0001).Higher6monthmortalityrates(13%vs4.2%p<
0.0001),recurrentmyocardialinfarctionincidence(7.6%vs2.9%p<0.0001),and
unplannedrehospitalizations(31%vs18%p<0.0001)werefoundamongthose
whosurvivedtodischarge.Outcomesinpatientswhoreceiveddialysiswasworse
thanwaspredictedbythecalculatedGRACEriskscoreforinhospitalmortality
(7.8%predictedvs12%observedp<0.05).ThissuggeststhattheGRACErisk
scoreunderestimatedtheriskofmajoreventsinthesepatients. [13]
InastudythatassessedtheimpactofprehospitaltimeonSTEMIoutcome,
Chughataietalsuggestthat"totaltimetotreatment"shouldbeusedasacore
measureinsteadof"doortoballoontime." [14]Thisisbecauseonscenetimewas
thebiggestfractionof"prehospitaltime."Thestudycomparedgroupswithtotal
timetotreatmentofmorethan120minutescomparedwith120minutesorlessand
foundmortalitieswere4comparedwith0andtransferstoatertiarycarefacility
were3comparedwith1,respectively.

STEMImechanismsandstentingoutcomesimilarinwomenand
men
Despitetheirsmallercoronaryvesselsandhigherriskprofile,womenwithSTEMI
appeartorespondjustaswellasmentoprimaryPCIandstenting,accordingtothe
OpticalCoherenceTomographyAssessmentofGenderDiversityinPrimary
Angioplasty(OCTAVIA)study. [15]OCTAVIA,whichwasdesignedtoexamine
genderdifferencesatthetimeofprimaryPCI,included140STEMIpatientsat14
Italiancenters,matchedbyageandriskfactors,whoreceivedaneverolimuseluting

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stent. [15]
OninitialOCT,nodifferencesbygenderwerefoundintheproportionofrupturedor
erodedplaques,thussuggestingthatthepathophysiologyofSTEMIisnearly
identicalinmenandwomen. [15]OnrepeatOCTatninemonths,intendedtoassess
stenthealing,morethan90%ofbothmenandwomenhadfullycoveredstent
struts.AlthoughOCTAVIAwasnotpoweredforclinicalendpoints,nosignificant
differencesindeath,reinfarction,stroke,stentthrombosis,ortargetvessel
reinterventionwereevidentatoneyear. [15]

PatientEducation
Patienteducationofriskfactorsisimportant,butmoreattentionisneeded
regardingdelaysindoortoballoontime,andonemajorbarriertoimprovingthis
delayispatienteducationregardinghisorhersymptoms.Lackofrecognitionof
symptomsmaycausetremendousdelaysinseekingmedicalattention.
Educatepatientsaboutthedangersofcigarettesmoking,amajorriskfactorfor
coronaryarterydisease(CAD).Theriskofrecurrentcoronaryeventsdecreases50%
at1yearaftersmokingcessation.Provideallpatientswhosmokewithguidance,
education,andsupporttoavoidsmoking.Smokingcessationclassesshouldbe
offeredtohelppatientsavoidsmokingafteramyocardialinfarction.Bupropion
increasesthelikelihoodofsuccessfulsmokingcessation.
DietplaysanimportantroleinthedevelopmentofCAD.Therefore,priortohospital
discharge,apatientwhohashadamyocardialinfarctionshouldbeevaluatedbya
dietitian.Patientsshouldbeinformedaboutthebenefitsofalowcholesterol,low
saltdiet.Inaddition,educatepatientsaboutAHAdietaryguidelinesregardinga
lowfat,lowcholesteroldiet.
Acardiacrehabilitationprogramafterdischargemayreinforceeducationand
enhancecompliance.
ThefollowingmnemonicmayusefulineducatingpatientswithCADregarding
treatmentsandlifestylechangesnecessitatedbytheircondition:
A=Aspirinandantianginals
B=Betablockersandbloodpressure(BP)
C=Cholesterolandcigarettes
D=Dietanddiabetes
E=Exerciseandeducation
Forpatientsbeingdischargedhome,emphasizethefollowing:
Timelyfollowupwithprimarycareprovider
Compliancewithdischargemedications,specificallyaspirinandother
medicationsusedtocontrolsymptoms
NeedtoreturntotheEDforanychangeinfrequencyorseverityof
symptoms
Forpatienteducationresources,seetheHeartHealthCenterandCholesterol
Center,aswellasHighCholesterol,CholesterolCharts(WhattheNumbersMean),
LifestyleCholesterolManagement,ChestPain,CoronaryHeartDisease,Heart
Attack,AnginaPectoris,CholesterolLoweringMedications,andStatinsfor
Cholesterol.
ClinicalPresentation

ContributorInformationandDisclosures
Author
DavidLCoven,MD,PhDAssistantProfessorofClinicalMedicine,ColumbiaUniversityCollegeofPhysicians
andSurgeonsDirector,CardiologyOutpatientClinic,StLukesSite,AttendingPhysician,Departmentof
Medicine,DivisionofCardiology,StLukesRooseveltHospitalCenter
DavidLCoven,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
AmericanMedicalAssociation,MassachusettsMedicalSociety
Disclosure:Nothingtodisclose.
Coauthor(s)
JamshidShirani,MDDirectorofCardiologyFellowshipProgram,DirectorofEchocardiographyLaboratory,
DirectorofHypertrophicCardiomyopathyClinic,StLuke'sUniversityHealthNetwork
JamshidShirani,MDisamemberofthefollowingmedicalsocieties:AmericanAssociationfortheAdvancement
ofScience,AmericanFederationforMedicalResearch,AmericanSocietyofEchocardiography,Associationof
SubspecialtyProfessors,AmericanCollegeofCardiology,AmericanCollegeofPhysicians,AmericanHeart
Association
Disclosure:Nothingtodisclose.
ArunKalyanasundaram,MD,MPHInterventionalCardiologyFellow,DepartmentofCardiology,Cleveland
Clinic
ArunKalyanasundaram,MD,MPHisamemberofthefollowingmedicalsocieties:AmericanCollegeof
Cardiology,AmericanCollegeofPhysicians,AmericanHeartAssociation,SocietyforCardiovascular
AngiographyandInterventions,SocietyofGeneralInternalMedicine,SouthernMedicalAssociation,Societyof
HospitalMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.

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ChiefEditor
EricHYang,MDAssociateProfessorofMedicine,DirectorofCardiacCatherizationLaboratoryand
InterventionalCardiology,MayoClinicArizona
EricHYang,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha
Disclosure:Nothingtodisclose.
Acknowledgements
CraigTBasson,MD,PhDGladysandRolandHarrimanProfessorofMedicine,DirectoroftheCenterfor
MolecularCardiology,DirectorofCardiovascularResearch,DivisionofCardiology,DepartmentofMedicine,Weill
CornellMedicalCollegeAttendingPhysician,NewYorkPresbyterianHospital
CraigTBasson,MD,PhDisamemberofthefollowingmedicalsocieties:AmericanCollegeofCardiologyand
AmericanHeartAssociation
Disclosure:Nothingtodisclose.
EdwardBessman,MD,MBAChairmanandClinicalDirector,DepartmentofEmergencyMedicine,John
HopkinsBayviewMedicalCenterAssistantProfessor,DepartmentofEmergencyMedicine,JohnsHopkins
UniversitySchoolofMedicine
EdwardBessman,MD,MBAisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanCollegeofEmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
DavidFMBrown,MDAssociateProfessor,DivisionofEmergencyMedicine,HarvardMedicalSchoolVice
Chair,DepartmentofEmergencyMedicine,MassachusettsGeneralHospital
DavidFMBrown,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
PhysiciansandSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
StevenJCompton,MD,FACC,FACPDirectorofCardiacElectrophysiology,AlaskaHeartInstitute,Providence
andAlaskaRegionalHospitals
StevenJCompton,MD,FACC,FACPisamemberofthefollowingmedicalsocieties:AlaskaStateMedical
Association,AmericanCollegeofCardiology,AmericanCollegeofPhysicians,AmericanHeartAssociation,
AmericanMedicalAssociation,andHeartRhythmSociety
Disclosure:Nothingtodisclose.
GarySetnik,MDChair,DepartmentofEmergencyMedicine,MountAuburnHospitalAssistantProfessor,
DivisionofEmergencyMedicine,HarvardMedicalSchool
GarySetnik,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,
NationalAssociationofEMSPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:SironaHealthSalaryManagementpositionSouthMiddlesexEMSConsortiumSalaryManagement
positionProceduresConsult.comRoyaltyOther
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1. ChouR,fortheHighValueCareTaskForceoftheAmericanCollegeofPhysicians.Cardiacscreeningwith
electrocardiography,stressechocardiography,ormyocardialperfusionimaging:adviceforhighvaluecare
fromtheAmericanCollegeofPhysicians.AnnInternMed.2015Mar17.162(6):43847.[Medline].
2. HammCW,BassandJP,AgewallS,etal.ESCGuidelinesforthemanagementofacutecoronary
syndromesinpatientspresentingwithoutpersistentSTsegmentelevation:TheTaskForceforthe
managementofacutecoronarysyndromes(ACS)inpatientspresentingwithoutpersistentSTsegment
elevationoftheEuropeanSocietyofCardiology(ESC).EurHeartJ.2011Sep21.[Medline].
3. AlpertJS,ThygesenK,AntmanE,BassandJP.Myocardialinfarctionredefinedaconsensusdocumentof
TheJointEuropeanSocietyofCardiology/AmericanCollegeofCardiologyCommitteefortheredefinition
ofmyocardialinfarction.JAmCollCardiol.2000Sep.36(3):95969.[Medline].
4. O'ConnorRE,BossaertL,ArntzHR,BrooksSC,DiercksD,FeitosaFilhoG,etal.Part9:acutecoronary
syndromes:2010InternationalConsensusonCardiopulmonaryResuscitationandEmergency
CardiovascularCareScienceWithTreatmentRecommendations.Circulation.2010Oct19.122(16Suppl
2):S42265.[Medline].
5. GardnerLS,NguyenPhamS,GreensladeJH,etal.Admissionglycaemiaanditsassociationwithacute
coronarysyndromeinEmergencyDepartmentpatientswithchestpain.EmergMedJ.2014Oct24.
[Medline].
6. BoggsW.Bloodglucosepredictsoutcomesofpatientswithchestpain.ReutersHealthInformation.
November11,2014.[FullText].
7. AntmanEM,TanasijevicMJ,ThompsonB,SchactmanM,McCabeCH,CannonCP,etal.Cardiacspecific
troponinIlevelstopredicttheriskofmortalityinpatientswithacutecoronarysyndromes.NEnglJMed.
1996Oct31.335(18):13429.[Medline].
8. HeidenreichPA,AlloggiamentoT,MelsopK,McDonaldKM,GoAS,HlatkyMA.Theprognosticvalueof
troponininpatientswithnonSTelevationacutecoronarysyndromes:ametaanalysis.JAmCollCardiol.
2001Aug.38(2):47885.[Medline].
9. BangaloreS,QinJ,SloanS,MurphySA,CannonCP.Whatistheoptimalbloodpressureinpatientsafter
acutecoronarysyndromes?:RelationshipofbloodpressureandcardiovasculareventsinthePRavastatin
ORatorVastatinEvaluationandInfectionTherapyThrombolysisInMyocardialInfarction(PROVEITTIMI)
22trial.Circulation.2010Nov23.122(21):214251.[Medline].

http://emedicine.medscape.com/article/1910735overview

6/11

14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

10. LeLeikoRM,VaccariCS,SolaS,MerchantN,NagamiaSH,ThoenesM,etal.Usefulnessofelevationsin
serumcholineandfreeF2)isoprostanetopredict30daycardiovascularoutcomesinpatientswithacute
coronarysyndrome.AmJCardiol.2009Sep1.104(5):63843.[Medline].
11. MaRC,TongPC.Testosteronelevelsandcardiovasculardisease.Heart.2010Nov.96(22):17878.
[Medline].
12. SanchisJ,NunezJ,BodiV,etal.InfluenceofcomorbidconditionsononeyearoutcomesinnonST
segmentelevationacutecoronarysyndrome.MayoClinProc.2011Apr.86(4):2916.[Medline].[FullText].
13. GurmHS,GoreJM,AndersonFAJr,etal.ComparisonofAcuteCoronarySyndromeinPatientsReceiving
VersusNotReceivingChronicDialysis(fromtheGlobalRegistryofAcuteCoronaryEvents[GRACE]
Registry).AmJCardiol.2012Jan1.109(1):1925.[Medline].
14. ChughtaiH,RatnerD,PozoM,etal.PrehospitaldelayanditsimpactontimetotreatmentinSTelevation
myocardialinfarction.AmJEmergMed.2011May.29(4):396400.[Medline].
15. WoodS.STEMIinWomen:SamePlaques,SameStentOutcomes:OCTAVIA.MedscapeMedicalNews.
Availableathttp://www.medscape.com/viewarticle/825391.Accessed:May27,2014.
16. ThanM,CullenL,ReidCM,LimSH,AldousS,ArdaghMW,etal.A2hdiagnosticprotocoltoassess
patientswithchestpainsymptomsintheAsiaPacificregion(ASPECT):aprospectiveobservational
validationstudy.Lancet.2011Mar26.377(9771):107784.[Medline].
17. ScheuermeyerFX,InnesG,GrafsteinE,etal.SafetyandEfficiencyofaChestPainDiagnosticAlgorithm
WithSelectiveOutpatientStressTestingforEmergencyDepartmentPatientsWithPotentialIschemic
ChestPain.AnnEmergMed.2012Jan4.[Medline].
18. AmsterdamEA,WengerNK.The2014AmericanCollegeofCardiologyACC/AmericanHeartAssociation
guidelineforthemanagementofpatientswithnonSTelevationacutecoronarysyndromes:ten
contemporaryrecommendationstoaidcliniciansinoptimizingpatientoutcomes.ClinCardiol.2015Feb.
38(2):1213.[Medline].
19. KellerT,ZellerT,OjedaF,etal.SerialchangesinhighlysensitivetroponinIassayandearlydiagnosisof
myocardialinfarction.JAMA.2011Dec28.306(24):268493.[Medline].
20. O'NeilBJ,HoekstraJ,PrideYB,LefebvreC,DiercksD,FrankPeacockW,etal.Incrementalbenefitof80
leadelectrocardiogrambodysurfacemappingoverthe12leadelectrocardiograminthedetectionofacute
coronarysyndromesinpatientswithoutSTelevationmyocardialinfarction:ResultsfromtheOptimal
CardiovascularDiagnosticEvaluationEnablingFasterTreatmentofMyocardialInfarction(OCCULTMI)
trial.AcadEmergMed.2010Sep.17(9):9329.[Medline].
21. DammanP,HolmvangL,TijssenJG,etal.UsefulnessoftheAdmissionElectrocardiogramtoPredict
LongTermOutcomesAfterNonSTElevationAcuteCoronarySyndrome(fromtheFRISCII,ICTUS,and
RITA3[FIR]Trials).AmJCardiol.2012Jan1.109(1):612.[Medline].
22. DammanP,WallentinL,FoxKA,etal.LongTermCardiovascularMortalityAfterProcedureRelatedor
SpontaneousMyocardialInfarctioninPatientsWithNonSTSegmentElevationAcuteCoronary
Syndrome:ACollaborativeAnalysisofIndividualPatientDataFromtheFRISCII,ICTUS,andRITA3
Trials(FIR).Circulation.2012Jan31.125(4):56876.[Medline].
23. IliouMC,FumeronC,BenoitMO,TuppinP,CalongeVM,MoattiN,etal.Prognosticvalueofcardiac
markersinESRD:ChronicHemodialysisandNewCardiacMarkersEvaluation(CHANCE)study.AmJ
KidneyDis.2003Sep.42(3):51323.[Medline].
24. OhmanEM,ArmstrongPW,ChristensonRH,GrangerCB,KatusHA,HammCW,etal.Cardiactroponin
Tlevelsforriskstratificationinacutemyocardialischemia.GUSTOIIAInvestigators.NEnglJMed.1996
Oct31.335(18):133341.[Medline].
25. LindahlB,TossH,SiegbahnA,VengeP,WallentinL.Markersofmyocardialdamageandinflammationin
relationtolongtermmortalityinunstablecoronaryarterydisease.FRISCStudyGroup.Fragminduring
InstabilityinCoronaryArteryDisease.NEnglJMed.2000Oct19.343(16):113947.[Medline].
26. NewbyLK,ChristensonRH,OhmanEM,ArmstrongPW,ThompsonTD,LeeKL,etal.Valueofserial
troponinTmeasuresforearlyandlateriskstratificationinpatientswithacutecoronarysyndromes.The
GUSTOIIaInvestigators.Circulation.1998Nov3.98(18):18539.[Medline].
27. LindahlB,VengeP,WallentinL.RelationbetweentroponinTandtheriskofsubsequentcardiaceventsin
unstablecoronaryarterydisease.TheFRISCstudygroup.Circulation.1996May1.93(9):16517.
[Medline].
28. StubbsP,CollinsonP,MoseleyD,GreenwoodT,NobleM.Prognosticsignificanceofadmissiontroponin
Tconcentrationsinpatientswithmyocardialinfarction.Circulation.1996Sep15.94(6):12917.[Medline].
29. AppleFS,ParvinCA,BuechlerKF,ChristensonRH,WuAH,JaffeAS.Validationofthe99thpercentile
cutoffindependentofassayimprecision(CV)forcardiactroponinmonitoringforrulingoutmyocardial
infarction.ClinChem.2005Nov.51(11):2198200.[Medline].
30. EggersKM,OldgrenJ,NordenskjldA,LindahlB.Diagnosticvalueofserialmeasurementofcardiac
markersinpatientswithchestpain:limitedvalueofaddingmyoglobintotroponinIforexclusionof
myocardialinfarction.AmHeartJ.2004Oct.148(4):57481.[Medline].
31. MacraeAR,KavsakPA,LustigV,BhargavaR,VandersluisR,PalomakiGE,etal.Assessingthe
requirementforthe6hourintervalbetweenspecimensintheAmericanHeartAssociationClassificationof
MyocardialInfarctioninEpidemiologyandClinicalResearchStudies.ClinChem.2006May.52(5):8128.
[Medline].
32. KavsakPA,MacRaeAR,NewmanAM,LustigV,PalomakiGE,KoDT,etal.Effectsofcontemporary
troponinassaysensitivityontheutilityoftheearlymarkersmyoglobinandCKMBisoformsinevaluating
patientswithpossibleacutemyocardialinfarction.ClinChimActa.2007May1.380(12):2136.[Medline].
33. MeuneC,BalmelliC,TwerenboldR,etal.PatientswithAcuteCoronarySyndromeandNormalHigh
sensitivityTroponin.AmJMed.2011Dec.124(12):11517.[Medline].
34. SaengerAK,JaffeAS.Requiemforaheavyweight:thedemiseofcreatinekinaseMB.Circulation.2008
Nov18.118(21):22006.[Medline].
35. SorensenJT,TerkelsenCJ,SteengaardC,etal.PrehospitaltroponinTtestinginthediagnosisandtriage
ofpatientswithsuspectedacutemyocardialinfarction.AmJCardiol.2011May15.107(10):143640.
[Medline].

http://emedicine.medscape.com/article/1910735overview

7/11

14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

36. AndersonJL,AdamsCD,AntmanEM,BridgesCR,CaliffRM,CaseyDEJr,etal.ACC/AHA2007
guidelinesforthemanagementofpatientswithunstableangina/nonSTElevationmyocardialinfarction:a
reportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForceonPractice
Guidelines(WritingCommitteetoRevisethe2002GuidelinesfortheManagementofPatientsWith
UnstableAngina/NonSTElevationMyocardialInfarction)developedincollaborationwiththeAmerican
CollegeofEmergencyPhysicians,theSocietyforCardiovascularAngiographyandInterve...JAmColl
Cardiol.2007Aug14.50(7):e1e157.[Medline].
37. VengeP,OhbergC,FlodinM,LindahlB.Earlyandlateoutcomepredictionofdeathintheemergency
roomsettingbypointofcareandlaboratoryassaysofcardiactroponinI.AmHeartJ.2010Nov.
160(5):83541.[Medline].
38. O'RiordanM.NegativeTroponinandCopeptinTestsRuleOutAcuteCoronarySyndrome.Medscape
MedicalNews.Sep32013.[FullText].
39. MisraD,LeibowitzK,GowdaRM,ShapiroM,KhanIA.RoleofNacetylcysteineinpreventionofcontrast
inducednephropathyaftercardiovascularprocedures:ametaanalysis.ClinCardiol.2004Nov.27(11):607
10.[Medline].
40. CharpentierS,CournotM,LauqueD,etal.Usefulnessofinitialglucoseleveltoimproveacutecoronary
syndromediagnosisintheemergencydepartment.EmergMedJ.2011Jul.28(7):5648.[Medline].
41. deLemosJA,MorrowDA,BentleyJH,OmlandT,SabatineMS,McCabeCH,etal.Theprognosticvalue
ofBtypenatriureticpeptideinpatientswithacutecoronarysyndromes.NEnglJMed.2001Oct4.
345(14):101421.[Medline].
42. JamesSK,LindahlB,SiegbahnA,StridsbergM,VengeP,ArmstrongP,etal.Nterminalprobrain
natriureticpeptideandotherriskmarkersfortheseparatepredictionofmortalityandsubsequent
myocardialinfarctioninpatientswithunstablecoronaryarterydisease:aGlobalUtilizationofStrategiesTo
Openoccludedarteries(GUSTO)IVsubstudy.Circulation.2003Jul22.108(3):27581.[Medline].
43. HubbardBL,NewtonCR,CarterPM,FowlerJJ,SchaldenbrandJ,SingalB,etal.TheinabilityofBtype
natriureticproteintopredictshorttermriskofdeathormyocardialinfarctioninnonheartfailurepatients
withmarginallyincreasedtroponinlevels.AnnEmergMed.2010Nov.56(5):47280.[Medline].
44. CavusogluE,MarmurJD,HojjatiMR,etal.Plasmainterleukin10levelsandadverseoutcomesinacute
coronarysyndrome.AmJMed.2011Aug.124(8):72430.[Medline].
45. GiuglianoRP,BraunwaldE.TheyearinnonSTsegmentelevationacutecoronarysyndrome.JAmColl
Cardiol.2008Sep23.52(13):1095103.[Medline].
46. JaffeAS,BabuinL,AppleFS.Biomarkersinacutecardiacdisease:thepresentandthefuture.JAmColl
Cardiol.2006Jul4.48(1):111.[Medline].
47. HjortshojS,KristensenSR,RavkildeJ.Diagnosticvalueofischemiamodifiedalbumininpatientswith
suspectedacutecoronarysyndrome.AmJEmergMed.2010Feb.28(2):1706.[Medline].
48. KatritsisDG,SiontisGC,KastratiA,van'tHofAW,NeumannFJ,SiontisKC,etal.Optimaltimingof
coronaryangiographyandpotentialinterventioninnonSTelevationacutecoronarysyndromes.EurHeart
J.2011Jan.32(1):3240.[Medline].
49. AntmanEM,CohenM,BerninkPJ,McCabeCH,HoracekT,PapuchisG,etal.TheTIMIriskscorefor
unstableangina/nonSTelevationMI:Amethodforprognosticationandtherapeuticdecisionmaking.
JAMA.2000Aug16.284(7):83542.[Medline].
50. NabiF,ChangSM,PrattCM,ParanilamJ,PetersonLE,FriasME,etal.Coronaryarterycalciumscoring
intheemergencydepartment:identifyingwhichpatientswithchestpaincanbesafelydischargedhome.
AnnEmergMed.2010Sep.56(3):2209.[Medline].
51. RogersIS,BanerjiD,SiegelEL,TruongQA,GhoshhajraBB,IrlbeckT,etal.Usefulnessof
comprehensivecardiothoraciccomputedtomographyintheevaluationofacuteundifferentiatedchest
discomfortintheemergencydepartment(CAPTURE).AmJCardiol.2011Mar1.107(5):64350.
[Medline].
52. LittHI,GatsonisC,SnyderB,SinghH,MillerCD,EntrikinDW,etal.CTangiographyforsafedischargeof
patientswithpossibleacutecoronarysyndromes.NEnglJMed.2012Apr12.366(15):1393403.
[Medline].
53. RosenbergS,ElashoffMR,BeinekeP,DanielsSE,WingroveJA,TingleyWG.Multicentervalidationof
thediagnosticaccuracyofabloodbasedgeneexpressiontestforassessingobstructivecoronaryartery
diseaseinnondiabeticpatients.AnnInternMed.2010Oct5.153(7):42534.[Medline].
54. MillerCD,HwangW,HoekstraJW,CaseD,LefebvreC,BlumsteinH,etal.Stresscardiacmagnetic
resonanceimagingwithobservationunitcarereducescostforpatientswithemergentchestpain:a
randomizedtrial.AnnEmergMed.2010Sep.56(3):209219.e2.[Medline].
55. RogersIS,BanerjiD,SiegelEL,etal.Usefulnessofcomprehensivecardiothoraciccomputedtomography
intheevaluationofacuteundifferentiatedchestdiscomfortintheemergencydepartment(CAPTURE).Am
JCardiol.2011Mar1.107(5):64350.[Medline].
56. MehtaSR,YusufS.TheClopidogrelinUnstableanginatopreventRecurrentEvents(CURE)trial
programmerationale,designandbaselinecharacteristicsincludingametaanalysisoftheeffectsof
thienopyridinesinvasculardisease.EurHeartJ.2000Dec.21(24):203341.[Medline].
57. StoneGW,MaeharaA,LanskyAJ,deBruyneB,CristeaE,MintzGS,etal.Aprospectivenaturalhistory
studyofcoronaryatherosclerosis.NEnglJMed.2011Jan20.364(3):22635.[Medline].
58. RosnerGF,KirtaneAJ,GenereuxP,LanskyAJ,CristeaE,GershBJ,etal.ImpactofthePresenceand
ExtentofIncompleteAngiographicRevascularizationAfterPercutaneousCoronaryInterventioninAcute
CoronarySyndromes:TheAcuteCatheterizationandUrgentInterventionTriageStrategy(ACUITY)Trial.
Circulation.2012May29.125(21):261320.[Medline].
59. YanTD,PadangR,PohC,etal.Drugelutingstentsversuscoronaryarterybypassgraftingforthe
treatmentofcoronaryarterydisease:ametaanalysisofrandomizedandnonrandomizedstudies.JThorac
CardiovascSurg.2011May.141(5):113444.[Medline].
60. RibichiniF,TomaiF,DeLucaG,etal.ImmunosuppressiveTherapywithOralPrednisonetoPrevent
RestenosisafterPCI.AMulticenterRandomizedTrial.AmJMed.2011May.124(5):43443.[Medline].
61. StoneGW,WitzenbichlerB,GuagliumiG,etal.HeparinplusaglycoproteinIIb/IIIainhibitorversus

http://emedicine.medscape.com/article/1910735overview

8/11

14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

bivalirudinmonotherapyandpaclitaxelelutingstentsversusbaremetalstentsinacutemyocardialinfarction
(HORIZONSAMI):final3yearresultsfromamulticentre,randomisedcontrolledtrial.Lancet.2011Jun25.
377(9784):2193204.[Medline].
62. MehtaSR,GrangerCB,BodenWE,StegPG,BassandJP,FaxonDP,etal.Earlyversusdelayedinvasive
interventioninacutecoronarysyndromes.NEnglJMed.2009May21.360(21):216575.[Medline].
63. JernbergT,JohansonP,HeldC,etal.Associationbetweenadoptionofevidencebasedtreatmentand
survivalforpatientswithSTelevationmyocardialinfarction.JAMA.2011Apr27.305(16):167784.
[Medline].
64. ThadaniU,OpieLH.Nitratesforunstableangina.CardiovascDrugsTher.1994Oct.8(5):71926.
[Medline].
65. CollaborativeoverviewofrandomisedtrialsofantiplatelettherapyI:Preventionofdeath,myocardial
infarction,andstrokebyprolongedantiplatelettherapyinvariouscategoriesofpatients.Antiplatelet
Trialists'Collaboration.BMJ.1994Jan8.308(6921):81106.[Medline].[FullText].
66. [Guideline]WrightRS,AndersonJL,AdamsCD,BridgesCR,CaseyDEJr,EttingerSM,etal.2011
ACCF/AHAFocusedUpdateoftheGuidelinesfortheManagementofPatientsWithUnstableAngina/
NonSTElevationMyocardialInfarction(Updatingthe2007Guideline):AReportoftheAmericanCollege
ofCardiologyFoundation/AmericanHeartAssociationTaskForceonPracticeGuidelines.Circulation.2011
May10.123(18):202260.[Medline].[FullText].
67. NijjerSS,WatsonG,AthanasiouT,MalikIS.Safetyofclopidogrelbeingcontinueduntilthetimeof
coronaryarterybypassgraftinginpatientswithacutecoronarysyndrome:ametaanalysisof34studies.
EurHeartJ.2011Dec.32(23):297088.[Medline].
68. MorelO,ElGhannudiS,JeselL,RadulescuB,MeyerN,WieselML,etal.Cardiovascularmortalityin
chronickidneydiseasepatientsundergoingpercutaneouscoronaryinterventionismainlyrelatedtoimpaired
P2Y12inhibitionbyclopidogrel.JAmCollCardiol.2011Jan25.57(4):399408.[Medline].
69. [Guideline]AbrahamNS,Hlatky,MA,AntmanEM,BhattDL,BjorkmanDJ,etal.ACCF/ACG/AHA2010
expertconsensusdocumentontheconcomitantuseofprotonpumpinhibitorsandthienopyridines:a
focusedupdateoftheACCF/ACG/AHA2008expertconsensusdocumentonreducingthegastrointestinal
risksofantiplatelettherapyandNSAIDuse.JAmCollCardiol.PublishedonlineNovember8,2010:[Full
Text].
70. Dexilant(dexlansoprazole).PrescribinginformationrevisedOctober28,2011.TakedaPharmaceutical
CompanyLTD.Availableathttp://www.accessdata.fda.gov/drugsatfda_docs/label/2011/022287s011lbl.pdf.
71. Prevacid(lansoprazole).PrescribinginformationrevisedOctober28,2011.TakedaPharmaceutical
CompanyLTD.Availableat
http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020406s076,021428s023lbl.pdf.
72. SquizzatoA,KellerT,RomualdiE,MiddeldorpS.Clopidogrelplusaspirinversusaspirinalonefor
preventingcardiovasculardisease.CochraneDatabaseSystRev.2011Jan19.CD005158.[Medline].
73. SimonT,StegPG,GilardM,BlanchardD,BonelloL,HanssenM,etal.ClinicalEventsasaFunctionof
ProtonPumpInhibitorUse,ClopidogrelUse,andCytochromeP4502C19GenotypeinaLargeNationwide
CohortofAcuteMyocardialInfarction:ResultsFromtheFrenchRegistryofAcuteSTElevationandNon
STElevationMyocardialInfarction(FASTMI)Registry.Circulation.2011Feb8.123(5):47482.[Medline].
74. MorrowDA,WiviottSD,WhiteHD,NicolauJC,BramucciE,MurphySA,etal.Effectofthenovel
thienopyridineprasugrelcomparedwithclopidogrelonspontaneousandproceduralmyocardialinfarctionin
theTrialtoAssessImprovementinTherapeuticOutcomesbyOptimizingPlateletInhibitionwithPrasugrel
ThrombolysisinMyocardialInfarction38:anapplicationoftheclassificationsystemfromtheuniversal
definitionofmyocardialinfarction.Circulation.2009Jun2.119(21):275864.[Medline].
75. MontalescotG,ColletJP,EcollanP,etal.EffectofPrasugrelPreTreatmentStrategyinPatients
UndergoingPercutaneousCoronaryInterventionforNSTEMI:TheACCOASTPCIStudy.JAmColl
Cardiol.2014Dec23.64(24):256371.[Medline].
76. BoggsW.HoldPrasugrelUntilRevascularizationDecisionIsMade,ResearchersSay.Medscape.Dec18
2014.[FullText].
77. WiviottSD,BraunwaldE,McCabeCH,MontalescotG,RuzylloW,GottliebS,etal.Prasugrelversus
clopidogrelinpatientswithacutecoronarysyndromes.NEnglJMed.2007Nov15.357(20):200115.
[Medline].
78. RoeMT,ArmstrongPW,FoxKA,WhiteHD,PrabhakaranD,GoodmanSG,etal.Prasugrelversus
ClopidogrelforAcuteCoronarySyndromeswithoutRevascularization.NEnglJMed.2012Aug25.
[Medline].
79. SciricaBM,BonacaMP,BraunwaldE,DeFerrariGM,IsazaD,LewisBS,etal.Vorapaxarforsecondary
preventionofthromboticeventsforpatientswithpreviousmyocardialinfarction:aprespecifiedsubgroup
analysisoftheTRA2PTIMI50trial.Lancet.2012Oct13.380(9850):131724.[Medline].
80. JamesS,AkerblomA,CannonCP,EmanuelssonH,HustedS,KatusH,etal.Comparisonofticagrelor,
thefirstreversibleoralP2Y(12)receptorantagonist,withclopidogrelinpatientswithacutecoronary
syndromes:Rationale,design,andbaselinecharacteristicsofthePLATeletinhibitionandpatient
Outcomes(PLATO)trial.AmHeartJ.2009Apr.157(4):599605.[Medline].
81. DouglasD.Ticagrelormorecardioprotectivethanclopidogrel.MedscapeMedicalNews.Jan11,2013.
Availableathttp://www.medscape.com/viewarticle/777535.Accessed:January23,2013.
82. KohliP,WallentinL,ReyesE,HorrowJ,HustedS,AngiolilloDJ,etal.ReductioninFirstandRecurrent
CardiovascularEventswithTicagrelorComparedwithClopidogrelinthePLATOStudy.Circulation.2012
Dec31.[Medline].
83. USFDAapprovesexpandedindicationforBRILINTAtoincludelongtermuseinpatientswithahistoryof
heartattack[pressrelease].AstraZeneca.Availableathttp://www.astrazeneca.com/Media/Press
releases/Article/20150903.September3,2015Accessed:September9,2015.
84. BonacaMP,BhattDL,CohenM,etal,forthePEGASUSTIMI54SteeringCommitteeandInvestigators.
Longtermuseofticagrelorinpatientswithpriormyocardialinfarction.NEnglJMed.2015May7.372
(19):1791800.[Medline].
85. O'RiordanM.Ticagrelorbestsclopidogrelforreducingstentthrombosisrisk:PLATO.MedscapeMedical

http://emedicine.medscape.com/article/1910735overview

9/11

14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

News.August2,2013.[FullText].
86. StegPG,HarringtonRA,EmanuelssonH,KatusHA,MahaffeyKW,MeierB,etal.StentThrombosiswith
TicagrelorversusClopidogrelinPatientswithAcuteCoronarySyndromes:AnAnalysisfromthe
ProspectiveRandomizedPLATOTrial.Circulation.2013Jul30.[Medline].
87. KastratiA,MehilliJ,NeumannFJ,DotzerF,tenBergJ,BollweinH,etal.Abciximabinpatientswith
acutecoronarysyndromesundergoingpercutaneouscoronaryinterventionafterclopidogrelpretreatment:
theISARREACT2randomizedtrial.JAMA.2006Apr5.295(13):15318.[Medline].
88. RoffiM,MoliternoDJ,MeierB,PowersER,GrinesCL,DiBattistePM,etal.Impactofdifferentplatelet
glycoproteinIIb/IIIareceptorinhibitorsamongdiabeticpatientsundergoingpercutaneouscoronary
intervention::DoTirofibanandReoProGiveSimilarEfficacyOutcomesTrial(TARGET)1yearfollowup.
Circulation.2002Jun11.105(23):27306.[Medline].
89. RoeMT,HarringtonRA,ProsperDM,PieperKS,BhattDL,LincoffAM,etal.Clinicalandtherapeutic
profileofpatientspresentingwithacutecoronarysyndromeswhodonothavesignificantcoronaryartery
disease.ThePlateletGlycoproteinIIb/IIIainUnstableAngina:ReceptorSuppressionUsingIntegrilin
Therapy(PURSUIT)TrialInvestigators.Circulation.2000Sep5.102(10):11016.[Medline].
90. TherouxP,AlexanderJJr,PharandC,etal.GlycoproteinIIb/IIIareceptorblockadeimprovesoutcomesin
diabeticpatientspresentingwithunstableangina/nonSTelevationmyocardialinfarction:resultsfromthe
PlateletReceptorInhibitioninIschemicSyndromeManagementinPatientsLimitedbyUnstableSignsand
Symptoms(PRISMPLUS)study.Circulation.2000Nov14.102(20):246672.[Medline].
91. GiuglianoRP,WhiteJA,BodeC,ArmstrongPW,MontalescotG,LewisBS,etal.Earlyversusdelayed,
provisionaleptifibatideinacutecoronarysyndromes.NEnglJMed.2009May21.360(21):217690.
[Medline].
92. ChadowHL,HauptmanRE,VanAukerM,RafiiSE,GunsburgMY,GiarraffaL,etal.Dripandship:anew
strategyforthetreatmentofacutecoronarysyndromes.JThrombThrombolysis.2000Aug.10(1):7782.
[Medline].
93. JanuzziJL,ChaeCU,SabatineMS,JangIK.ElevationinserumtroponinIpredictsthebenefitoftirofiban.
JThrombThrombolysis.2001May.11(3):2115.[Medline].
94. OlerA,WhooleyMA,OlerJ,GradyD.Addingheparintoaspirinreducestheincidenceofmyocardial
infarctionanddeathinpatientswithunstableangina.Ametaanalysis.JAMA.1996Sep11.276(10):811
5.[Medline].
95. StegPG,JollySS,MehtaSR,AfzalR,XavierD,RupprechtHJ,etal.Lowdosevsstandarddose
unfractionatedheparinforpercutaneouscoronaryinterventioninacutecoronarysyndromestreatedwith
fondaparinux:theFUTURA/OASIS8randomizedtrial.JAMA.2010Sep22.304(12):133949.[Medline].
96. FoxKA,AntmanEM,CohenM,BigonziF.Comparisonofenoxaparinversusunfractionatedheparinin
patientswithunstableanginapectoris/nonSTsegmentelevationacutemyocardialinfarctionhaving
subsequentpercutaneouscoronaryintervention.AmJCardiol.2002Sep1.90(5):47782.[Medline].
97. MahaffeyKW,FergusonJJ.Exploringtheroleofenoxaparininthemanagementofhighriskpatientswith
nonSTelevationacutecoronarysyndromes:theSYNERGYtrial.AmHeartJ.2005Apr.149(4
Suppl):S8190.[Medline].
98. LevEI,HasdaiD,ScapaE,TobarA,AssaliA,LahavJ,etal.Administrationofeptifibatidetoacute
coronarysyndromepatientsreceivingenoxaparinorunfractionatedheparin:effectonplateletfunctionand
thrombusformation.JAmCollCardiol.2004Mar17.43(6):96671.[Medline].
99. AlexanderJH,LopesRD,JamesS,etal.Apixabanwithantiplatelettherapyafteracutecoronary
syndrome.NEnglJMed.2011Aug25.365(8):699708.[Medline].
100. BoggsW.Lowerrivaroxabandosebetterinacutecoronarysyndrome.MedscapeMedicalNews.May30,
2013.[FullText].
101. MegaJL,BraunwaldE,WiviottSD,MurphySA,PlotnikovA,GotchevaN,etal.Comparisonofthe
EfficacyandSafetyofTwoRivaroxabanDosesinAcuteCoronarySyndrome(fromATLASACS2TIMI
51).AmJCardiol.2013May24.[Medline].
102. vanReesVellingaTE,PetersRJ,etal.EfficacyandsafetyoffondaparinuxinpatientswithSTsegment
elevationmyocardialinfarctionacrosstheagespectrum.ResultsfromtheOrganizationfortheAssessment
ofStrategiesforIschemicSyndromes6(OASIS6)trial.AmHeartJ.2010Dec.160(6):104955.[Medline].
103. JollySS,FaxonDP,FoxKA,etal.Efficacyandsafetyoffondaparinuxversusenoxaparininpatientswith
acutecoronarysyndromestreatedwithglycoproteinIIb/IIIainhibitorsorthienopyridines:resultsfromthe
OASIS5(FifthOrganizationtoAssessStrategiesinIschemicSyndromes)trial.JAmCollCardiol.2009
Jul28.54(5):46876.[Medline].
104. NajjarSS,RaoSV,MelloniC,etal.IntravenouserythropoietininpatientswithSTsegmentelevation
myocardialinfarction:REVEAL:arandomizedcontrolledtrial.JAMA.2011May11.305(18):186372.
[Medline].
105. SorensenJT,TerkelsenCJ,NorgaardBL,etal.Urbanandruralimplementationofprehospitaldiagnosis
anddirectreferralforprimarypercutaneouscoronaryinterventioninpatientswithacuteSTelevation
myocardialinfarction.EurHeartJ.2011Feb.32(4):4306.[Medline].
106. DammanP,HirschA,WindhausenF,TijssenJG,deWinterRJ.5yearclinicaloutcomesintheICTUS
(InvasiveversusConservativeTreatmentinUnstablecoronarySyndromes)trialarandomizedcomparison
ofanearlyinvasiveversusselectiveinvasivemanagementinpatientswithnonSTsegmentelevationacute
coronarysyndrome.JAmCollCardiol.2010Mar2.55(9):85864.[Medline].
107. StoneGW,McLaurinBT,CoxDA,BertrandME,LincoffAM,MosesJW,etal.Bivalirudinforpatientswith
acutecoronarysyndromes.NEnglJMed.2006Nov23.355(21):220316.[Medline].
108. KastratiA,NeumannFJ,SchulzS,etal.AbciximabandheparinversusbivalirudinfornonSTelevation
myocardialinfarction.NEnglJMed.2011Nov24.365(21):19809.[Medline].
109. BraunwaldE,AntmanEM,BeasleyJW,CaliffRM,CheitlinMD,HochmanJS,etal.ACC/AHAguideline
updateforthemanagementofpatientswithunstableanginaandnonSTsegmentelevationmyocardial
infarction2002:summaryarticle:areportoftheAmericanCollegeofCardiology/AmericanHeart
AssociationTaskForceonPracticeGuidelines(CommitteeontheManagementofPatientsWithUnstable
Angina).Circulation.2002Oct1.106(14):1893900.[Medline].

http://emedicine.medscape.com/article/1910735overview

10/11

14/10/2015

AcuteCoronarySyndrome:PracticeEssentials,Background,Etiology

110. BuenoH,BetriuA,HerasM,etal.Primaryangioplastyvs.fibrinolysisinveryoldpatientswithacute
myocardialinfarction:TRIANA(TRatamientodelInfartoAgudodemiocardioeNAncianos)randomizedtrial
andpooledanalysiswithpreviousstudies.EurHeartJ.2011Jan.32(1):5160.[Medline].[FullText].
111. ChangAM,WalshKM,ShoferFS,McCuskerCM,LittHI,HollanderJE.RelationshipBetweenCocaine
UseandCoronaryArteryDiseaseinPatientsWithSymptomsConsistentWithanAcuteCoronary
Syndrome.AcadEmergMed.2010Dec23.[Medline].
112. JamesS,AngiolilloDJ,CornelJH,ErlingeD,HustedS,KontnyF,etal.Ticagrelorvs.clopidogrelin
patientswithacutecoronarysyndromesanddiabetes:asubstudyfromthePLATeletinhibitionandpatient
Outcomes(PLATO)trial.EurHeartJ.2010Dec.31(24):300616.[Medline].[FullText].
113. [Guideline]KushnerFG,HandM,SmithSCJr,KingSB3rd,AndersonJL,AntmanEM,etal.2009
FocusedUpdates:ACC/AHAGuidelinesfortheManagementofPatientsWithSTElevationMyocardial
Infarction(updatingthe2004Guidelineand2007FocusedUpdate)andACC/AHA/SCAIGuidelineson
PercutaneousCoronaryIntervention(updatingthe2005Guidelineand2007FocusedUpdate):areportof
theAmericanCollegeofCardiologyFoundation/AmericanHeartAssociationTaskForceonPractice
Guidelines.Circulation.2009Dec1.120(22):2271306.[Medline].[FullText].
114. LopesRD,AlexanderKP,ManoukianSV,BertrandME,FeitF,WhiteHD,etal.Advancedage,
antithromboticstrategy,andbleedinginnonSTsegmentelevationacutecoronarysyndromes:resultsfrom
theACUITY(AcuteCatheterizationandUrgentInterventionTriageStrategy)trial.JAmCollCardiol.2009
Mar24.53(12):102130.[Medline].
115. MalkinCJ,PughPJ,MorrisPD,AsifS,JonesTH,ChannerKS.Lowserumtestosteroneandincreased
mortalityinmenwithcoronaryheartdisease.Heart.2010Nov.96(22):18215.[Medline].
116. MehtaSR,TanguayJF,EikelboomJW,JollySS,JoynerCD,GrangerCB,etal.Doubledoseversus
standarddoseclopidogrelandhighdoseversuslowdoseaspirininindividualsundergoingpercutaneous
coronaryinterventionforacutecoronarysyndromes(CURRENTOASIS7):arandomisedfactorialtrial.
Lancet.2010Oct9.376(9748):123343.[Medline].
117. MorrowDA,SciricaBM,KarwatowskaProkopczukE,MurphySA,BudajA,VarshavskyS,etal.Effectsof
ranolazineonrecurrentcardiovasculareventsinpatientswithnonSTelevationacutecoronarysyndromes:
theMERLINTIMI36randomizedtrial.JAMA.2007Apr25.297(16):177583.[Medline].
118. PareG,MehtaSR,YusufS,etal.EffectsofCYP2C19genotypeonoutcomesofclopidogreltreatment.N
EnglJMed.2010Oct28.363(18):170414.[Medline].
119. RaoSV,SherwoodMW.Isn'titabouttimewelearnedhowtousebloodtransfusioninpatientswith
ischemicheartdisease?.JAmCollCardiol.2013Dec6.[Medline].
120. SilvainJ,AbtanJ,KerneisM,MartinR,FinziJ,VignalouJB,etal.ImpactofRedBloodCellTransfusion
onPlateletAggregationandInflammatoryResponseinAnemicCoronaryandNonCoronaryPatientsThe
TRANSFUSION2study.JAmCollCardiol.2013Dec6.[Medline].
121. StilesS.MoreEvidenceThatBloodTransfusionsRaiseThrombosisRiskinACSPatients.Medscape
[serialonline].Availableathttp://www.medscape.com/viewarticle/818076.Accessed:December30,2013.

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/1910735overview

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