The LIPID (Long-Term Intervention with Pravastatin in Ischaemic Disease) trial demonstrated that, compared with placebo, pravastatin achieved a 26% reduction in mortality rates (P=.004) for patients with UA, as well as statistically significant reductions in the incidence of subsequent MI, coronary revascularization, and stroke.150 The PROVE IT (Pravastatin or Atorvastatin Evaluation and Infection Therapy)-TIMI 22 trial found that, compared with moderate lipid lowering after ACS with standard-dose pravastatin (40 mg/d), intensive lipid lowering with high-dose atorvastatin (80 mg/d) achieved a 16% reduction in the primary composite end point of all-cause death, MI, UA requiring rehospitalization or revascularization, and stroke.151 The benefit was linked to statistically significant reductions in both LDL cholesterol and CRP concentrations.152. Prasugrel is an irreversible P2Y12 ADP receptor antagonist that was recently approved by the US Food and Drug Administration. Acute coronary syndromes | Treatment summaries | BNF | NICE [34][35] This phenomenon is described as weekend effect. When this scoring system was used, patients could be stratified across a 10-fold gradient of risk ranging from 4.7% to 40.9% (P<.001).82 Thus, the TIMI risk score enables identification of or allows detection of high-risk patients, who have been shown to reap more benefit from newer, potent therapies such as GP IIb/IIIa inhibitors83 and an early invasive strategy.40,84 Other risk scores (ie, the GRACE [Global Registry of Acute Coronary Events] risk score and the PURSUIT [Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy] risk score) have greater value in predicting mortality.65,85,86 There are separate Throux P, Waters D, Qiu S, McCans J, de Guise P, Juneau M. Aspirin versus heparin to prevent myocardial infarction during the acute phase of unstable angina, Heparin resistance in acute coronary syndromes, Delayed-onset heparin-induced thrombocytopenia and thrombosis, Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin, Assessment of the treatment effect of enoxaparin for unstable Angina/Non-Q-wave myocardial infarction: TIMI 11B-ESSENCE meta-analysis, Ferguson JJ, Califf RM, Antman EM, et al.SYNERGY Trial Investigators, Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial, de Lemos JA, Blazing MA, Wiviott SD, et al.A to Z Investigators, Enoxaparin versus unfractionated heparin in patients treated with tirofiban, aspirin and an early conservative initial management strategy: results from the A phase of the A-to-Z trial. (PROVE IT-TIMI 22) Investigators, C-reactive protein levels and outcomes after statin therapy. QUICK TAKE Ticagrelor versus Prasugrel in Acute Coronary Syndromes 01:59. The platelet GP IIb/IIIa inhibitors are potent and specific inhibitors of platelet aggregation. [8][10], Though ACS is usually associated with coronary thrombosis, it can also be associated with cocaine use. Unauthorized use prohibited. Clopidogrel vs Aspirin in the Chronic Maintenance Period for Patients With Acute Coronary Syndrome. c For more details on management of patients with UA/NSTEMI after diagnostic angiography, see Figure 9 of reference 42. d See recommendations in section 3.2.3 of reference 42. ), Address correspondence to Amit Kumar, MD, Department of Hospital Medicine, University of Massachusetts Medical School, 55 Lake Ave N, Worcester, MA 01655 (, GUID:799AB898-AE9F-4539-B6F4-9BB94954B79C, Lloyd-Jones D, Adams R, Carnethon M, et al.American Heart Association Statistics Committee and Stroke Statistics Subcommittee, Heart disease and stroke statistics2009 update. Long-term antithrombotic therapy at hospital discharge after unstable angina (UA)/nonST-segment elevation myocardial infarction (NSTEMI). [29], The TIMI risk score can identify high risk patients in non-ST segment elevation MI ACS[30] and has been independently validated. Evidence for increased collagenolysis by interstitial collagenases-1 and -3 in vulnerable human atheromatous plaques, Expression of neutrophil collagenase (matrix metalloproteinase-8) in human atheroma: a novel collagenolytic pathway suggested by transcriptional profiling. [9], In unstable angina, symptoms may appear on rest or on minimal exertion. Each year in the United States, approximately 1.36 million hospitalizations are required for ACS (listed either as a primary or a secondary discharge diagnosis), of which 0.81 million are for myocardial infarction (MI) and the remainder are for UA. Glycoprotein IIb/IIIa receptor blockade improves outcomes in diabetic patients presenting with unstable angina/non-ST-elevation myocardial infarction: results from the Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) study, Platelet glycoprotein IIb/IIIa inhibitors reduce mortality in diabetic patients with non-ST-segment-elevation acute coronary syndromes. The 2007 ACC/AHA guidelines for managing UA/NSTEMI state that the first step in assessing patients with chest discomfort or other symptoms suggestive of ACS is Admission to the critical care unit is recommended if there is evidence of active, ongoing ischemia or injury or of hemodynamic or electrical instability; otherwise, placing patients in a telemetry step-down unit is reasonable. Direct Thrombin Inhibitors. Acute coronary syndrome is a term that describes a range of conditions related to sudden, reduced blood flow to the heart. Hyde TA, French JK, Wong CK, Straznicky IT, Whitlock RM, White HD. She is currently waiting for her first open-heart surgery after . Although only white clots are found in patients with UA/NSTEMI,33 red clots form in patients with STEMI.34 The differences in the underlying pathophysiology of UA/NSTEMI and STEMI call for different therapeutic goals and approaches. National Library of Medicine 2023 Jun 26;16 (12):1553-1555. doi: 10.1016/j.jcin.2023.03.004. These extend from acute myocardial infarction through minimal myocardial injury to unstable angina. Commissioners and providers. Aims: Guidelines recommend management with an invasive coronary angiogram in acute coronary syndromes (ACS), but most studies excluded patients with advanced chronic kidney disease (CKD). The benefits and risks of triple antithrombotic therapy with aspirin, clopidogrel, and warfarin have not been clearly established. A high rate of recurrent atherothrombotic events despite the administration of dual-antiplatelet therapy with aspirin and clopidogrel has sparked great interest in finding more potent inhibitors of the P2Y12 ADP receptor. Monocyte chemo attractive protein (MCP)-1 has been shown in a number of studies to identify patients with a higher risk of adverse outcomes after ACS. As Eylev Akboga 1 pointed out, an increased monocyte count and decreased high-density lipoprotein cholesterol (HDL-C) level as well as a high monocyte to HDL-C ratio (MHR), robust and reliable indicators of inflammatory status, were closely associated with severe CAD assessed by SYNTAX score, in-stent restenosis, and saphenous vein graft disease. For example, it does not adequately represent the posterior, lateral, and apical walls of the left ventricle. Saturday: 9 a.m. - 5 p.m. CT [26], If there is no evidence of ST segment elevation on the electrocardiogram, delaying urgent angioplasty until the next morning is not inferior to doing so immediately. Acute coronary syndrome. The term acute coronary syndrome (ACS) refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), nonST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). This topic will review the evidence that supports the use of parenteral anticoagulant therapy in all patients with acute non-ST elevation acute coronary syndromes (NSTEACS), which include both unstable angina and acute non-ST elevation myocardial infarction. These include: Your health care professional can help you understand your personal risk and what you can do about it. cardiac biomarkers such as troponin levels, "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", "Clinical diagnosis of acute coronary syndrome in patients with chest pain and a normal or non-diagnostic electrocardiogram", "Prevalence, Clinical Characteristics, and Mortality among Patients with Acute Myocardial Infarction Presenting Without Chest Pain", "Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction", "2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation", "Questions and answers on workup diagnosis and risk stratification: a companion document of the 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation", "Acute Coronary Syndromes (Heart Attack; Myocardial Infarction; Unstable Angina) - Heart and Blood Vessel Disorders", "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines", "Chest Pain in the Emergency Department: Differential Diagnosis", "Current state-of-play in spontaneous coronary artery dissection", "Diagnosis and Management of MINOCA Patients", "Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction", "Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care", "2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines", "Smoke-free Legislation and Hospitalizations for Acute Coronary Syndrome", "Part 10: acute coronary syndromes: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care", "Rapid Triage, Transfer, and Treatment with Percutaneous Coronary Intervention for Patients with ST-Segment Elevation Myocardial Infarction", "Thrombolysis versus primary percutaneous coronary intervention for ST elevation myocardial infarctions at Chilliwack General Hospital", "Choosing between Enoxaparin and Fondaparinux for the management of patients with acute coronary syndrome: A systematic review and meta-analysis", "Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial", "Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology", "The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making", "Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population", "Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE)", "Changes in mortality on weekend versus weekday admissions for Acute Coronary Syndrome in the United States over the past decade", Arrhythmogenic right ventricular dysplasia, https://en.wikipedia.org/w/index.php?title=Acute_coronary_syndrome&oldid=1167471338, Short description is different from Wikidata, Articles with unsourced statements from October 2021, Creative Commons Attribution-ShareAlike License 4.0. Key exclusion criteria were planned coronary-artery bypass grafting for the acute coronary syndrome event, creatinine clearance of less than 30 ml per minute, active liver disease, or use of . He has received research grants and support from Accumetrics, AstraZeneca, Bristol-Myers Squibb/sanofi Partnership, GlaxoSmithKline, Merck, and the Merck/Schering Plough Partnership. [27] Using statins in the first 14 days after ACS reduces the risk of further ACS. These well-known conditions are both acute coronary syndromes (ACS), an umbrella term for situations in which blood supplied to the heart muscle is suddenly blocked. Autoimmune heparin-induced thrombocytopenia in association with thrombosis is a rare but dangerous complication of UFH administration (incidence is <0.2%).137 When clinical findings suggest that this complication has occurred, all heparin therapy should be immediately discontinued. When occlusions are found, they can be intervened upon mechanically with angioplasty and usually stent deployment if a lesion, termed the culprit lesion, is thought to be causing myocardial damage. Multimarker approach to risk stratification in non-ST elevation acute coronary syndromes: simultaneous assessment of troponin I, C-reactive protein, and B-type natriuretic peptide, The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. McDermott MM, Mandapat AL, Moates A, et al. Natriuretic peptide both B-type natriuretic peptide (BNP) and N-terminal proBNP can be applied to predict the risk of death and heart failure following ACS. 7272 Greenville Ave. These high-risk manifestations of coronary atherosclerosis are important causes of the use of emergency medical care and hospitalization in the United States. [15], In the setting of acute chest pain, the electrocardiogram (ECG or EKG) is the investigation that most reliably distinguishes between various causes. Measurements of the cardiac-specific troponins T and I allow for highly accurate, sensitive, and specific determination of myocardial injury in the context of ischemic symptoms; these troponins have replaced CK-MB as the preferred marker for the detection of myocardial necrosis. Each year in the United States, 6 to 7 million persons present to EDs with the symptom of chest pain or other symptoms suggestive of possible ACS; of these, approximately 20% to 25% receive a final diagnosis of UA or MI.44 The differential diagnosis of patients with chest pain is shown in Table 1. van der Wal AC, Becker AE, van der Loos CM, Das PK. Santopinto J, Gurfinkel EP, Torres V, et al. Aspirin. Chest pain caused by acute coronary syndromes can come on suddenly, as is the case with a heart attack. Acute coronary syndromes (ACS) clinical resources. Some patients may present without chest pain; in one review, 2 . Acute coronary syndrome (ACS) refers to a group of conditions that include ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina. Accessibility Arakawa N, Nakamura M, Aoki H, Hiramori K. Relationship between plasma level of brain natriuretic peptide and myocardial infarct size. Acute Coronary Syndromes | Circulation - AHA/ASA Journals A diagnosis of NSTEMI can be made when the ischemia is sufficiently severe to cause myocardial damage that results in the release of a biomarker of myocardial necrosis into the circulation (cardiac-specific troponins T or I, or muscle and brain fraction of creatine kinase [CK-MB]). Four randomized trials have each demonstrated that, compared with placebo, aspirin reduces the risk of death or MI by more than 50% for patients presenting with UA/NSTEMI.35,36,119,120 The ACC/AHA guidelines recommend an initial daily dose of 162 to 325 mg, followed by a daily dose of 75 to 162 mg for long-term secondary prevention.42 Absolute contraindications to aspirin therapy include documented aspirin allergy (eg, asthma or anaphylaxis), active bleeding, or a known platelet disorder. Expand All Cardiac catheterization. Authors Brian A Bergmark 1 , Njambi Mathenge 2 , Piera A Merlini 3 , Marilyn B Lawrence-Wright 4 , Robert P Giugliano 5 Affiliations Resources and clinical information for health professionals. A heart attack occurs when the narrowed artery becomes totally blocked, usually by a blood clot or plaque. Acute Coronary Syndrome - PubMed b For example, recurrent symptoms/ischemia, heart failure, or serious arrhythmia. Non-ST-elevation myocardial infarction (NSTEMI), ST-elevation MI (STEMI), and unstable angina are the three traditional types of ACS. Treatment for acute coronary syndrome includes medicinesand a procedure known as angioplasty,during which doctors inflate a small balloon to open the artery. Nitroglycerin should initially be given sublingually or by buccal spray (0.3-0.6 mg) every 5 minutes for a total of 3 doses. King SB, III, Smith SC, Jr, Hirshfeld JW, Jr, et al. Chest pain or discomfort may immediately signal that somethings wrong with your heart. The earliest rising biomarkers are myoglobin and creatine kinase (CK) isoforms (leftmost curve). C-reactive protein levels allowed a differentiation between high-risk Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators. Differential Diagnosis of Patients With Chest Pain. Platelets play a crucial role in ACS, and newer antiplatelet drugs continue to be developed with the goal of maximizing the reduction in atherothrombotic events while minimizing bleeding complications. All patients presenting to the ED with chest discomfort or other symptoms suggestive of ACS should be considered high-priority triage cases. Findings on ECG associated with UA include ST-segment depression, transient ST-segment elevation, T-wave inversion, or some combination of these factors; depending on the severity of the clinical presentation, these findings are present in 30% to 50% of patients.39,50,51 New ST-segment deviation, even of only 0.05 mV, is an important and specific measure of ischemia and prognosis.50-52 T-wave inversion is sensitive for ischemia but is less specific, unless it is marked (0.3 mV).39 An ST-segment elevation of 0.1 mV or more, if present in at least 2 contiguous leads, indicates acute MI in 90% of patients, as confirmed by serial measurements of cardiac biomarkers.53 It is important to compare current and previous findings on ECG because studies suggest that patients with no ECG changes are at a lower risk of complications than those with ECG changes.54, Because the process of myocardial ischemia is quite dynamic and a single 12-lead ECG provides only a snapshot view of this process, the ACC/AHA guidelines recommend that patients hospitalized for UA/NSTEMI undergo serial ECG tracings or continuous ST-segment monitoring.42,55,56, Cardiac biomarkers should be measured for all patients who present with chest discomfort or other symptoms suggestive of ACS. [9] This may be associated with sweating, nausea, or shortness of breath. Various LMWHs (dalteparin, enoxaparin, and nadroparin) have been compared with UFH for the treatment of UA/NSTEMI, but only enoxaparin has been found to have a clear benefit. Unstable angina pectoris: morbidity and mortality in 57 consecutive patients evaluated angiographically, Angioscopic evaluation of coronary artery thrombi in acute coronary syndromes, Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit lesion in patients presenting with ischemic cardiac pain at rest: results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Patients with negative results from diagnostic testing can be discharged with specific instructions for activity, medications, and additional testing. Family physicians need to identify and mitigate risk factors early, as well as. The prognostic value of B-type natriuretic peptide in patients with acute coronary syndromes, B-type natriuretic peptide at presentation and prognosis in patients with ST-segment elevation myocardial infarction: an ENTIRE-TIMI-23 substudy. 23 stable angina (SA), 21 unstable angina (UA), and 50 ST-segment elevation myocardial infarction (STEMI . Back Acute coronary syndromes. Wiviott SD, Morrow DA, Frederick PD, et al. The accepted management of unstable angina and acute coronary syndrome is therefore empirical treatment with aspirin, a second platelet inhibitor such as clopidogrel, prasugrel or ticagrelor, and heparin (usually a low-molecular weight heparin), with intravenous nitroglycerin and opioids if the pain persists. Morrow DA, Antman EM, Snapinn SM, McCabe CH, Theroux P, Braunwald E. An integrated clinical approach to predicting the benefit of tirofiban in non-ST elevation acute coronary syndromes: application of the TIMI Risk Score for UA/NSTEMI in PRISM-PLUS, Troponin-T and N-terminal pro-B-type natriuretic peptide predict mortality benefit from coronary revascularization in acute coronary syndromes: a GUSTO-IV substudy, Eagle KA, Lim MJ, Dabbous OH, et al.GRACE Investigators, A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry, Granger CB, Goldberg RJ, Dabbous O, et al.Global Registry of Acute Coronary Events Investigators, Predictors of hospital mortality in the global registry of acute coronary events. Heart attack and unstable angina are both acute coronary syndromes (ACS). The CURE (Clopidogrel in Unstable Angina to Prevent Recurrent Events) trial randomly assigned 12,562 patients to receive either aspirin alone (75-325 mg/d) or aspirin plus clopidogrel (300-mg loading dose, then 75 mg/d).121 The incidence of the primary end point of cardiovascular death, MI, or stroke was 20% lower for both low-risk and high-risk patients with UA/NSTEMI who received aspirin plus clopidogrel (11.4%) than for those who received aspirin alone (9.3%; P<.0001).38 Benefit was seen as early as 24 hours after the initiation of treatment (the Kaplan-Meier curves began diverging after just 2 hours) and continued throughout the trial's 1-year treatment period. Overcoming uncertainty: Bianca Beetham's heart story . However, troponin measurements have some drawbacks. symptoms include dyspnea (most common), nausea and vomiting, diaphoresis, and unexplained fatigue.46 Atypical presentations are more common among women and elderly people. guidelines have given the early invasive strategy a class I, level of evidence A recommendation for patients with UA/NSTEMI who are at high risk (Table 6).42 The guidelines recommend either a conservative or an invasive strategy for low-risk patients because the outcomes achieved by these approaches are similar for these patients. As a library, NLM provides access to scientific literature. Unstable angina. [22] Other analgesics such as nitrous oxide are of unknown benefit. During the past quarter of a century, huge advances have been made in our understanding of the pathophysiology of ACS, and these advances have been accompanied by important breakthroughs in the management of this condition.
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