Management of Acute Coronary Syndromes

Acute Coronary Syndrome covers the spectrum of clinical conditions ranging from unstable angina to non-ST elevation myocardial infarction and ST elevation myocardial infarction. These life-threatening disorders are a major cause of emergency medical care, hospitalization and mortality. Management of Acute Coronary Syndromes is designed to provide busy clinicians with a comprehensive guide to the investigation, diagnosis and treatment of these syndromes. It encompasses the latest technologies, including the use of biomarkers and non-invasive imaging procedures.For each condition, the reader is taken through all of the therapeutic options available; in each case the indications and contraindications are evaluated in the light of the latest clinical trials. Potential complications are dealt with in a similar fashion, permitting the reader to anticipate and manage problems as they arise. The authors also present evidence-based recommendations for long-term care of at-risk patients, encompassing pharmacologic therapies and lifestyle management.The book concludes with a comprehensive collection of appendices that include treatment algorithms, risk scores and a summary of the latest management guidelines.Management of Acute Coronary Syndromes is the most up to date and comprehensive evidence-based guide to managing acute coronary syndromes, in a compact and usable format. It will be of interest to busy specialist physicians in cardiovascular medicine, cardiac and vascular surgery, and critical care, as well as primary care physicians and hospitalists who care for patients with these syndromes.

Dr. Eli Gelfand is a clinical cardiologist, who provides comprehensive care for patients with a full range of heart and vascular problems at the Beth Israel Deaconess Medical Center.
He is the Director of the Vascular Diagnostic Laboratory, Harvard Medical School and is the , Harvard Medial School and is the Associate Cardiovascular Fellowship Director at Beth Israel Deaconess Medical Center.

Dr. Christopher P. Cannon, is an Associate Professor of Medicine at Harvard Medical School and an Associate Physician in the Cardiovascular Division at Brigham and Women's Hospital in Boston, Massachusetts. He is a senior investigator of the Thrombolysis in Myocardial Infarction (TIMI) Study Group. Dr. Cannon has published more than 500 original articles, reviews, editorials, book chapters, and electronic publications in the field of acute coronary syndromes.
Dr. Cannon has received numerous awards including the Alfred Steiner Research Award, Upjohn Achievement in Research Award, and Robert F. Loeb Award for Excellence in Clinical Medicine. He is a Fellow of the American Heart Association and of the American College of Cardiology.

List of contributors	p. xiii
Foreword	p. xv
Pathophysiology of acute coronary syndromes	p. 1
Introduction	p. 1
Formation of atherosclerotic plaque	p. 2
Plaque instability and the development of ACS	p. 5
Myocardial ischemia	p. 7
Thrombus formation	p. 7
Platelets	p. 7
Secondary hemostasis	p. 9
Dynamic obstruction	p. 10
Progressive mechanical obstruction	p. 10
Inflammation	p. 11
Secondary unstable angina	p. 11
References	p. 11
Diagnosis of acute coronary syndrome	p. 13
Introduction	p. 13
Definition of myocardial infarction	p. 13
History	p. 14
Risk factors	p. 17
Physical examination	p. 17
Electrocardiography	p. 19
The pathophysiologic basis of ST segment changes during ischemia	p. 19
Electrocardiography in ST-elevation MI and identification of the infarct-related artery	p. 20
Electrocardiography in unstable angina and NSTEMI	p. 26
Cardiac biomarkers	p. 26
Noninvasive imaging	p. 29
Echocardiography	p. 29
Myocardial perfusion imaging	p. 30
Coronary computed tomography	p. 30
Cardiovascular magnetic resonance imaging	p. 31
Stress testing for diagnosis of ACS	p. 32
Overall diagnostic pathway for ACS	p. 32
References	p. 34
Unstable angina and non-ST-elevation myocardial infarction	p. 37
Introduction	p. 37
Causes of UA/NSTEMI	p. 37
Presentation of UA/NSTEMI	p. 38
General strategies in management of UA/NSTEMI	p. 39
Risk stratification of patients with UA/NSTEMI	p. 40
Initial management of UA/NSTEMI in the emergency department	p. 42
Pharmacologic treatment of ischemia in UA/NSTEMI	p. 43
Beta-blockers	p. 44
Nitrates	p. 44
Calcium channel blockers	p. 45
Angiotensin-converting enzyme inhibitors	p. 45
Morphine	p. 46
Oxygen	p. 46
Invasive versus conservative strategy	p. 46
Antiplatelet therapy in UA/NSTEMI	p. 49
Aspirin	p. 54
Clopidogrel	p. 55
Prasugrel	p. 57
Glycoprotein llb/llla inhibitors	p. 58
Anticoagulant therapy in UA/NSTEMI	p. 61
Unfractionated heparin	p. 61
Enoxaparin	p. 62
Direct thrombin inhibitors	p. 65
Fondaparinux	p. 66
Oral anticoagulation in UA/NSTEMI	p. 67
Fibrinolysis in UA/NSTEMI	p. 68
Early lipid-lowering therapy in patients with UA/NSTEMI	p. 68
Predischarge noninvasive risk stratification after UA/NSTEMI	p. 69
Overall management of UA/NSTEMI	p. 71
References	p. 71
ST-segment-elevation myocardial infarction	p. 79
Introduction	p. 79
Global treatment goals in STEMI	p. 79
Prehospital management and triage	p. 80
Transport decisions	p. 82
Management prior to reperfusion	p. 82
Primary reperfusion therapy for STEMI	p. 83
Fibrinolysis	p. 83
Combination fibrinolysis	p. 86
Markers of fibrinolysis effectiveness	p. 86
Complications of fibrinolysis	p. 88
Primary percutaneous coronary intervention	p. 88
Comparison of PCI with fibrinolysis	p. 90
Timing of primary PCI	p. 91
PCI following fibrinolytic therapy	p. 94
Rescue PCI	p. 94
Facilitated PCI	p. 94
Routine PCI after successful fibrinolysis	p. 96
Overall reperfusion strategy	p. 97
Coronary artery bypass grafting for treatment of STEMI	p. 98
Adjunctive pharmacologic treatment of STEMI	p. 98
Antiplatelet agents	p. 98
Anticoagulation therapy	p. 101
Other adjunctive therapy	p. 105
Hospital care following successful reprefusion	p. 110
References	p. 114
Special considerations in acute coronary syndromes	p. 123
Secondary unstable angina	p. 123
Acute coronary syndrome in patients with diabetes mellitus	p. 123
General considerations	p. 123
Primary ACS therapy in diabetics	p. 124
Glycemic control in diabetics with ACS	p. 125
Coronary revascularization in diabetics	p. 126
Metabolic syndrome and ACS	p. 127
Chronic kidney disease in ACS	p. 127
Young patients with ACS	p. 130
ACS in the setting of cocaine use	p. 130
ACS in patients with normal coronary arteries or mild CAD	p. 132
Myocarditis	p. 132
Acute transient apical ballooning syndrome	p. 133
Postoperative ACS	p. 134
ACS in a pregnant woman	p. 135
Hyperthyroidism and ACS	p. 136
ACS in patients exposed to radiation	p. 137
Trauma and ACS	p. 137
References	p. 137
Complications of acute coronary syndrome	p. 141
Introduction	p. 141
Pump failure	p. 141
General principle	p. 141
Clinical presentation	p. 142
Prognosis	p. 144
Treatment	p. 144
Right ventricular infarction	p. 148
Introduction	p. 148
Clinical presentation	p. 148
Diagnosis	p. 149
Management	p. 150
Prognosis	p. 152
Mechanical complications of ACS	p. 152
Introduction	p. 152
Left ventricular free wall rupture	p. 152
Ventricular septal rupture	p. 153
Acute mitral regurgitation	p. 154
Left ventricular aneurysm	p. 155
Left ventricular pseudoaneurysm	p. 157
Pericardial complications	p. 157
Arrhythmic complications of ACS	p. 159
Bradyarrhythmias	p. 159
Atrial fibrillation	p. 163
Ventricular tachycardia and fibrillation	p. 163
Complications involving bleeding	p. 164
Complications of percutaneous coronary intervention	p. 165
References	p. 170
Post-hospitalization care of patients with acute coronary syndrome	p. 173
Introduction	p. 173
Pharmacologic measures	p. 173
Aspirin	p. 173
Clopidogrel	p. 174
Beta adrenergic blockade	p. 177
Renin-angiotensin-aldosterone inhibitors	p. 179
Lipid-lowering theraphy	p. 185
Warfarin	p. 189
Influenza vaccination	p. 192
Medications of limited benefit to patients following ACS	p. 192
Vitamins/antioxidants	p. 192
Estrogen replacement therapy	p. 192
Nonsteroidal anti-inflammatory agents and related compounds	p. 194
Nonpharmacologic measures	p. 195
Antiarrhythmic devices	p. 195
Therapy of comorbidities following ACS	p. 198
Diabetes mellitus	p. 198
Hypertension	p. 199
Depression	p. 199
Lifestyle recommendations following ACS	p. 200
General physical activity and structured cardiac rehabilitation	p. 200
Sexual activity after ACS	p. 201
Smoking cessation	p. 201
Diet/nutrition and weight loss	p. 202
References	p. 204
Appendix	p. 209
Index	p. 217
Table of Contents provided by Ingram. All Rights Reserved.

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Management of Acute Coronary Syndromes

Summary

Author Biography

Table of Contents

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