Management of Acute Coronary Syndromes (eBook)

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.

Management of Acute Coronary Syndromes 3
Contents 9
List of contributors 15
Foreword 17
Chapter 1 Pathophysiology of acute coronary syndromes 19
Introduction 19
Formation of atherosclerotic plaque 20
Plaque instability and the development of ACS 23
Myocardial ischemia 25
Thrombus formation 25
Platelets 25
Secondary hemostasis 27
Dynamic obstruction 28
Progressive mechanical obstruction 28
Inflammation 29
Secondary unstable angina 29
References 29
Chapter 2 Diagnosis of acute coronary syndrome 31
Introduction 31
Definition of myocardial infarction 31
History 32
Risk factors 35
Physical examination 35
Electrocardiography 37
The pathophysiologic basis of ST segment changes during ischemia 37
Electrocardiography in ST-elevation MI and identification of the infarct-related artery 38
Electrocardiography in unstable angina and NSTEMI 44
Cardiac biomarkers 44
Noninvasive imaging 47
Echocardiography 47
Myocardial perfusion imaging 48
Coronary computed tomography 48
Cardiovascular magnetic resonance imaging 49
Stress testing for diagnosis of ACS 50
Overall diagnostic pathway for ACS 50
References 52
Chapter 3 Unstable angina and non-ST-elevation myocardial infarction 55
Introduction 55
Causes of UA/NSTEMI 55
Presentation of UA/NSTEMI 56
General strategies in management of UA/NSTEMI 57
Risk stratification of patients with UA/NSTEMI 58
Initial management of UA/NSTEMI in the emergency department 60
Pharmacologic treatment of ischemia in UA/NSTEMI 61
Beta-blockers 62
Nitrates 62
Calcium channel blockers 63
Angiotensin-converting enzyme inhibitors 63
Morphine 64
Oxygen 64
Invasive versus conservative strategy 64
Antiplatelet therapy in UA/NSTEMI 67
Aspirin 72
Clopidogrel 73
Prasugrel 75
Glycoprotein IIb/IIIa inhibitors 76
Anticoagulant therapy in UA/NSTEMI 79
Unfractionated heparin 79
Enoxaparin 80
Direct thrombin inhibitors 83
Fondaparinux 84
Oral anticoagulation in UA/NSTEMI 85
Fibrinolysis in UA/NSTEMI 86
Early lipid-lowering therapy in patients with UA/NSTEMI 86
Predischarge noninvasive risk stratification after UA/NSTEMI 87
Overall management of UA/NSTEMI 89
References 89
Chapter 4 ST-segment-elevation myocardial infarction 97
Introduction 97
Global treatment goals in STEMI 97
Prehospital management and triage 98
Transport decisions 100
Management prior to reperfusion 100
Primary reperfusion therapy for STEMI 101
Fibrinolysis 101
Combination fibrinolysis 104
Markers of fibrinolysis effectiveness 104
Complications of fibrinolysis 106
Primary percutaneous coronary intervention 106
Comparison of PCI with fibrinolysis 108
Timing of primary PCI 109
PCI following fibrinolytic therapy 112
Rescue PCI 112
Facilitated PCI 112
Routine PCI after successful fibrinolysis 114
Overall reperfusion strategy 115
Coronary artery bypass grafting for treatment of STEMI 116
Adjunctive pharmacologic treatment of STEMI 116
Antiplatelet agents 116
Anticoagulation therapy 119
Other adjunctive therapy 123
Hospital care following successful reperfusion 128
References 132
Chapter 5 Special considerations in acute coronary syndromes 141
Secondary unstable angina 141
Acute coronary syndrome in patients with diabetes mellitus 141
General considerations 141
Primary ACS therapy in diabetics 142
Glycemic control in diabetics with ACS 143
Coronary revascularization in diabetics 144
Metabolic syndrome and ACS 145
Chronic kidney disease in ACS 145
Young patients with ACS 148
ACS in the setting of cocaine use 148
ACS in patients with normal coronary arteries or mild CAD 150
Myocarditis 150
Acute transient apical ballooning syndrome 151
Postoperative ACS 152
ACS in a pregnant woman 153
Hyperthyroidism and ACS 154
ACS in patients exposed to radiation 155
Trauma and ACS 155
References 155
Chapter 6 Complications of acute coronary syndrome 159
Introduction 159
Pump failure 159
General principle 159
Clinical presentation 160
Prognosis 162
Treatment 162
Right ventricular infarction 166
Introduction 166
Clinical presentation 166
Diagnosis 167
Management 168
Prognosis 170
Mechanical complications of ACS 170
Introduction 170
Left ventricular free wall rupture 170
Ventricular septal rupture 171
Acute mitral regurgitation 172
Left ventricular aneurysm 173
Left ventricular pseudoaneurysm 175
Pericardial complications 175
Arrhythmic complications of ACS 177
Bradyarrhythmias 177
Atrial fibrillation 181
Ventricular tachycardia and fibrillation 181
Complications involving bleeding 182
Complications of percutaneous coronary intervention 183
References 188
Chapter 7 Post-hospitalization care of patients with acute coronary syndrome 191
Introduction 191
Pharmacologic measures 191
Aspirin 191
Clopidogrel 192
Beta adrenergic blockade 195
Renin–angiotensin–aldosterone inhibitors 197
Lipid-lowering therapy 203
Warfarin 207
Influenza vaccination 210
Medications of limited benefit to patients following ACS 210
Vitamins/antioxidants 210
Estrogen replacement therapy 210
Nonsteroidal anti-inflammatory agents and related compounds 212
Nonpharmacologic measures 213
Antiarrhythmic devices 213
Therapy of comorbidities following ACS 216
Diabetes mellitus 216
Hypertension 217
Depression 217
Lifestyle recommendations following ACS 218
General physical activity and structured cardiac rehabilitation 218
Sexual activity after ACS 219
Smoking cessation 219
Diet/nutrition and weight loss 220
References 222
Appendix 227
Index 235
Color plates 241