PATHOPHYSIOLOGY The pathophysiology of UA/NSTEMI involves a broad timeline with three phases rather than an isolated ischemic event

. Traditionally, attention focused only on the acute phase of UA/NSTEMI, whereas the pathophysiology may actually begin several decades before the acute clinical event, and then may span more than 20 years afterward. The acute event, which usually involves thrombus formation at the site of a ruptured or eroded atherosclerotic plaque, is currently referred to as ³atherothrombosis´ (see Chap. 38) , a term that is replacing ³atherosclerosis´ because it more fully describes the pathophysiology of the disease that involves both progression and disruption of the atheroma and superimposed thrombosis. The acute ischemia in UA/NSTEMI can also result from an increase in myocardial oxygen demand (e.g., precipitated by tachycardia or hypertension) and/or by a reduction in supply (e.g., due to reduction in coronary lumen diameter by platelet-rich thrombi, vasospasm, or hypotension). Rapid progression of the underlying coronary artery disease can also occur in some patients. A sequence of events has been documented in UA/NSTEMI, in which there is first a reduction in coronary sinus oxygen saturation (signifying a reduction in coronary blood flow), then ST segment depression, followed by chest discomfort, and elevations in blood pressure and/or heart rate. Thrombosis The central role of coronary artery thrombosis (see also Chaps. 38 and 82) in the pathogenesis of UA/NSTEMI is supported by six sets of observations: (1) at autopsy, thrombi usually localize at the site of a ruptured or eroded coronary plaque ( Fig. 53-3 )[7]; (2) coronary atherectomy specimens demonstrate a high incidence of thrombotic lesions as compared with those obtained from stable angina patients; (3) coronary angioscopy frequently visualizes thrombus in UA/NSTEMI[8]; (4) Coronary angiography has demonstrated ulceration or irregularities suggesting a ruptured plaque, and/or thrombus in many patients ( Fig. 53-4 )[9]; (5) elevation of several markers of platelet activity and fibrin formation supports ongoing thrombosis [13] [14]; and (6) the improvement in the clinical outcome by antithrombotic therapy. Platelet Activation and Aggregation Platelets play a key role in the transformation of a stable atherosclerotic plaque to an unstable lesion ( Fig. 53-5 ) (see also Chap. 82 ). Rupture or ulceration of an atherosclerotic plaque often exposes the subendothelial matrix (e.g., collagen and tissue factor) to circulating blood. The first step is platelet adhesion via platelet glycoprotein (GP) Ib binding to von Willebrand factor and GP VI binding to collagen. Platelet activation ensues which leads to (1) a shape change in the platelet (from a smooth discoid shape to a spiculated form, which increases the surface area on which thrombin generation can occur); (2) degranulation of the platelet alpha and dense granules, releasing thromboxane A2, serotonin, and other platelet aggregatory and chemoattractant agents; and (3) increased expression of GP IIb/IIIa on the platelet surface and a conformational change in GP IIb/IIIa that enhances affinity for fibrinogen. The final step is platelet aggregation (i.e., the formation of the platelet plug). Fibrinogen binds to the activated platelet GP IIb/IIIa, creating a growing platelet aggregate. Secondary Hemostasis Simultaneously with formation of the platelet plug, the plasma coagulation system is activated. Tissue factor triggers most coronary artery thrombosis. (see Chap. 38 and 82 .) Ultimately, factor X is activated (to factor Xa), which leads to generation of thrombin (factor IIa), which plays a central role in arterial thrombosis: (1) thrombin converts fibrinogen to fibrin; (2) thrombin powerfully stimulates platelet aggregation; and (3) it activates factor XIII, which leads to cross-linking and stabilization of the fibrin clot. Thrombin molecules are incorporated into coronary thrombi and can form the nidus of rethrombosis. Coronary Vasoconstriction There are three settings in which the process of dynamic coronary obstruction is identified: (1) Prinzmetal variant

[18] Transient (i.[15] Secondary Unstable Angina This form of unstable angina results from an imbalance in myocardial oxygen supply and demand caused by conditions extrinsic to the coronary arteries in patients with prior coronary stenosis. and hyperviscosity states. ST depression (or transient ST elevation) and T wave changes occur in up to 50 percent of patients.[4] CLINICAL PRESENTATION Women present more often with unstable angina. serotonin and thromboxane A2. Secondary angina appears to have a worse prognosis than primary unstable angina (see Table 53-1 ). as well as those present within the thrombus. patients with unstable angina also have higher rates of prior MI. thyrotoxicosis. and extracardiac vascular disease. Electrocardiogram In UA/NSTEMI. angina. hyperadrenergic states. T wave changes are sensitive but not as specific for acute ischemia. previous coronary revascularization. comprising 30-45 percent of patients with unstable angina in several studies compared with 25 to 30 percent of patients with NSTEMI and approximately 20 percent of patients with STEMI. unless they are marked (>0. and elevations of left ventricular afterload such as hypertension or aortic stenosis. portends the worst prognosis in UA/NSTEMI. Secondary unstable angina can also occur because of impaired oxygen delivery.3 mV) ( Fig. [21] [22] Continuous ECG Monitoring . 53-6 ). A dysfunctional coronary endothelium with reduced production of nitric oxide and increased release of endothelin can also lead to vasoconstriction. which occurs in approximately 10 percent of patients. [6] [7] Conditions that increase oxygen demand include tachycardia (e. Rarely. cold immersion. cocaine. or mental stress[14] can also cause coronary vasoconstriction. 48 and 76) . However. However. hypoxemia. fever. such as thrombin. This is most commonly seen in the setting of restenosis following percutaneous coronary intervention (PCI) (see Chap.05 mV ST depression. Traditionally.e. atrial fibrillation with rapid ventricular response). Signs that suggest that UA/NSTEMI involves a large fraction of the left ventricle include diaphoresis. and (3) (the most common) local vasoconstrictors released from platelets. New (or presumably new) ST segment deviation is a specific and important measure of ischemia and prognosis. pale cool skin.1 mV ST depression. approximately 80 percent of patients with UA/NSTEMI have a history of cardiovascular disease and most have evidence of prior coronary risk factors. 55) . Progressive Mechanical Obstruction The fourth etiology of UA/NSTEMI results from progressive luminal narrowing. <20 minutes) ST elevation. (2) coronary vasoconstriction causing ³microcirculatory angina´ results from constriction of the small intramural coronary resistance vessels (see Chaps.[17] Clinical Examination The physical examination may be unremarkable or may support the diagnosis of cardiac ischemia.[16] In comparison to the latter.g. sinus tachycardia. angiographic and atherectomy studies in non-PCI patients have shown progressive luminal narrowing of the culprit vessel related to rapid cellular proliferation. the severity of left ventricular dysfunction causes hypotension. ST depression has only been considered significant if it is •0.1 mV²as occurs in 20 to 25 percent of patients. as occurs in anemia.. a third or fourth heart sound. and basilar rales on lung examination.. or hypotension.[18] and they can have an adverse prognosis approaching that of patients with 0. Adrenergic stimuli.[16] Indeed.angina[13] (see later). an additional 20 percent of patients will present with 0.

which are more sensitive than CK-MB. usually in the emergency department to diagnose the presence or absence of coronary artery disease (in patients with low likelihood of coronary disease) (see Chap. Low-level elevation of cardiac troponin is associated with a higher risk of death or recurrent ischemic events.[23] Because each assay differs. respectively. to evaluate the extent of residual ischemia. Because serum cholesterol levels fall as much as 30 to 40 percent beginning 24 hours following UA/NSTEMI or STEMI. who had elevations of troponin but no apparent coronary artery disease on angiography. although the sensitivity and diagnostic accuracy of some of these tests have only recently matched the accuracy of currentgeneration laboratory-based assays. and to guide further therapy as part of an ³early conservative´ strategy. each hospital needs to review the specific cut points defined by the assay used. elevations of markers of myocardial necrosis (i. If only a later sample is obtained. in which troponin elevations in the absence of coronary artery disease (CAD) is associated with an adverse prognosis. Evaluation for other secondary causes of UA/NSTEMI.[27] Laboratory Tests A chest x-ray may be useful in identifying pulmonary congestion or edema. had a significantly worse prognosis than those who were troponin negative without coronary disease. troponin T or I) identify patients with the diagnosis of NSTEMI.[20] even when used in conjunction with troponins and clinical variables.Continuous ECG monitoring serves two purposes in UA/NSTEMI: (1) to identify arrhythmias. clinical trials have used high-fidelity Holter monitors to detect ST segment deviation. (3) to evaluate left . such as congestive heart failure. with a 6-month rate of death or MI of 5. Despite increasingly accurate assays. 49) . treatable risk factors for coronary atherothombosis. noninvasive testing is used (1) at presentation. they should be measured at the time of initial presentation.[26] An analysis from TACTICS-TIMI 18 also raised a cautionary note that these troponin elevations should not be discarded as simply a false positive. (2) after hospitalization and medical therapy has begun. which would be more likely in patients with NSTEMI involving a significant proportion of the left ventricle or in those with known left ventricular dysfunction. Cardiac Necrosis Markers for Diagnosis of NSTEMI Among patients presenting with symptoms consistent with UA/NSTEMI.[21] With the use of troponins. the clinician should be aware that this low-density lipoprotein (LDL) value likely may be as much as 30 to 40 percent lower than the patient's actual baseline. assessing thyroid function in patients who present with UA/NSTEMI and persistent tachycardia). which is a strong marker of adverse outcome.3 percent and 0 percent. The presence of congestion confers an adverse prognosis. apparent false-positive troponin elevations have been found in patients later found at coronary angiography not to have epicardial stenoses. Other circulating markers of increased risk are discussed subsequently. Noninvasive Testing In the management of UA/NSTEMI. (2) to identify recurrent ST segment deviation indicative of ischemia. [25] [26] Although the appropriate cut point to define an elevated troponin has engendered controversy. Patients presenting with UA/NSTEMI. which is associated with a worse prognosis.[25] These elevations may be the result of an alternative diagnosis.[3] may also be appropriate in selected patients (e. For the latter goal. CK-MB.[24] Point-of-care tests can have a positive versus negative result or provide a quantitative result.e.. is useful in identifying important. Obtaining a serum lipid panel including low-density lipoprotein and high-density lipoprotein cholesterol.g. growing consensus has focused on use of the 99th percentile of a normal population of subjects[21] and not greater than a 10 percent coefficient of variation. a greater percentage of patients are classified as having NSTEMI. a measure of reproducibility of the assay.

13 and 51) . Exercise testing is generally recommended unless the patient cannot walk sufficiently to achieve a significant workload²in which case pharmacological stress testing provides an alternative. [19] [34] Women and non-whites comprise a larger proportion of patients with symptoms of UA/NSTEMI without epicardial coronary disease²suggesting either a difficulty in making a firm diagnosis of UA/NSTEMI in these groups and/or a different pathophysiological mechanism for their clinical presentation (see also Chap. was: 34 percent had significant obstruction (>50 percent luminal diameter stenosis) of three vessels. and 13 percent had no coronary stenosis >50 percent. For most patients ECG stress testing is recommended if the ECG lacks significant ST segment abnormalities. compared to those without thrombus.ventricular function.e.[9] ³Haziness´ of a lesion has been used as an angiographic marker of possible thrombus.[29] Approximately 5 to 10 percent had left main stem stenosis >50 percent. MI. 28 percent had two vessel disease. as opposed to ³red´ thrombi.[30] Contraindications to stress testing are a recent recurrence of rest pain. The markers of high risk are either evidence of ischemia on stress testing or left ventricular dysfunction (either at rest or stress induced). evidence of ischemia) has long been assumed to be necessary and has been utilized in the conservative arms of most randomized trials. especially if it is associated with ECG changes or other signs of instability (hemodynamic or arrhythmic).. it is not generally available for routine clinical care. Although useful for research purposes. Patients with UA/NSTEMI have impaired coronary flow as measured by the TIMI flow grade or frame count. Angioscopy and Intravascular Ultrasound Greater definition of the culprit lesion has been possible using angioscopy.[29] Registries of unselected UA/NSTEMI patients have reported similar findings. or a combination. more often seen in patients with acute ST elevation MI. If ST abnormalities exist. Stress myocardial perfusion imaging with sestamibi or stress echocardiographic imaging has slightly more sensitivity than ECG stress testing alone and has shown greater prognostic value. [31] [32] The safety of early stress testing in patients with UA/NSTEMI has been debated. and TIMI myocardial perfusion grade²especially those with an elevated troponin level. Features suggesting thrombus include globular intraluminal masses with a rounded or polypoid shape (see Fig. 53-4 ). The short-term prognosis is excellent in this group of patients.[9] These angiographic findings may represent disrupted atherosclerotic plaque.[16] Approximately one third of patients with UA/NSTEMI without a critical epicardial obstruction have impaired coronary flow assessed angiographically²suggesting a pathophysiological role for coronary microvascular dysfunction. 76 ). and expertise in interpretation.[32] The culprit lesion in UA/NSTEMI typically exhibits an eccentric stenosis with scalloped or overhanging edges and a narrow neck (see also Chap. Intravascular ultrasound examination identified more echolucent plaques and fewer calcified lesions among patients with unstable versus .[31] which is independently associated with adverse outcomes. where ³white´ (platelet-rich) thrombi are frequently observed.. 20 ). Certain results from noninvasive tests portend high risk of future cardiac events in patients with UA. 26 percent had single vessel disease. The merits of various modalities of stress testing have been compared in relatively small series of patients (see also Chaps.e. but is generally cost effective only in higher risk patients.[16] whereas patients with NSTEMI have more extensive disease than those who present with unstable angina. but this finding is less specific. A recommended approach is to individualize the choice based on patient characteristics. thrombus. and stable coronary artery disease. Coronary Arteriographic Findings The extent of coronary disease among patients with UA/NSTEMI enrolled in the invasive arm of TACTICS-TIMI 18. Patients with angiographically visualized thrombus have impaired coronary flow and worse clinical outcomes. or symptom-limited stress testing is safe after a period of at least 24 to 48 hours of stabilization. but evidence from the several trials has suggested pharmacological. then perfusion or echo imaging is recommended. and (4) to estimate prognosis (i. The need for angiography and revascularization for patients who had a strongly positive stress test (i. risk stratification). local availability. Women and non-whites with UA/NSTEMI have less extensive coronary disease than their counterparts. who systematically underwent angiography.

Those determined to be at highest risk should be admitted to the coronary care unit. Patients sometimes referred to as ³low risk. whereas those at intermediate or lower risk may be admitted to a monitored bed on a cardiac step-down unit. greater extent of coronary disease. Studies of coronary anatomy using angiography.[19] This finding likely results from the older age. Patients with UA have lower short-term mortality (1. Specific subgroups of patients.1 percent for each type). whereas the mortality risk of the two types of MI is similar (5. risk stratification plays a central role in the evaluation and management of patients with this condition. identified by clinical features. the remaining plaques often provoke recurrent events. is actually worse for patients with either UA or NSTEMI compared with STEMI.Clinical Indicators of Increased Risk in UA/NSTEMI History Advanced age (> 70 yr) Diabetes mellitus Post±myocardial infarction angina Prior peripheral vascular disease Prior cerebrovascular disease Clinical Presentation Braunwald class II or III (acute or subacute rest pain) Braunwald class B (secondary unstable angina) Heart failure/hypotension Multiple episodes of pain within 24 hr . with a prognosis that ranges from one with an excellent outcome with modest adjustments in therapeutic regimen to one in which the risk of death or MI is high. Clinical predictors can also assist triage of patients. RISK STRATIFICATION PATHOPHYSIOLOGY OF LONG-TERM RISK FOLLOWING ACUTE CORONARY SYNDROME. Thus. Natural History. and recurrent cardiac events in the months to years following a clinical ACS event.[19] The early mortality risk in ACS is related to the extent of myocardial damage and resulting hemodynamic compromise. and prior MI and comorbidities²such as diabetes and impaired renal function²in patients with UA/NSTEMI versus STEMI.[33] or angioscopy.´ and those who are at low likelihood of having ACS. can be evaluated and managed in emergency department observation units or chest pain centers (see Chap. 53-7 ). longterm outcomes²both for mortality and nonfatal events. electrocardiographic findings and/or cardiac (or vascular) markers are at higher risk of adverse outcomes ( Table 53-2 ). Furthermore. more diffuse active coronary disease. these groups appear to derive greater benefit from aggressive antithrombotic and/or interventional therapies (see later). intravascular coronary ultrasound. An important concept that has emerged regarding the long-term outcome following an ACS event is that the risk of recurrent ischemic events links to multifocal lesions other than the culprit lesion responsible for the ACS event. [8] have shown multiple active plaques in addition to the culprit lesion ( Fig.stable angina. 49) .[33] These findings provide an important pathophysiological link between inflammation. TABLE 53-2 -. The percentage of patients with more than one active plaque on angiography was related to an increasing baseline Creactive protein (CRP) level. Accordingly. Methods of Risk Stratification Because patients with UA/NSTEMI are a heterogeneous group. as aggressive interventional approaches are used to successfully treat the culprit lesion.7 percent at 30 days) than those with NSTEMI or STEMI.[34] In contrast. requiring intensive treatment.

001. Clinical Variables The aforementioned classification of unstable angina[3] (see Table 53-1 ) has proved clinically useful in several studies for identifying high-risk patients. both p< 0.[39] Risk Assessment by ECG The admission ECG is useful in predicting long-term adverse outcomes.3 mV Left bundle branch block Cardiac Markers Increased troponin T or I or creatine kinase-MB Increased C-reactive protein or white blood cell count Increased B-type natriuretic peptide Elevated creatinine Elevated glucose or hemoglobin A1C Angiogram Thrombus Multivessel disease Left ventricular dysfunction UA/NSTEMI = unstable angina/non-ST elevation myocardial infarction.05 mV T wave inversion •0. and/or secondary unstable angina. Patients with NSTEMI. independent predictors of 1-year death or MI included left bundle branch block (risk ratio 2.45).[35] Diabetic patients with UA/NSTEMI are at approximately 50 percent higher risk than nondiabetics (see also Chap. In the TIMI III Registry of patients with UA/NSTEMI. defined as associated with an elevated biomarker of necrosis.8). those with either cerebrovascular disease or peripheral arterial vascular disease) also appear to have approximately 50 percent higher rates of death or recurrent ischemic events compared with patients without previous peripheral or cerebrovascular disease. the higher the mortality risk. ST segment deviation >0.[4] High-Risk Clinical Subgroups. [25] [26] [44] Beyond just a positive versus negative test result.[18] There appears to be a gradient of risk based on the degree of ST segment deviation. 60 ). [40] [41] As with STEMI.ECG ST segment deviation •0.[40] Risk Assessment by Cardiac Markers CK-MB AND THE TROPONINS. a higher risk of MI (or recurrent MI) was observed with lower degrees of troponin elevation in several studies. post-MI unstable angina.e. notably those with ongoing or recurrent rest pain. thus the overall rate of death or MI is equally high among patients with low or higher troponin values. Increasing age is associated with a significant increase in adverse outcomes in patients with UA/NSTEMI. have a worse long-term prognosis than those with UA.[36] Patients with extracardiac vascular disease (i. 57 ).[41] On the other hand. there is a linear relation between the level of troponin T or I in the blood and subsequent risk of death²the higher the troponin level. CK-MB. [26] [45] [46] . even after controlling for other differences in baseline characteristics (see also Chap. patients with UA/NSTEMI who present with evidence of congestive heart failure (Killip Class>II) have an increased risk of death.. or troponin.05 mV (risk ratio 2.

If respiratory depression develops. The effect of nitrates on mortality was evaluated in the large randomized trials for patients with suspected MI (both ST elevation and NSTEMI). administration of betaadrenergic blocking agents (beta blockers) and intravenous nitroglycerin (5 to 10 mg/min using nonabsorbing tubing) is recommended. reduction of myocardial oxygen demand. If pain persists after three sublingual tablets (or buccal sprays) at 5-minute intervals.6 mg) if the patient is experiencing ischemic pain. or they may replace intravenous nitroglycerin if the patient has been pain-free for 12 to 24 hours. the goal of nitrate therapy is relief of pain.[82] In addition. Thus. but dosing should attempt to have an 8. Nitrates should initially be given sublingually or by buccal spray (0. Consequently. reinfarction.3 to 0. Contraindications to use of nitrates are hypotension or the use of sildenafil (Viagra) or related compounds within the previous 24 hours. thus. but its venodilatory effects may produce beneficial hemodynamic effects by reducing preload. The latter is especially useful in the setting of pulmonary congestion. with sublingual or buccal nitroglycerin given as needed for new episodes of pain. Although there is no absolute maximum dose. and. It is advisable to provide supplemental oxygen only to patients with cyanosis. beta blockers are recommended for patients with UA/NSTEMI who do not have contraindications to beta- . meperidine can be substituted for the latter patients. beta blockers were shown to reduce infarct size. continuous ECG monitoring (i. or if at low or intermediate risk to a monitored bed.4 to 2. declines below 92 percent.General Measures Patients with UA/NSTEMI if at high risk should be admitted to an intensive (cardiac) care unit. In these settings. telemetry) is used to detect cardiac arrhythmias. If hypotension develops following administration of morphine. repeat doses can be administered every 5 to 30 minutes. In patients with persistent pain despite therapy with nitrates and beta blockers (see later).to 10-hour nitrate-free interval to avoid the development of tolerance.e. morphine sulfate 1 to 4 mg intravenously is usually administered. measured by oximetry. naloxone (0. extensive rales and/or when arterial O2 saturation. Ambulation as tolerated is permitted if the patient has been stable without recurrent chest discomfort for at least 12 to 24 hours or following revascularization. [81] [82] No benefit on mortality was observed in the overall population or in the subgroup of patients with NSTEMI. Morphine may act both as an analgesic and anxiolytic. Contraindications include hypotension or allergy. [83] [84] In patients with acute MI (in studies that included patients with both ST elevation and NSTEMI). Nitrates Nitrates are endothelium-independent vasodilators that both increase myocardial blood flow by coronary vasodilation and reduce myocardial oxygen demand²the latter effect produced by venodilation leading to reduced myocardial preload.. 51) . Relief of chest pain is an initial goal of treatment. in subgroup analyses of patients with non-Q-wave MI in several trials. chronic nitrate therapy can frequently be tapered off in the long-term management of patients. Bed rest is usually prescribed initially for patients with UA/NSTEMI. Dosing of nitrates depends on the formulation. and pressors are rarely needed. reduction in ventricular wall stress. With careful blood pressure monitoring. Supplemental oxygen is frequently administered to patients with UA/NSTEMI. and mortality (see Chap. with primary therapy being aspirin. beta blockers and other anti-ischemic therapies. The rate of the nitroglycerin infusion may be increased by 10 mg/min every 3 to 5 minutes until relief of symptoms occurs or systolic blood pressure falls to below 100 mm Hg.[83] the benefits of beta blockers (intravenous followed by oral) have been observed.0 mg) may be given. supine positioning or intravenous saline should restore blood pressure. Beta Blockers Several placebo-controlled trials in UA/NSTEMI have shown benefit of beta blockers in reducing subsequent MI and/or recurrent ischemia. a dose of 200 mg/min is generally used as a ceiling. Topical or oral nitrates can be used if the episode of pain has resolved. clopidogrel. but its usefulness has not been documented.

[12] and directly inhibiting platelet aggregation (GP IIb/IIIa inhibitors) (see Fig. They may be used in patients who have persistent or recurrent symptoms but are currently recommended only in patients who have persistent ischemia after treatment with full-dose nitrates and beta blockers.[84] In the DAVIT II trial of patients with suspected MI or unstable angina. known systolic dysfunction with acute pulmonary edema. followed by 50 mg orally twice daily titrated up to 100 mg twice daily. 82 ) Antiplatelet Agents Antiplatelet therapy is one of the cornerstones of therapy in UA/NSTEMI and is directed at decreasing the formation of thromboxane A2 (aspirin). followed by oral administration. three given 2 to 5 minutes apart. [92] [93] The benefit emerges within the first day of treatment. inhibiting the P2Y12 component of the adenosine diphosphate (ADP) receptor pathway of platelet activation (thienopyridines).g. and reduces blood viscosity by inhibiting adenosine diphosphate (ADP) action on platelet receptors. history of bronchospasm). with a more than 50 percent reduction in the risk of death or myocardial infarction in patients presenting with UA/NSTEMI. Examples of doses tested in large trials include atenolol (5 to 10 mg IV bolus followed by 100 mg orally daily). Antithrombotic Therapy (see also Chap. This inhibition of cyclooxygenase is permanent. However. and physician familiarity. thereby blocking the synthesis of thromboxane A2 (TxA2) by the platelet ( Fig. Oral doses of diltiazem and verapamil range from 30-90 mg four times daily to 360 mg once daily of the long-acting preparation. of whom nearly one half did not have confirmed MI..g. 53-10 ). specifically the P2Y12 component of the ADP receptor (see Fig. CLOPIDOGREL Clopidogrel is a thienopyridine derivative that in-hibits platelet aggregation. such as pindolol. and it is primary therapy for these patients.. beta blockers should not be initiated in patients with evidence of decompensated heart failure until they are stabilized.2 percent. Such patients should be treated with heart-rate slowing calcium channel blockers (e. However.3 percent on placebo to 5.[90] Thus. indicating that these agents may be safely used in patients with UA/NSTEMI with left ventricular dysfunction. von Willebrand factor) . and in those with hypertension. thus the antiplatelet effects last for the lifetime of the platelets. In the Diltiazem Reinfarction Study. which does not lower heart rate.) Calcium Channel Blockers Calcium channel blockers have vasodilatory effects and lower blood pressure. approximately 7 to 10 days. in patients with acute MI with left ventricular dysfunction or congestive heart failure.[86] Nifedipine. increases bleeding time. early intravenous beta blockers should be used. diltiazem reduced recurrent MI from 9. this decreases overall platelet aggregation at the site of the thrombus. has been shown to be harmful in patients with acute MI when not co-administered with a beta blocker. By decreasing the amount of TxA2 released. Blockade of this receptor not only inhibits the ADP-induced platelet activation and subsequent aggregation but appears to decrease platelet activation by other stimuli (e. If ischemia and chest pain is ongoing. which would act to stimulate other platelets. persistent hypotension. 53-10 ). ASPIRIN Aspirin permanently acetylates cyclooxygenase 1 (COX-1). in patients with contraindications to beta blockers. diltiazem or verapamil). a harmful effect of diltiazem was observed. in patients with UA/NSTEMI. involving 576 patients with non-Q-wave MI. aspirin dramatically reduces adverse clinical events both early in the course of treatment of UA/NSTEMI. and some also slow heart rate. Several trials have demonstrated clear beneficial effects of aspirin. No harm with long-term treatment with amlodipine[87] or felodipine[88] was observed in patients with documented left ventricular dysfunction and coronary artery disease.[85] Importantly. those with intrinsic sympathomimetic activity (ISA). metoprolol (5 mg IV boluses. should not be selected. 53-5 ).blockade (bradycardia.[12] It achieves its antiaggregatory action by inhibiting the binding of ADP to its platelet receptors. cost. verapamil tended to reduce recurrent MI or death. advanced atrioventricular block. The choice of which beta blocker can be individualized based on the drug's pharmacokinetics.

collagen. and heparin-induced thrombocytopenia. LMWH binds less avidly to plasma proteins and thus has a more consistent anticoagulant effect in relation to the dose administered. serotonin. and titration of UFH using a standardized nomogram (example in Table 53-4 ) with a target range of APTT between 1. LMWHs are more affected by renal dysfunction than UFH.[133] Its high bioavailability allows for subcutaneous administration. eptifibatide. and others). and in clinical trials does not increase the incidence of neutropenia or thrombotic thrombocytopenic purpura compared with aspirin alone. Anticoagulants HEPARIN Anticoagulation.´ is thought to result from the heterogeneity of unfractionated heparins and to the neutralization of heparin by circulating plasma factors and by proteins released by activated platelets. These agents combine factor IIa and factor Xa inhibition and thus inhibit both the action and generation of thrombin. because the P2Y12 receptor is part of the overall amplification of platelet activation. Three agents are available for use in UA/NSTEMI²abciximab. clopidogrel appears to be as effective as ticlopidine in preventing stent thrombosis. and tirofiban²with the former currently approved only in patients undergoing PCI. [103] [104] When added to aspirin. with each given by bolus and continuous infusion. Finally. A meta-analysis of .[132] LMWH causes thrombocytopenia at a lower rate than UFH. inhibition of this receptor appears to have a broader effect in decreasing platelet activation than inhibition ADP-induced aggregation alone.as well. ADP. 53-5 ).[89] A meta-analysis showed a trend toward a 33 percent reduction in death or MI comparing UFH plus aspirin versus aspirin alone.[ GLYCOPROTEIN IIB/IIIA INHIBITORS The GP IIb/IIIa inhibitors prevent the final common pathway of platelet aggregation. These agents inhibit platelet aggregation caused by all types of stimuli (e. Also. provide a very stable level of anticoagulation.[130] Clinically. the anticoagulant effect of UFH can be reversed more effectively with protamine DIRECT THROMBIN INHIBITORS Direct thrombin inhibitors have a potential advantage over indirect thrombin inhibitors such as UFH or LMWH in that they do not require antithrombin and can inhibit clot-bound thrombin. Based on available data. and the dose should be reduced in patients with a creatinine clearance <30 mL/min. in the event of bleeding. the fibrinogen-mediated cross linkage of platelets (see Fig. However. especially when APTT is elevated. thrombin..g. LMWH also induces a greater release of tissue factor pathway inhibitor than does UFH. its greater anti-factor Xa activity inhibits thrombin generation more effectively. the first agent in this class. which is more common with longer durations of treatment LOW-MOLECULAR-WEIGHT HEPARIN (LMWH) LMWHs have been widely tested as a means of improving on anticoagulation with UFH.[130] and do not cause thrombocytopenia. Adverse effects include bleeding. and monitoring of the level of anticoagulation is not necessary.[129] Variability in the anticoagulant effects of UFH. and it is not neutralized by platelet factor 4. also they do not interact with plasma proteins. Clopidogrel avoids the hematologic complications associated with ticlopidine. traditionally with unfractionated heparin (UFH) is a cornerstone of therapy for patients with UA/NSTEMI. frequent monitoring of the anticoagulant response using activated partial thromboplastin time (APTT) is recommended with titrations made according to a standardized nomogram aiming for an APTT of 50 to 70 seconds ( Table 53-4 ).[132] LMWH has several potential advantages over UFH: First. The receptor blocking activity of the latter two agents and the accompanying bleeding risk subside promptly after discontinuation of the infusion. the current ACC/AHA Guidelines recommend a weight adjusted dosing of UFH (60 U/kg bolus and 12 U/kg/hr infusion).5 to 2 times control or approximately 50 and 70 seconds. frequent monitoring of APTT (every 6 hours until in the target range and every 12 to 24 hours thereafter).[99] Thus. so-called ³heparin resistance.

or aspirin (75 mg daily). between bivalirudin plus GP IIb/IIIa inhibitor and UFH/enoxaparin plus a GP IIb/IIIa inhibitor.0 percent versus 5. stenting). bivalirudin plus a GP IIb/IIIa inhibitor. 16. LMWH).[143] No differences were observed in the direct comparison of the anticoagulants: i.0 percent of patients receiving aspirin alone.0 percent of patients receiving warfarin and aspirin (p = 0.[28] The proposed mechanism for adverse effect of fibrinolysis in UA/NSTEMI is a prothrombotic effect of fibrinolysis. including hirudin. Patients were managed with an early invasive strategy. Food and Drug Administration±approved indication for lepirudin and argatroban is for anticoagulation in patients with heparin-induced thrombocytopenia (HIT) and associated thromboembolic disease.[145] Rates of major bleeding were 0.[149] Research is ongoing to identify alternative oral anticoagulants.e.[148] The combination of all three agents has not been tested prospectively to date but might be associated with a high bleeding risk during long-term therapy. Bivalirudin has recently been studied in UA/NSTEMI. FIBRINOLYTIC THERAPY FOR UA/NSTEMI No benefit of fibrinolysis in UA/NSTEMI has been observed. the rates of both recurrent MI and intracranial hemorrhage were higher with tissue plasminogen activator treatment versus placebo in this population. ORAL ANTICOAGULATION Several trials have examined oral anticoagulation with warfarin following ACS. myocardial infarction. Although initial large trials failed to show a significant benefit of long-term warfarin plus aspirin versus aspirin alone.7 percent for major bleeding.001). UFH.S. and use of clopidogrel for as short a time as recommended for the type of stent placed. warfarin (titrated meticulously to an INR of 2. aspirin alone (160 mg daily). Use of all three agents together is sometimes needed among patients with atrial fibrillation or other strong indications for warfarin (e.g. efegatran. For the bivalirudin alone group. [148] [149] [150] In the largest study. the rate of death. However. which is .[144] subsequent trials suggested that if a sufficient degree of anticoagulation were achieved.7 percent of patients receiving warfarin (p = 0. Thus.5).. there were no differences in the efficacy endpoint.0 to 2. bivalirudin. Fibrinolytic agents can activate platelets. The primary endpoint was the composite of death. including oral direct thrombin inhibitors and factor Xa inhibitors in place of coumadin. the combination of aspirin plus warfarin was more effective than aspirin alone for long-term secondary prevention. p<0.0 to 2. with the rationale that prolonged treatment might extend the benefit of early anticoagulation with an antithrombin agent (e.819 patients with UA/NSTEMI to one of three treatments: UFH or enoxaparin plus a GP IIb/IIIa inhibitor.8 percent versus 11.[142] The only current U. 4930 patients with ACS within the prior 8 weeks were randomized to warfarin alone (target international normalized ratio (INR) of 2.17 percent in patients receiving aspirin (p<0. unplanned revascularization for ischemia. or inogatran. Among patients without a coronary stent but with another indication for warfarin.03). argatroban. or thromboembolic cerebral stroke occurred in 20. and 15. and the dissolution of the fibrin clot exposes clot-bound thrombin. or bivalirudin alone. The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial randomized 13. the clinical use of aspirin plus warfarin is limited. the ACC/AHA Guidelines recommend use of low-dose aspirin (75 to 81 mg daily).g. MI. showed a modest 9 percent reduction in death or MI at 30 days.001). a benefit accrued from the combination of aspirin plus warfarin.7 percent. the substitution of bivalirudin as the anticoagulant among patients receiving supplemental GP IIb/IIIa inhibitors did not change efficacy or safety outcomes.3 percent versus 5. such as chronic atrial fibrillation or severe left ventricular dysfunction who are at high risk of systemic embolization. the lack of need for monitoring of the INR. to avoid the need for monitoring the INR. but a lower rate of bleeding (3.62 percent per treatment-year in both groups receiving warfarin and 0.5). combined with warfarin (target INR of 2. with rates of 11. and major bleeding at 30 days.[145] During an average of 4 years of follow-up. but the strategy of bivalirudin alone was associated with less bleeding than the combination of a GP IIb/IIIa inhibitor with either UFH or enoxaparin. and the frequent use of PCI and stenting in the patient population in whom the need for clopidogrel is well established.7 percent for the efficacy endpoint. favoring the direct thrombin inhibitor over unfractionated heparin.[143] Thus..2).. In such patients. and 5. given the similar benefit seen with clopidogrel plus aspirin over aspirin alone. the combination of aspirin plus warfarin would be preferable as the long-term antithrombotic strategy.8 to 4. when compared with the group receiving UFH/enoxaparin plus a GP IIb/IIIa inhibitor.all direct thrombin inhibitors studied through 2001.001.

[110] A second study compared an immediate invasive approach (but without GP IIb/IIIa inhibition) with a strategy that included early GP IIb/IIIa inhibition followed by catheterization within 24 to 48 hours. the culprit vessel is totally occluded and can only improve with fibrinolysis. To date. based on studies in acute MI. an early invasive strategy is now recommended in patients with UA/NSTEMI with ST segment changes and/or positive troponin on admission or that evolves over the next 24 hours. Percutaneous Coronary Intervention PCI is an effective means of reducing coronary obstruction. but based on available information the optimal timing appears to be within the first 48 hours of presentation. Accordingly. 52 ). [162] [163] Additional trials are ongoing to evaluate the optimal timing of an invasive approach. The other is a more conservative approach with initial medical management with catheterization and revascularization only for recurrent ischemia either at rest or on a noninvasive stress test. especially when clopidogrel is stopped. six trials have shown a significant benefit of an early invasive therapy Indications for Invasive versus Conservative Management Strategies Based on multiple randomized trials. ten randomized trials have studied the relative merits of these two strategies. The first three and the most recent trial did not demonstrate a significant difference. other high-risk indicators. improving acute ischemia. although the presence of UA/NSTEMI or visualized thrombus can increase the risk of acute complications such as abrupt closure or MI (as compared with patients with stable angina or those without visualized thrombus) Thus. More than . these prothrombotic forces can lead to progression of the thrombus to total occlusion.[161] An early invasive strategy is also advised in those who present with UA/NSTEMI within 6 months of a prior PCI. 55) . however.[164] This observation has emphasized the need for effective long-term (likely 2 or more years) dual antiplatelet therapy in these patients (see Chap. generally >95 percent. use of GP IIb/IIIa inhibitors. two observational studies of the timing of angiography failed to find any major differences in outcomes among patients who underwent protocol-mandated catheterization within the first 12 hours versus 12 to 24 versus 24 to 48 hours.[163] Recent studies. TREATMENT STRATEGIES AND INTERVENTIONS Two general approaches to the use of cardiac catheterization and revascularization in UA/NSTEMI exist: an early invasive strategy. compared with a delayed invasive strategy (average time to catheterization.[158] Similarly. and improving regional and global left ventricular function in patients with UA/NSTEMI (see also Chap. have emphasized the risk of late stent thrombosis following drugeluting stent implantation. Because most patients with UA/NSTEMI have a patent culprit artery. thereby causing a new MI (as was observed in TIMI IIIB). the choice is between PCI and CABG. clopidogrel. fibrinolytic therapy is not indicated in UA/NSTEMI. This study did not find an improvement in the immediate invasive approach as compared with an early invasive strategy. in STEMI.[162] Timing of an Invasive Strategy The Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-COOL) trial found a benefit of an immediate invasive strategy with an average time from randomization to catheterization of only 2 hours. Benefit of an early invasive approach also applies to patients with prior CABG. Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting When revascularization is required in patients with UA/NSTEMI. and/or other antithrombotic drugs in such patients improves both acute and long-term outcomes following PCI. 4 days). involving routine early cardiac catheterization and revascularization with percutaneous coronary intervention (PCI) or coronary bypass grafting (CABG) depending on the coronary anatomy.[28] In contrast. such as recurrent ischemia or evidence of congestive heart failure. Use of drug-eluting stents reduces the risk of restenosis. Current angiographic success rates are high.[2] An early invasive approach appears warranted in those with cardiogenic shock. however.enzymatically active and can lead to clot formation. In addition. are indications for an early invasive strategy. in whom restenosis may be frequent.

[174] Over a longer period of follow-up. Based in part on these results. [170] [171] a not observations confirmed using ramipril and perindopril in the HOPE and EUROPA trials.[176] highlighting the importance of early initiation of intensive statin therapy post-ACS ( Fig. No randomized trials are available to document its benefit.5 percent absolute mortality benefit of early (initiated within 24 hours) angiotensin-converting enzyme (ACE) inhibitor therapy in patients with acute MI. 42 and 51) .004). in the PROVE-IT TIMI 22 trial. one in ACS and two in stable coronary artery disease patients. Lipid-Lowering Therapy Long-term treatment with lipid-lowering therapy. Based on the results of these trials. 54 .[171] In the Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) trial. [168] [169] Notably. but this method can effectively stabilize patients with refractory ischemia. a prespecified subgroup of more than 3200 UA patients. 53-19 ). respectively. especially with statins.[178] Intraaortic Balloon Pump Counterpulsation Intraaortic balloon pump (IABP) counterpulsation is a very effective means of increasing diastolic coronary blood flow and reducing left ventricular afterload.[177] There have been three additional trials of intensive statin therapy. However. showing a highly significant 16 percent reduction in coronary death or MI with intensive versus standard statin therapy ( Fig. that showed equivalent outcomes in post MI patients between captopril and valsartan.[170] These agents are also indicated in patients who cannot tolerate ACE inhibitors. [168] [169] These results suggest an anti-ischemic effect of this entire class of agents.[173] Trials testing the clinical benefit of early initiation of statin therapy post-ACS have found early reductions in recurrent ischemic events. MI.eight trials have compared PCI and CABG in patients with is-chemic heart disease. the ISIS-4 study showed no benefit in patients without ST elevation.[175] A benefit emerged after only 30 days post-ACS. has shown benefit in patients following acute MI and unstable angina (see also Chaps. many of whom had UA/NSTEMI.g. 53-20 ). CABG is recommended for patients with disease of the left main coronary artery and multivessel disease and impaired left ventricular function. whereas CABG is associated with more effective relief of angina. Although the PEACE trial did not show any benefit with trandolapril. an .[172] When initiated in-hospital at the time of an ACS. For other patients. The results of these trials are reviewed in Chap. studies have found improved long-term treatment rates. IABP counterpulstation is usually reserved for patients with UA/NSTEMI who are refractory to maximal medical therapy and those with hemodynamic compromise who are awaiting cardiac catheterization. but a higher rate of repeat procedures.. 51 ). 51 ). [81] [82] However.[79] Long-term use of ACE inhibition does prevent recurrent ischemic events and mortality in a broad population of patients now including those with any evidence of CAD (see also Chap. intensive lipid-lowering therapy with atorvastatin 80 mg resulted in a 16 percent reduction in the primary endpoint and a 25 percent reduction in death. this may have been because the patients were at relatively low risk at baseline due to more intensive statin therapy and coronary revascularization. the Adult Treatment Panel III of the National Cholesterol Education Program issued an update in which they recommended a new optional therapeutic LDL goal of <70 mg/dl in highrisk patients with coronary heart disease. Other Therapies Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers For acute treatment. or urgent revascularization compared with moderate lipid-lowering therapy with pravastatin 40 mg. which act in concert to reduce ischemia ( Chap. either PCI or CABG may be suitable: PCI is associated with a slightly lower initial morbidity and mortality than CABG.[169] Angiotensin receptor blockers can be substituted for ACE inhibitors based on the Valsartan in Acute Myocardial Infarction Trial (VALIANT) trial. captopril or enalapril reduced recurrent MI and the need for revascularization in the SAVE and SOLVD trials. The average LDLs achieved in the two arms were 62 mg/dl and 95 mg/dl. three large trials showed a 0. pravastatin therapy led to a significant 26 percent reduction in total mortality (p = 0. which have been analyzed by meta-analysis. or those identified to have very high-risk coronary anatomy (e. such as those with a history of an acute coronary syndrome. left main stenosis) as a bridge to PCI or CABG.

analysis of 12.730 MI patients (NSTEMI and STEMI) with cardiogenic shock found that increased use of IABP counterpulstation was associated with lower mortality.[179 .

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