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doi:10.1016/j.ccc.2007.07.003 criticalcare.theclinics.com
710 BHATHEJA & MUKHERJEE
Table 1
Causes of unstable angina and non–ST-segment elevation myocardial infarctiona
1. Nonocclusive thrombus on pre-existing plaque
2. Dynamic obstruction (coronary artery spasm or vasoconstriction)
3. Progressive mechanical obstruction
4. Inflammation or infection
5. Secondary UA
a
These causes are not mutually exclusive; some patients have R2 causes.
From Braunwald E. Unstable angina: an etiologic approach to management. Circulation
1998;98:2220; with permission.
ACUTE CORONARY SYNDROMES 711
Table 2
Three types of presentations of unstable angina
Rest angina Angina occurring at rest and prolonged,
usually O20 minutes
New-onset angina New-onset angina of at least CCSa class III severity
Increasing angina Previously diagnosed angina that has become
distinctly more frequent, longer in duration,
or lower in threshold (ie, increased by R1
CCS class to at least CCS class III severity)
a
Canadian Cardiac Society classification.
Data from Savonitto S, Cohen MG, Politi A, et al. Extent of ST-segment depression and
cardiac events in non-ST-segment elevation acute coronary syndromes. Eur Heart J
2005;26:2106–13.
712 BHATHEJA & MUKHERJEE
should warrant the same degree of concern as chest pain. Constant pain that
lasts for many hours or days, or only a few seconds, and easily is reproduc-
ible with palpation of the chest wall is less likely to be ischemic in origin.
Pain that clearly is pleuritic or positional or located with the tip of one finger
also is unlikely to be cardiac in origin. A history and ECG aid physicians in
classifying the presentation as high, intermediate, or low likelihood of acute
ischemia caused by CAD (Table 3) [8].
Presence of hypotension, mitral regurgitation murmur, unequal pulses,
tachycardia, pulmonary rales, bruits, and gallop aid not only in diagnosing
Table 3
Likelihood that signs and symptoms represent an acute coronary syndrome secondary to
coronary disease
Feature High likelihood Intermediate Low likelihood
likelihood
Any of the following: Absence of Absence of high- or
high-likelihood intermediate-likelihood
features and presence features but may have:
of any of the
following:
History Chest or left arm pain Chest or left arm Probable ischemic
or discomfort as chief pain or discomfort symptoms in absence
symptom reproducing as chief symptom of any of the
prior documented intermediate
angina likelihood
characteristics
Known history of CAD, Age O70 years Recent cocaine use
including MI Male gender Diabetes
mellitus
Examination Transient mitral Extracardiac vascular Chest discomfort
regurgitation, disease reproduced by
hypotension, palpation
diaphoresis,
pulmonary edema,
or rales
ECG New, or presumably Fixed Q waves T-wave flattening
new, transient or inversion in leads
ST-segment deviation with dominant
(R0.5 mm) or T-wave R waves
inversion (R2 mm) Abnormal ST Normal ECG
with symptoms segments or
T waves not
documented
to be new
Cardiac Elevated cardiac Normal Normal
markers troponin I, troponin
T, or CK-MB
From Braunwald E, Mark DB, Jones RH, et al. Unstable angina: diagnosis and manage-
ment. Rockville, MD: Agency for Health Care Policy and Research and the National Heart,
Lung, and Blood Institute, US Public Health Service, US Department of Health and Human
Services; 1994; AHCPR Publication No. 94-0602.
ACUTE CORONARY SYNDROMES 713
Diagnostic evaluation
Electrocardiography
Most patients who have UA/NSTEMI have some ECG changes. The
ECG is important for diagnostic and risk stratification purposes. Specific
characteristics and the magnitude of pattern abnormalities increase the
likelihood of CAD. ST–T-segment depression portends a poorer prognosis
than T-wave inversion alone or no ECG changes [11]. New or dynamic
ST-segment depression is suggestive of acute ischemia with an increase in
thrombin activity associated with elevated fibrinopeptides [12]. Inverted
T waves also may suggest ischemia or NSTEMI, although the risk is less
than that with ST-segment depression. Nonspecific ST-segment changes
(%0.5 mm) and T-wave changes (%2 mm) are not uncommon and may
be related to drugs (phenothiazines, digitalis, and so forth), hyperventila-
tion, or repolarization abnormalities in association with left ventricular
(LV) hypertrophy or conduction disturbances. Conversely, the ECG may
be normal in 1% to 6% of patients who have NSTEMI and in
approximately 4% of patients who have UA [13].
The Global Use of Strategies to Open Occluded Coronary Arteries in
Acute Coronary Syndromes (GUSTO-IIb) trial demonstrated that the
30-day incidence of death or MI was 10.5% in those who had ST-segment
depression versus 5.5% in patients who had T-wave inversion, and a higher
mortality also was seen at 6-month follow-up [14]. The sum of ST depres-
sion is a strong independent predictor of short-term mortality and the risk
increases with the magnitude of depression [15].
Biochemical markers
Although many markers and assays that detect myocardial necrosis are
available, the cardiac troponins T and I and the creatinine kinase–MB
(CK-MB) isoform are those used most commonly, with the troponins
gaining acceptance as the markers of choice in ACS. These have achieved
an important role in diagnostic, prognostic, and treatment pathways by
virtue of their high degree of sensitivity and specificity and their relative
ease of use and interpretation. The joint statement of the European Society
of Cardiology and the American College of Cardiology (ACC) defines
myonecrosis as when the peak concentration of troponin T or I exceeds
the decision limit (99th percentile for a reference group) on at least one
occasion in a 24-hour period [16]. This new definition has increased the fre-
quency of the diagnosis of NSTEMI in patients who have ACS by 30%.
Troponin I may be more accurate in patients who have renal insufficiency
714 BHATHEJA & MUKHERJEE
Noninvasive testing
Noninvasive stress testing is recommended for risk stratification (Table 4)
in patients who are at low to intermediate risk and are free of angina at rest
or minimal activity and heart failure for at least 24 hours. Although exercise
ECG is the most appropriate testing modality, choice of stress test is based
on the resting ECG, ability to exercise, and local expertise. Treadmill testing
is suitable in patients who have good exercise tolerance in whom the ECG is
free of ST-segment abnormalities, bundle branch block, LV hypertophy,
intraventricular conduction delay, paced rhythm, pre-excitation, and
digoxin effect. Echocardiography has the advantage of allowing for bedside
and rapid determination of LV function. Imaging modalities, such as echo-
cardiography or nuclear imaging, should be added in patients who have
ECG abnormalities that prevent accurate interpretation and also in those
Fig. 1. Relationship between cardiac troponin levels and risk for mortality at 42 days in
patients who have ACS. (Reproduced from Antman EM, Tanasijevic MJ, Thompson B, et al.
Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary
syndromes. N Engl J Med 1996;335:1342–9; with permission. Copyright Ó 1996, Massachusetts
Medical Society.)
ACUTE CORONARY SYNDROMES 715
Table 4
Risk stratification based on noninvasive testing
High risk (O3% annual mortality rate)
1. Severe resting LV dysfunction (LVEF !35%)
2. High-risk treadmill score (score % 11)
3. Severe exercise LV dysfunction (exercise LVEF !35%)
4. Stress-induced large perfusion defect (particularly if anterior)
5. Stress-induced multiple perfusion defects of moderate size
6. Large, fixed perfusion defect with LV dilation or increased lung uptake (thallium-201)
7. Stress-induced moderate perfusion defect with LV dilation or increased lung uptake
(thallium-201)
8. Echocardiographic wall motion abnormality (involving O2 segments) developing at a low
dose of dobutamine (%10 mg kg 1 $ min 1) or at a low heart rate (!120 bpm)
9. Stress echocardiographic evidence of extensive ischemia.
Intermediate risk (1%–3% annual mortality rate)
1. Mild/moderate resting LV dysfunction (LVEF 35%–49%)
2. Intermediate-risk treadmill score (11 ! score !5)
3. Stress-induced moderate perfusion defect without LV dilation or increased lung intake
(thallium-201)
4. Limited stress echocardiographic ischemia with a wall motion abnormality only at higher
doses of dobutamine involving %2 segments.
Low risk (!1% annual mortality rate)
1. Low-risk treadmill score (score R5)
2. Normal or small myocardial perfusion defect at rest or with stress
3. Normal stress echocardiographic wall motion or no change of limited resting wall motion
abnormalities during stress
Abbreviation: LVEF, left ventricular ejection fraction.
From Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the
management of patients with chronic stable angina. J Am Coll Cardiol 1999;33:2092–197; with
permission. Copyright Ó 1999 American College of Cardiology.
(PCI) within the past 6 months or a prior coronary artery bypass graft
(CABG), or new ST-segment depression on ECG [8]. This approach,
specifically in those who are troponin positive, has proved to reduce
rehosopitalization, severe angina, and long-term major cardiovascular
events. The goal of early invasive therapy is not only to visualize the
coronary vasculature, the extent and nature of the coronary obstruction,
and the feasability of revascularization but also to assess the ventricular
function and associated valvular disease.
Those who do not have the high-risk features described previously may
not necessarily benefit from an invasive approach, and a conservative
approach with medical therapy and risk stratification with an noninvasive
imaging may be a reasonable strategy. Fig. 2 is a simplified algorithm for
management of patients who have ACS based on American College of Car-
diology/American Heart Association guidelines.
Complications
If left untreated, 5% to 10% of patients who have UA die and 10% to
20% suffer nonfatal MI within 30 days. One quarter of patients who have
NSTEMI develop Q-wave MI, with the remaining having non–Q-wave
MI. Arrhythmia, congestive heart failure, and cardiogenic shock are
life-threatening complications. Recurrent ischemia may result in need for
urgent coronary artery revascularization. The Thrombolysis in Myocardial
Infarction (TIMI) risk score (Fig. 3) [19] has been shown to predict death,
MI, and need for urgent revascularization. Another risk score that has
been studied is the Global Registry of Acute Coronary Events (GRACE)
risk score, which predicts 6-month postdischarge death (Fig. 4) [20].
Early invasive management may be associated with a shorter hospital
stay, less in-hospital mortality, and other adverse outcomes. Those who
have the highest risk derive the maximum benefit. There is a higher risk
for blood transfusions, however, with this approach [21].
Therapy
Once the diagnosis of ACS is made, resources should be mobilized for
effective and immediate management of this condition. The strategy should
be relief of ischemia and prevention of the serious adverse outcomes of
reinfarction and death. This may be achieved by prompt initiation of appro-
priate therapy, ongoing risk stratification, and, in selected cases, coronary
artery revascularization. Coronary angiography performed after NSETMI
has shown that in most patients, the infarction is associated with incomplete
occlusion of the infarct-related artery; 37% of patients have no identifiable
culprit lesion; and only 13% have a single occlusion of the infarct-related
artery [22]. As UA and NSTEMI are distinguishable mainly by the rise in
ACUTE CORONARY SYNDROMES 717
Fig. 2. Approach to patients who have ACS. (From ACC/AHA Guidelines for the Manage-
ment of Patients with Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction.
J Am Coll Cardiol 2000;36:970–1062; with permission. Copyright Ó 2002 American College of
Cardiology.)
cardiac biomarkers, which may not be detectable for few hours after
presentation, the initial management is the same.
General measures
Bed rest is recommended strongly in the presence of ongoing ischemia.
When symptom free, mobility to a chair or bedside commode may be
718 BHATHEJA & MUKHERJEE
Fig. 3. TIMI risk score for UA/NSTEMI. The rates of composite endpoints (ie, all-cause mor-
tality, MI, and recurrent ischemia) through day 14 in the TIMI 11B trial depending on the level
of risk factors. The seven risk factors are age R65 years, presence of R3 risk factors for CAD,
prior coronary stenosis of R50%, ST deviation, aspirin use in the last 7 days, severe angina,
and elevated cardiac biomarkers. (Reproduced from Antman EM, Cohen M, Bernink PJ,
et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognosti-
cation and therapeutic decision making. JAMA 2000;284:835–42; with permission.)
Anti-ischemic agents
Nitrates
Nitroglycerine has a potent endothelium-independent vasodilator effect
on the coronary and peripheral vascular beds. Nitrates dilate venous
capacitance vessels and peripheral arterioles, with a predominant decrease
in preload and a lesser effect on afterload, thereby decreasing myocardial
wall stress and oxygen demand. These drugs also may increase myocardial
oxygen delivery by dilating epicardial coronary arteries and increasing
collateral flow. Although there are no randomized placebo-controlled trials
ACUTE CORONARY SYNDROMES 719
Fig. 4. GRACE prediction scorecard and nomogram for all-cause mortality from discharge to
6 months. (Reproduced from Eagle KA, Lim MJ, Dabbous OH, et al. A validated prediction
model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge
death in an international registry. JAMA 2004;291:2727–33; with permission.)
b-Blockers
b-Blockers are recommended for all patients who have UA/NSTEMI,
unless contraindicated. If there is ongoing ischemia or chest pain, they
initially are given intravenously followed by oral delivery. Inhibition of b1
receptors in the myocardium decreases myocardial contractility, systolic
blood pressure, sinus node rate, and atrioventricular (AV) node conduction
velocity. By reducing contractility and slowing the heat rate, they decrease
myocardial oxygen demand, shifting the oxygen supply-demand ratio in
favor of the ischemic myocardium. Although, there are limited clinical trial
data on the use of b-blockers in UA and non–Q-wave MI, its use is associ-
ated with a 13% relative reduction in the risk for progression to MI [25].
There is no evidence of superiority of any member of this class over the
others, but b1 selective blockers (metoprolol or atenolol) are preferred
over those with intrinsic sympathomimetic activity. Caution should be
exercised in patients who have active asthma, and therapy should not be
initiated in those presenting with severe conduction disturbances, congestive
heart failure, bradycardia, or hypotension [26]. In patients who have LV
systolic dysfunction after an acute MI, long-term use of carvedilol is
associated with reduction of all-cause and cardiovascular mortality and
recurrent, nonfatal MIs.
Antiplatelet therapy
Aspirin. Platelet activation and aggregation is the core to pathophysiology
of ACS, as platelets play a major role in the thrombotic response to a rup-
tured coronary plaque. Aspirin inhibits platelet aggregation by inhibiting
ACUTE CORONARY SYNDROMES 721
versus aspirin alone, a meta-analysis of six trials showed that the addition of
UFH to aspirin reduced risk for death or MI by 33% compared with aspirin
alone [47]. Most of these benefits are short term and do not seem sustained,
which may be the result of reactivation of the thrombotic milieu after its dis-
continuation. Although there is no defined duration of therapy, it usually is
administered for 2 to 5 days. With the concomitant use of GP IIb/IIIa inhib-
itors, caution needs to be observed with regard to bleeding and a lower dose
of UFH usually is recommended.
Direct thrombin and factor X inhibitors. Direct thrombin inhibitors have the
mechanistic advantage over heparin of inhibiting clot-bound thrombin and
not being inhibited by circulating plasma proteins and platelet factor 4 [56].
The aPTT can be used to monitor anticoagulation activity but usually is not
necessary. Hirudin is an irreversible inhibitor of thrombin and is excreted
primarily from kidneys. Its use is associated with a reduction in death,
MI, and refractory angina but there is an increased risk for bleeding [57].
Bivalirudin is a synthetic polypeptide that is akin to hirudin in being able
to form a bivalent complex with thrombin leading to a potent and selective
inhibition of thrombin. In contrast to hirudin, it has a shorter plasma half-
life of less than 30 minutes that gives it a potential advantage of minimizing
bleeding risk. The use of bivalirudin alone in patients presenting with
UA/NSTEMI and high-risk features is associated with improved net clinical
benefit compared with the UFH/enoxaparin plus GP IIb/IIIa inhibitor,
primarily driven by a reduction in bleeding (3% versus 5.7%, P ! .001
for superiority). Additionally, the use of bivalirudin plus a GP IIb/IIIa
inhibitor is noninferior compared with UFH/enoxaparin plus GP IIb/IIIa
inhibitor [58]. Even long-term clinical outcomes at 6 months to 1 year
with bivalirudin and provisional GP IIb/IIIa inhibitor are comparable to
that of UFH with GP IIb/IIa inhibitor in patients undergoing PCI. Reduced
bleeding complications, ease of use, reduced cost, and the ability to permit
selective rather than universal use of GP IIb/IIIa inhibitor substantiates the
benefit of this drug in PCI and ACS. Moreover, the effect of bivalirudin was
greatest in those who had high-risk features and independent of the choice
of GP IIb/IIIa inhibitor used or pretreatment with thienopyridine [59]. In
addition to this, bivalirudin can be used in patients who have heparin-
induced thrombocytopenia.
Fondaparinux is a synthetic pentasaccharide that is a novel factor Xa
inhibitor. It acts early in the coagulation cascade by binding to AT, thus
ACUTE CORONARY SYNDROMES 727
Coronary revascularization
Coronary angiography helps define the extent and location of CAD,
ventricular function, and presence of any other significant valvular
problems. Those who have left main- or three-vessel disease, especially
with LV dysfunction or diabetes, or those who have two-vessel disease
involving the left anterior descending artery with reduced ejection fraction
often are managed by surgical revascularization (CABG). Almost 30% to
40% of patients have multivessel stenosis, and significant left main stenosis
is seen in 4% to 10% of patients. Thus, these patients may undergo CABG,
as seen in the 33% to 42% of patients in the trials with ‘‘early revasculari-
zation’’ strategy (FRISC II [61]; Treat Angina with aggrastat and determine
Cost of Therapy with an Invasive or Conservative Strategy [TACTICS]-
TIMI 18 [42]; and Randomized Intervention Trial of unstable Angina
[RITA] 3 [62]). The number of patients who have ACS requiring surgical
revascularization has diminished in the contemporary era.
With the advent of drug-eluting stents, the restenosis rate has been
reduced to single digits and, along with low complication rates, PCI seems
the preferred revascularization strategydparticularly in patients who have
preserved LV function, one- or two-vessel disease, or contraindications
for surgery. The decision to pursue an early conservative strategy versus
an early invasive strategy aimed toward revascularization has been
evaluated [42,61,62]. Although similar in scope, these trials differed in design
and level of patient acuity. In FRISC II [61] and TIMI 18 [42], an early
invasive strategy was preceded by standard anti-ischemic and antithrom-
botic medications and was associated with a reduced risk for death, MI,
and rehospitalization. The benefits were most significant in high- or interme-
diate-risk subsets (age O65 years, troponin positive, or ST-segment
728 BHATHEJA & MUKHERJEE
Fig. 6. Effect of combined use of evidence-based medical therapies (aspirin, b-blocker, statin,
angiotensin converting enzyme) on 6-month mortality in patients who have ACS. Appropriate-
ness levels (I–IV) are compared with level 0 (nonuse of any of the indicated medications) and
show a gradient of survival benefit in this cohort. Level 4 means all four medications were
used; level 3 means three out of four medications were used; level 2 means two out of four med-
ications were used; and level 1 means only one out of four medications was used. (Reproduced
from Mukherjee D, Fang J, Chetcuti S, et al. Impact of combination evidence-based medical
therapy on mortality in patients with acute coronary syndromes. Circulation 2004;109:745–9;
with permission.)
Summary
ACS remains associated with high rates of adverse cardiovascular events
despite recent advances. Clinical studies have shown that early diagnosis
and appropriate evidence-based therapies improve outcomes. The clinical
history, physical examination, ECG, and biomarkers (such as troponin)
provide critical information for early risk stratification. Most patients in
the United States undergo an early invasive strategy where patients are
taken to a cardiac catheterization laboratory within 48 hours and revascu-
larization is performed if indicated. Such a strategy seems particularly
beneficial in high-risk patients and is recommended in such individuals by
ACUTE CORONARY SYNDROMES 731
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