Review Article
Non-ST Segment Elevation Acute Coronary Syndromes: A Comprehensive Review
Abstract
As the non-ST segment elevation acute coronary syndromes (NSTEACS) include unstable angina pectoris (UAP) and the non-ST segment elevation myocardial infarction (NSTEMI), acute diagnosis and risk stratification can often prove challenging. This review will cover guidelines and strategies for risk assessment, contemporary approaches to acute patient management as well as recommendations for timing of specialist referral.
Key Points
* Non-ST segment elevation acute coronary syndromes are varying manifestations of the same disease process along a spectrum of disease severity.
* Non-ST segment elevation acute coronary syndromes are most commonly caused by disruption of vulnerable plaques.
* The goal of risk stratification is to identify who will fail medical management and who will need urgent referral for revascularization.
* Eighty percent of patients with acute coronary syndrome can be stabilized within 48 hours after being started on an intensive medical program for ischemia.
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References
1. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction-summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol2002;40:1366–1374.
2. Roe MT, Harrington RA, Prosper DM, et al. Clinical and therapeutic profile of patients presenting with acute coronary syndromes who do not have significant coronary artery disease. The Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Circulation 2000;102:1101–1106.
3. Schroeder AP, Falk E. Vulnerable and dangerous coronary plaques. Atherosclerosis 1995;118 [Suppl]:S141–S149.
4. Patrono C, Renda G. Platelet activation and inhibition in unstable coronary syndromes. Am J Cardiol1997;80:17E–20E.
5. Andrews RK, Shen Y, Gardiner EE, et al. Platelet adhesion receptors and (patho)physiological thrombus formation. Histol Histopathol 2001;16:969–980.
6. Kerensky RA, Wade M, Deedwania P, et al; Veterans Affairs Non-Q-Wave Infarction Stategies in-Hospital (VANQWISH) Trial Investigators. Revisiting the culprit lesion in non-Q-wave myocardial infarction. Results from the VANQWISH trial angiographic core laboratory. J Am Coll Cardiol2002;39:1456–1463.
7. TIMI IIIA Group. Early effects of tissue-type plasminogen activator added to conventional therapy on the culprit coronary lesion in patients presenting with ischemic cardiac pain at rest. Results of the Thrombolysis in Myocardial Ischemia (TIMI IIIA) Trial. Circulation 1993;87:38–52.
8. Wong GC, Morrow DA, Murphy S, et al. Elevations in troponin T and I are associated with abnormal tissue level perfusion: a TACTICS-TIMI 18 substudy. Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction. Circulation2002;106:202–207.
9. Lopez de Sa E, Lopez-Sendon J, Anguera I, et al. (PEPA) Investigators. Prognostic value of clinical variables at presentation in patients with non-ST-segment elevation acute coronary syndromes: results of the Proyecto de Estudio del Pronostico de la Angina (PEPA). Medicine (Baltimore) 2002;81:434–442.
10. Antman EM, Cohen M, Bernink PJ, et al. The TIMI risk score for unstable angina/non-ST elevation MI: a method for prognostication and therapeutic decision making. | | JAMA 2000;284:835–842.
11. Cannon CP, McCabe CH, Stone PH, et al. The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia. J Am Coll Cardiol 1997;30:133–140.
12. Kaul P, Fu Y, Chang WC, et al. Prognostic value of ST segment depression in acute coronary syndromes: insights from PARAGON-A applied to GUSTO-IIb. PARAGON-A and GUSTO IIb Investigators. Platelet IIb/IIIa Antagonism for the Reduction of Acute Global Organization Network. J Am Coll Cardiol 2001;38:64–71.
13. Stone PH, Thompson B, Zaret BL, et al. Factors associated with failure of medical therapy in patients with unstable angina and non-Q wave myocardial infarction. A TIMI-IIIB database study. Eur Heart J 1999;20:1084–1093.
14. Ohman EM, Armstrong PW, Christenson RH, et al. Cardiac troponin T levels for risk stratification in acute myocardial ischemia. GUSTO IIA Investigators. N Engl J Med 1996;335:1333–1341.
15. Rao SV, Ohman EM, Granger CB, et al. Prognostic value of isolated troponin elevation across the spectrum of chest pain syndromes. Am J Cardiol 2003;91:936–940.
16. Yeghiazarians Y, Braunstein JB, Askari A, et al. Unstable angina pectoris. N Engl J Med2000;342:101–114.
17. Thadani U, Opie LH. Nitrates for unstable angina. Cardiovasc Drugs Ther 1994;8:719–726.
18. Fitzgerald DJ, Roy L, Robertson RM, et al. The effects of organic nitrates on prostacyclin biosynthesis and platelet function in humans. Circulation 1984;70:297–302.
19. Metoprolol in acute myocardial infarction: mortality. Patient population. The MIAMI Trial Research Group. Am J Cardiol 1985;56:15G–22G.
20. Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. II. Unstable angina, heart failure, primary prevention with aspirin, and risk factor modification. JAMA1988;260:2259–2263.
21. Collaborative overview of randomised trials of antiplatelet therapy. I. Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Antiplatelet Trialists’ Collaboration. BMJ 1994;308:81–106.
22. Mehta SR, Yusuf S; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Study Investigators. The Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Study Investigators trial programme; rationale, design and baseline characteristics including a meta-analysis of the effects of thienopyridines in vascular disease. Eur Heart J 2000;21:2033–2041.
23. Hongo RH, Ley J, Dick SE, et al. The effect of clopidogrel in combination with aspirin when given before coronary artery bypass grafting. J Am Coll Cardiol 2002;40:231–237.
24. Gansera B, Schmidtler F, Spiliopoulos K, et al. Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy. Thorac Cardiovasc Surg2003;51:185–189.
25. Kong DF, Hasselblad V, Harrington RA, et al. Meta-analysis of survival with platelet glycoprotein IIb/IIIa antagonists for percutaneous coronary interventions. Am J Cardiol 2003;92:651–655.
26. Chan AW, Moliterno DJ, Berger PB, et al; TARGET Investigators. Triple antiplatelet therapy during percutaneous coronary intervention is associated with improved outcomes including one-year survival: results from the Do Tirofiban and ReoProGive Similar Efficacy Outcome Trial (TARGET). J Am Coll Cardiol 2003;42:1188–1195.
27. Kastrati A, Mehilli J, Schuhlen H, et al; Intracoronary Stenting and Antithrombotic Regimen-Rapid Early Action for Coronary Treatment Study Investigators.A clinical trial of abciximab in elective percutaneous coronary intervention after pretreatment with clopidogrel. N Engl J Med 2004;350:232–238.
28. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. The PURSUIT Trial Investigators. Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin Therapy. N Engl J Med 1998;339:436–443.
29. Inhibition of the platelet glycoprotein IIb/IIIa receptor with tirofiban in unstable angina and non-Q-wave myocardial infarction. Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Signs and Symptoms (PRISM-PLUS) Study Investigators. N Engl J Med1998;338:1488–1497.
30. Ottervanger JP, Armstrong P, Barnathan ES, et al; GUSTO IV-ACS Investigators.Long-term results after the glycoprotein IIb/IIIa inhibitor abciximab in unstable angina: one-year survival in the GUSTO IV-ACS (Global Use of Strategies To Open Occluded Coronary Arteries IV–Acute Coronary Syndrome) Trial. Circulation 2003;107:437–442.
31. Sabatine MS, Januzzi JL, Snapinn S, et al. A risk score system for predicting adverse outcomes and magnitude of benefit with glycoprotein IIb/IIIa inhibitor therapy in patients with unstable angina pectoris. Am J Cardiol 2001;88:488–492.
32. Theroux P, Alexander JJr, Pharand C, et al. 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. Circulation 2000;102:2466–2472.
33. Morrow DA, Cannon CP, Rifai N, et al. TACTICS-TIMI 18 Investigators. Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial. JAMA 2001;286:2405–12.
34. Januzzi JL, Chae CU, Sabatine MS, et al. Elevation in serum troponin I predicts the benefit of tirofiban. J Thromb Thrombolysis 2001;11:211–215.
35. Roffi M, Moliterno DJ, Meier B, et al; TARGET Investigators. Impact of different platelet glycoprotein IIb/IIIa receptor inhibitors among diabetic patients undergoing percutaneous coronary intervention: Do Tirofiban and ReoPro Give Similar Efficacy Outcomes Trial (TARGET) 1-year follow-up. Circulation2002;105:2730–2736.
36. Weitz JI. Low-molecular-weight heparins. N Engl J Med 1997;337:688–698.
37. Oler A, Whooley MA, Oler J, et al. Adding heparin to aspirin reduces the incidence of myocardial infarction and death in patients with unstable angina. A meta-analysis. JAMA 1996;276:811–815.
38. Ohman EM, Granger CB, Rice L, et al; The Complication After Thrombocytopenia Caused by Heparin (CATCH) Registry steering committee.Identification, diagnosis and treatment of heparin-induced thrombocytopenia and thrombosis: a registry of prolonged heparin use and thrombocytopenia among hospitalized patients with and without cardiovascular disease. J Thromb Thrombolysis 2005;19:11–19.
39. Cohen M, Demers C, Gurfinkel EP et al. A comparison of low-molecular-weight heparin with unfractionated heparin for unstable coronary artery disease. The Efficacy and Safety of Subcutaneous Enoxaparin in Non-Q-Wave Coronary Events Study Group. N Engl J Med 1997;337:447–452.
40. Antman EM, McCabe, CH Gurfinkel EP, Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial. Circulation 1999;100:1593–1601.
41. Fox KA, Antman EM, Cohen M, et al; ESSENCE/TIMI 11B Investigators.Comparison of enoxaparin versus unfractionated heparin in patients with unstable angina pectoris/non-ST-segment elevation acute myocardial infarction having subsequent percutaneous coronary intervention. Am J Cardiol 2002;90:477–482.
42. Low-molecular-weight heparin during instability in coronary artery disease (Fragmin) during Instability in Coronary Artery Disease (FRISC) Study Group. Lancet 1996;347:561–568.
43. Petersen JL, Mahaffey KW, Hasselblad V, et al. Efficacy and bleeding complications among patients randomized to enoxaparin or unfractionated heparin for antithrombin therapy in non-ST-segment elevation acute coronary syndromes: a systematic overview. JAMA 2004;292:89–96.
44. Cannon CP, Braunwald E, Mccabe CH, et al; Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators.Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med 2004;350:1495–1504.
45. Ray KK, Cannon CP, McCabe CH, et al; PROVE IT TIMI 22 investigators.Early and late benefits of high-dose atorvastatin in patients with acute coronary syndromes: results from the PROVE IT TIMI 22 trial. J Am Coll Cardiol 2005;46:1405–1410.
46. Effects of tissue plasminogen activator and a comparison of early invasive and conservative strategies in unstable angina and non-Q-wave myocardial infarction. Results of the TIMI IIIB Trial Thrombolysis in Myocardial Ischemia. Circulation 1994;89:1545–1556.
47. Boden WE, O’Rourke RA, Crawford MH, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators.N Engl J Med 1998;338:1785–1792.
48. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet 1999;354:708–715.
49. Cannon CP, Weintraub WS, Demopoulos LA, et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)–Thrombolysis in Myocardial Infarction 18 Investigators.Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban. N Engl J Med2001;344:1879–1887.
50. de Winter RJ, Windhausen F, Cornel JH, et al; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators.Early invasive versus selectively invasive management for acute coronary syndromes. N Engl J Med 2005;353:1095–1104.
51. Sabatine MS, Morrow DA, Giugliano RP, et al. Implications of upstream glycoprotein IIb/IIIa inhibition and coronary artery stenting in the invasive management of unstable angina/non-ST-elevation myocardial infarction: a comparison of the Thrombolysis In Myocardial Infarction (TIMI) IIIB trial and the Treat angina with Aggrastat and determine Cost of Therapy with Invasive or Conservative Strategy (TACTICS)-TIMI 18 trial. Circulation 2004;109:874–880.
52. Holmes DR, Hasdai D. Cardiogenic shock complicating non-ST-segment elevation acute coronary syndrome. In: Hasdai D, Berger PB, Batter A et al ed. Cardiogenic Shock: Diagnosis and Treatment. Totowa, Humana Press 2002, pp 35–41.
53. Sanborn TA, Sleeper LA, Bates E, et al. Impact of thrombolysis, aortic counterpulsation and their combination in cardiogenic shock complicating acute myocardial infarction: a report from the SHOCK Trial Registry Should we emergently revascularize Occluded Cornaries for cardiogenic shocK? J Am Coll Cardiol 2000;36 (Suppl): A1123–A1129.
54. Iakobishvili Z, Behar S, Boyko V, et al. Does current treatment of cardiogenic shock complicating the acute coronary syndromes comply with guidelines? Am Heart J 2005;149:98–103.
55. Chadow HL, Hauptman RE, VanAuker M, et al. Drip and ship: a new strategy for the treatment of acute coronary syndromes. J Thromb Thrombolysis 2000;10:77–82.
