acute coronary syndrome; unstable angina (ACS)
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Introduction
- Chest pain of myocardial ischemia that occurs at rest, new onset of pain with exertion, or pain that has accelerated (more frequent, longer in duration, or lower in threshold).
- Recurrent (especially early morning) angina within the 1st few weeks following myocardial infarction is also considered acute coronary syndrome (unstable angina).
Etiology
- rupture or fissuring of atherosclerotic plaques (most common)
- severe anemia
- hypertension
- heart failure
- coronary vasospasm
- Kawasaki disease in young persons
- history of childhood mucocutaneous febrile illness[56]
- non-cardiac surgery[41]
- may occur after eating the elderly[57][58]
Epidemiology
- 80% of patients hospitalized with acute coronary syndrome are >= 65 years of age[26]
Pathology
- rupture or fissuring of atherosclerotic plaques results in
- thrombus formation
- increased platelet reactivity
- increased coronary vasomotor tone.
- left ventricular dysfunction, pulmonary edema, transient mitral regurgitation, or hypotension during episodes of ischemia indicates extensive areas of myocardium at risk
Clinical manifestations
- chest pain in about 2/3 of patients[11]
- women present without chest pain more frequently than men 38& vs 27%[11]
- dyspnea is most common presentations in women, diabetics & elderly
- other features may be present
Laboratory
- markers of myocardial infarction
- recheck in 2-3 hours
- serum BNP may be elevated (see Differential diagnosis:)
Diagnostic procedures
- electrocardiogram:
- pre-hospital 12-lead EKG may improve outcomes[27]
- ST segment elevation or ST segment depression *H* > 1 mm in 2 contiguous leads
- new left bundle branch block *H*
- Q waves, old ST segment or T wave abnormalities *I*
- T-wave inversion > 2 mm *H*
- T wave inversion in leads with dominant R waves *L*
- deep, symmetric T-wave inversions in leads V2 & V3, accompanied by a flat ST segment, is suggestive of a critical stenosis of the proximal left anterior descending coronary artery (Wellens syndrome)[47]
- echocardiogram may show regional wall abnormalities
- routine cardiac stress testing is not recommended for asymptomatic patients after acute coronary syndrome who are not entering a cardiac rehabilitation program[3]
- early noninvasive cardiac testing associated with slight decreases in myocardial infarction & death[50]
*H*=high, *I*=intermediate, *L* low risk
No advantage to routine early coronary angiography[9]
Radiology
- CT angiography
- can rule out acute coronary syndrome[13]
- shortens hospital stay but increases subsequent testing & radiation exposure with no reduction in overall cost of care[17]
- early CT angiography does not change 1 year outcome[53]
Complications
- 10-20% risk of progression to acute myocardial infarction
- women with low risk features may be at increase risk when treated with invasive strategy[3]
- depression is a risk factor for poor outcomes[25]
- SSRI escitalopram may lower cardiovascular risk in patients with depression after acute coronary syndrome[42]
Differential diagnosis
- see chest pain, chest pain syndrome
- heart failure is usually associated with dyspnea, but not chest pain (see Laboratory:)
- hypoglycemia unlikely to occur after eating in a patient with type 2 diabetes[57][58]
Management
- see initial management of acute coronary syndrome
- ischemia-guided strategy based on TIMI score or GRACE score[3]
- patients with stable angina with good exercise tolerance are low risk unless imaging demonstrates left main coronary artery disease or multivessel coronary artery disease[56]
- see ST segment elevation acute coronary syndrome & non ST segment elevation acute coronary syndrome
- general
- hospitalization
- bed rest, sedation
- correction of precipitating factors
- hypertension
- anemia - blood transfusion when Hct > 25% helpful[6]
- hypoxia
- the TIMI risk score is used to predict risk of death or nonfatal MI in patients presenting with unstable angina or NSTEMI
- goals of treatment
- aggressively relieve ischemic symptoms with anti-anginal drugs
- morphine for pain relief
- inhibit thrombosis in susceptible patients
- oxygen:
- 2-4 liters/min by nasal cannula
- do not continue for more than 3 hours unless hypoxia is present
- pharmacologic agents
- antiplatelet agents
- aspirin 162-325 mg PO initially, then
- P2Y12 receptor inhibitor (dual antiplatelet therapy or DAPT)
- clopidogrel (Plavix) 75 mg PO QD, prasugrel, or ticagrelor[3]
- clopidogrel noninferior to ticagrelor & with less bleeding[46][51]
- use in combination with aspirin 81 mg QD[3] (DAPT)
- low-dose rivaroxaban no better than aspirin[39]
- addition of low-dose rivaroxaban to DAPT results in increased bleeding[39]
- esomeprazole more effective than famotidine in preventing GI bleed[14]
- unless CABG is likely
- continue for 1 year[3]
- clopidogrel (Plavix) 75 mg PO QD, prasugrel, or ticagrelor[3]
- all patients with unstable angina should receive aspirin plus P2Y12 receptor inhibitor (DAPT) for 1 year[3]
- it is reasonable to continue DAPT for up to 36 months if reduced LVEF, saphenous vein grafting or diabetes mellitus & low risk of bleeding[3]
- abciximab (ReoPro)
- may be useful for unstable angina without persistent ST segment elevation[5]
- unless CABG is likely (long 1/2 life)
- ticagrelor (Brilinta) is more effective clopidogrel with similar bleeding risk[15][16] but more expensive
- low-dose prasugrel as effective as standard dose ticagrelor[48]
- unfractionated heparin or low-molecular-weight heparin at presentation[3]
- nitrates, except with suspected right ventricular MI[32]
- not indicated unless ongoing chest pain (NEJM)[56]
- beta blockers (intravenous esmolol)[32]
- contraindicated with cardiogenic shock or high-grade AV block
- if contraindicated, use diltiazem or verapamil[3][32]
- both beta-blockers & calcium channel blockers contraindication with acute heart failure, pulmonary edema
- calcium channel blocker if beta-blocker contraindication or failure of beta-blocker to control angina pectoris &/or hypertension[56]
- add ACE inhibitor for patients with an anterior wall MI, LV dysfunction, heart failure, or diabetes mellitus[32]
- all patients[3]
- high-intensity statin[3]
- in patients with heart failure, use loop diuretic rather than thiazide diuretic
- spironolactone of uncertain value[3]
- anticoagulants increase risk of major bleeding that offset their antithrombotic benefit[18]
- antiplatelet agents
- thrombolytic therapy (ST segment elevation)
- revascularization may be superior to thrombolytic therapy
- immediate percutaneous coronary intervention (within 2 hours)
- if transfer can be facilitated within 2 hours of hospital arrival[3]
- benefits high-risk patients only
- recurrent angina or myocardial ischemia
- elevated troponin I (NSTEMI)
- heart failure
- new or worsening mitral regurgitation
- sustained ventricular tachycardia
- hemodynamic instability
- STEMI, LBBB, posterior wall MI[3]
- bivalirudin vs unfractionated heparin at the time of PCI roughly equivalent[34]
- early percutaneous coronary intervention (within 12-24 hours)
- no high-risk features (above)
- TIMI score >=3
- Grace score >= 141 (Grace 2.0 score)
- rising troponin levels
- new ST segment depression
- delayed percutaneous coronary intervention (within 72 hours)
- TIMI score = 2
- Grace score = 109-140 (Grace 2.0 score)
- ischemia guided
- TIMI score = 0-1
- Grace score < 108 (Grace 2.0 score)
- harm of routine PCI exceeds benefit[30]
- diagnostic coronary angiography within 72 hours of hospitalization associated with lower short-term risk for adverse cardiac events[36]
- editorialists not convinced[36]
- composite of myocardial infarction, stroke, death, & urgent revascularization less frequent with invasive strategy in octagenarians than with conservative approach (41% vs. 61%)[8]
- coronary angiography associated with reduced 1 year mortality in patients admitted with unstable angina (3.2% vs 8.0%)[40]
- addition of revascularization did not affect mortality[40]
- immediate percutaneous coronary intervention (within 2 hours)
- secondary prophylaxis
- HMG CoA reductase inhibitor (statin)
- start within 24-96 hours[3]
- more intensive LDL cholesterol lowering appears to be associated with better outcomes
- see PROVE-IT, REVERSAL, GRACE studies
- atorvastatin 80 mg[28]
- no benefit to startin statin within 14 days[10]
- start chronic cardioselective beta-blocker within 3-21 days (atenolol, metoprolol)[3]
- continue for 3 years[28]
- ACE inhibitor (ARB as an alternative) or if
- eplerenone (Inspra) for LV dysfunction after MI[3]
- P2Y12 receptor inhibitor
- clopidogrel 75 mg plus aspirin 81 mg for 1 year with or without coronary stent[28] (least expensive)
- low-dose prasugrel appears to be as safe & effective as standard-dose ticagrelor for elderly or low-weight patients with ACS[48]
- SSRI escitalopram may lower cardiovascular risk in patients with depression after acute coronary syndrome[42]
- no benefit of routine screening for depression[44]
- HMG CoA reductase inhibitor (statin)
- follow-up
- all patients should be referred for cardiac rehabilitation
- postpone elective surgery for 12 months[3]
Notes
- routine use of the Global Registries of Acute Coronary Events (GRACE) risk score may increase use of early invasive strategy but not other aspects of care[52]
More general terms
More specific terms
Additional terms
- Acute Coronary Syndrome (ACS) pretest probability assessment
- initial management of acute coronary syndrome
- TIMI risk score
References
- ↑ Stedman's Medical Dictionary 26th ed, 27th ed Williams & Wilkins, Baltimore, 1995, 1999
- ↑ Yusuf S, Zhao F, Mehta SR et al Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001 Aug 16;345(7):494-502. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11519503
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 3.18 3.19 3.20 3.21 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018. 2020.
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Journal Watch 24(9):69-70, 2004
Nissen SE, Tuzcu EM, Schoenhagen P, Brown BG, Ganz P, Vogel RA, Crowe T, Howard G, Cooper CJ, Brodie B, Grines CL, DeMaria AN; REVERSAL Investigators. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial. JAMA. 2004 Mar 3;291(9):1071-80. PMID: https://www.ncbi.nlm.nih.gov/pubmed/14996776
Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, Joyal SV, Hill KA, Pfeffer MA, Skene AM; 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 Apr 8;350(15):1495-504. Epub 2004 Mar 08. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15007110 - ↑ 5.0 5.1 Journal Watch 22(6):47, 2002 Journal Watch 22(6):47, 2002 Boersma E, Harrington RA, Moliterno DJ, White H, Theroux P, Van de Werf F, de Torbal A, Armstrong PW, Wallentin LC, Wilcox RG, Simes J, Califf RM, Topol EJ, Simoons ML. Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: a meta-analysis of all major randomised clinical trials. Lancet. 2002 Jan 19;359(9302):189-98. Erratum in: Lancet 2002 Jun 15;359(9323):2120. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11812552
- ↑ 6.0 6.1 Journal Watch 24(21):158, 2004 Rao SV, Jollis JG, Harrington RA, Granger CB, Newby LK, Armstrong PW, Moliterno DJ, Lindblad L, Pieper K, Topol EJ, Stamler JS, Califf RM. Relationship of blood transfusion and clinical outcomes in patients with acute coronary syndromes. JAMA. 2004 Oct 6;292(13):1555-62. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15467057
- ↑ Mehta SR et al, Routine vs Selective Invasive Strategies in Patients with Acute Coronary Syndromes. A Collaborative Meta-analysis of Randomized Trials. JAMA 293(33), 2908, 2005
- ↑ 8.0 8.1 Gibler WB, Cannon CP, Blomkalns AL, Char DM, Drew BJ, Hollander JE, Jaffe AS, Jesse RL, Newby LK, Ohman EM, Peterson ED, Pollack CV; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Nursing; Quality of Care and Outcomes Research Interdisciplinary Working Group; Society of Chest Pain Centers. Practical implementation of the Guidelines for Unstable Angina/ Non-ST-Segment Elevation Myocardial Infarction in the emergency department. Ann Emerg Med. 2005 Aug;46(2):185-97. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/16046952 <Internet> http://circ.ahajournals.org/cgi/content/abstract/111/20/2699
- ↑ 9.0 9.1 de Winter RJ, Windhausen F, Cornel JH, Dunselman PH, Janus CL, Bendermacher PE, Michels HR, Sanders GT, Tijssen JG, Verheugt FW; 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 Sep 15; 353:1095-104. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16162880
Boden WE. Acute coronary syndromes without ST-segment elevation - What is the role of early intervention? N Engl J Med 2005 Sep 15; 353:1159-61 - ↑ 10.0 10.1 Briel M, Schwartz GG, Thompson PL, de Lemos JA, Blazing MA, van Es GA, Kayikcioglu M, Arntz HR, den Hartog FR, Veeger NJ, Colivicchi F, Dupuis J, Okazaki S, Wright RS, Bucher HC, Nordmann AJ. Effects of early treatment with statins on short-term clinical outcomes in acute coronary syndromes: a meta-analysis of randomized controlled trials. JAMA. 2006 May 3;295(17):2046-56. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16670413
Vale N, Nordmann AJ, Schwartz GG et al Statins for acute coronary syndrome. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD006870. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21678362 - ↑ 11.0 11.1 11.2 Canto JG et al, Symptom presentation of women with acute coronary syndromes: Myth vs reality. Arch Intern Med 2007, 167:2405 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18071161
Dracup K The challenge of women and heart disease. Arch Intern Med 2007, 167:2396 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18071159 - ↑ Wright SR et al 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline) J Am Coll Cardiol, (Published online 28 March 2011) <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/21444889 <Internet> http://content.onlinejacc.org/cgi/content/full/j.jacc.2011.02.009
- ↑ 13.0 13.1 Litt HI et al CT Angiography for Safe Discharge of Patients with Possible Acute Coronary Syndromes N Engl J Med, March 26, 2012 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/22449295 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1201163
- ↑ 14.0 14.1 Ng F-H et al. Esomeprazole compared with famotidine in the prevention of upper gastrointestinal bleeding in patients with acute coronary syndrome or myocardial infarction. Am J Gastroenterol 2012 Mar; 107:389. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22108447
- ↑ 15.0 15.1 Prescriber's Letter 19(5): 2012 COMMENTARY: Antiplatelets After Acute Coronary Syndrome or Coronary Stent CHART: Comparison of Oral Antithrombotics Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=280526&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 16.0 16.1 Jneid H et al 2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update). A report of the American College of Cardiology Foundation/American Heart Association Task Force of Practice Guidelines. http://circ.ahajournals.org/content/early/2012/07/16/CIR.0b013e318256f1e0.full.pdf+html
- ↑ 17.0 17.1 Hoffmann U et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 2012 Jul 26; 367:299 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22830462
Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med 2012 Jul 26; 367:375 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22830468 - ↑ 18.0 18.1 Komocsi A et al Use of New-Generation Oral Anticoagulant Agents in Patients Receiving Antiplatelet Therapy After an Acute Coronary Syndrome Systematic Review and Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2012;():1-9 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23007264 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1362940
Hernandez AV No Place for Novel Oral Anticoagulants in Current Treatment of Acute Coronary Syndromes, Comment on "Use of New-Generation Oral Anticoagulant Agents in Patients Receiving Antiplatelet Therapy After an Acute Coronary Syndrome" <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/23007954 <Internet> http://archinte.jamanetwork.com/article.aspx?articleid=1362889 - ↑ Kalra S, Duggal S, Valdez G, Smalligan RD. Review of acute coronary syndrome diagnosis and management. Postgrad Med. 2008 Apr;120(1):18-27 PMID: https://www.ncbi.nlm.nih.gov/pubmed/18467805
- ↑ Giugliano RP, White JA, Bode C et al Early versus delayed, provisional eptifibatide in acute coronary syndromes. N Engl J Med. 2009 May 21;360(21):2176-90. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19332455
- ↑ Montalescot G, Cayla G, Collet JP et al Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial. JAMA. 2009 Sep 2;302(9):947-54 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19724041
- ↑ Stone GW, Bertrand ME, Moses JW et al Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial. JAMA. 2007 Feb 14;297(6):591-602. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17299194
- ↑ Anderson JL, Adams CD, Antman EM et al ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007 Aug 14;50(7):e1-e157. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17692738
Anderson JL, Adams CD, Antman EM et al 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Jun 11;61(23):e179-e347. PMID: https://www.ncbi.nlm.nih.gov/pubmed/23639841 Free full text - ↑ Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005 Nov 23;294(20):2623-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16304077
- ↑ 25.0 25.1 Lichtman JH et al Depression as a Risk Factor for Poor Prognosis Among Patients With Acute Coronary Syndrome: Systematic Review and Recommendations: A Scientific Statement From the American Heart Association. Circulation. Feb 24, 2014 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24566200 <Internet> http://circ.ahajournals.org/content/early/2014/02/24/CIR.0000000000000019.full.pdf
- ↑ 26.0 26.1 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
- ↑ 27.0 27.1 Quinn T et al. Effects of prehospital 12-lead ECG on processes of care and mortality in acute coronary syndrome: A linked cohort study from the Myocardial Ischaemia National Audit Project. Heart 2014 Apr 14 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/24732676 <Internet> http://heart.bmj.com/content/early/2014/04/07/heartjnl-2013-304599
- ↑ 28.0 28.1 28.2 28.3 28.4 28.5 Prescriber's Letter 21(5): 2014 Improving Outcomes After Myocardial Infarction. Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=300522&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ The NNT: Statins for Acute Coronary Syndrome http://www.thennt.com/nnt/statins-for-acute-coronary-syndrome/
Vale N, Nordmann AJ, Schwartz GG et al Statins for acute coronary syndrome. Cochrane Database Syst Rev. 2011 Jun 15;(6):CD006870. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21678362 - ↑ 30.0 30.1 30.2 30.3 The NNT: Early Invasive Management for Acute Coronary Syndromes. http://www.thennt.com/nnt/early-invasive-management-for-acute-coronary-syndromes/
Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2010 Mar 17;(3):CD004815 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20238333 - ↑ 31.0 31.1 The NNT: Heparin Given for Acute Coronary Syndromes (Unstable Angina, NSTEMI, STEMI) http://www.thennt.com/nnt/heparin-for-acute-coronary-
- ↑ 32.0 32.1 32.2 32.3 32.4 Rosendorff C et al. Treatment of hypertension in patients with coronary artery disease: A scientific statement from the American Heart Association, American College of Cardiology, and American Society of Hypertension. J Am Coll Cardiol 2015 May 12; 65:1998 PMID: https://www.ncbi.nlm.nih.gov/pubmed/25840655
- ↑ 2012 Writing Committee Members, Jneid H et al 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non-ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2012 Aug 14;126(7):875-910 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22800849
- ↑ 34.0 34.1 Valgimigli M et al Bivalirudin or Unfractionated Heparin in Acute Coronary Syndromes. N Engl J Med. Sept 1, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26324049 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1507854
Berger PB Finding the Proper Context for the MATRIX Trial. N Engl J Med. Sept 1, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26324050 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMe1509637 - ↑ Makki N, Brennan TM, Girotra S. Acute coronary syndrome. J Intensive Care Med. 2015 May;30(4):186-200 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24047692
- ↑ 36.0 36.1 36.2 Hansen KW, Sorensen R, Madsen M et al Effectiveness of an Early Versus Conservative Invasive Treatment Strategy in Acute Coronary Syndromes: A Nationwide Cohort Study. Ann Intern Med. Published online 27 October 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26502223 <Internet> http://annals.org/article.aspx?articleid=2466363
Curtis JP, Krumholz HM Challenges of Comparative Effectiveness Research With Observational Data. Ann Intern Med. Published online 27 October 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26501410 <Internet> http://annals.org/article.aspx?articleid=2466367 - ↑ Tegn N, Abdelnoor M, Aaberge L et al Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial. Lancet. 2016;387(10023):1057-1065. Jan 12, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26794722 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2815%2901166-6/abstract
Psaltis PJ, Nicholls SJ Management of acute coronary syndrome in the very elderly. Lancet. Jan 12, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26794723 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2900036-2/abstract - ↑ 38.0 38.1 Wallentin L, Lindhagen L, Arnstrom E et al. Early invasive versus non-invasive treatment in patients with non-ST-elevation acute coronary syndrome (FRISC-II): 15 year follow-up of a prospective, randomised, multicentre study. Lancet 2016 Aug 29; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27585757
Weintraub WS. Invasive management of acute coronary syndromes. Lancet 2016 Aug 29 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27585758 - ↑ 39.0 39.1 39.2 Ohman EM, Roe MT, Steg PG et al. Clinically significant bleeding with low-dose rivaroxaban versus aspirin, in addition to P2Y12 inhibition, in acute coronary syndromes (GEMINI-ACS-1): A double-blind, multicentre, randomised trial. Lancet 2017 Mar 18; <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28325638 <Internet> http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30751-1/abstract
- ↑ 40.0 40.1 40.2 Vogrin S, Harper R, Paratz E et al Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable Angina. Ann Intern Med. 2017. May 2. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28462421 <Internet> http://annals.org/aim/article/2624285/comparative-effectiveness-routine-invasive-coronary-angiography-managing-unstable-angina
Jolly SS, Devereaux PJ Does Knowledge of the Coronary Anatomy Save Lives in Patients With Unstable Angina? Ann Intern Med. 2017. May 2 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28462428 <Internet> http://annals.org/aim/article/2624993/does-knowledge-coronary-anatomy-save-lives-patients-unstable-angina - ↑ 41.0 41.1 41.2 Helwani MA, Amin A, Lavigne P et al. Etiology of acute coronary syndrome after noncardiac surgery. Anesthesiology 2018 Jun; 128:1084 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29481375
- ↑ 42.0 42.1 42.2 Kim JM, Stewart R, Lee YS et al Effect of Escitalopram vs Placebo Treatment for Depression on Long-term Cardiac Outcomes in Patients With Acute Coronary Syndrome. A Randomized Clinical Trial. JAMA. 2018;320(4):350-358. PMID: https://www.ncbi.nlm.nih.gov/pubmed/30043065 https://jamanetwork.com/journals/jama/fullarticle/2688569
- ↑ Lingel JM, Srivastava MC, Gupta A. Management of coronary artery disease and acute coronary syndrome in the chronic kidney disease population-A review of the current literature. Hemodial Int. 2017 Oct;21(4):472-482. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28093874
- ↑ 44.0 44.1 Kronish IM, Moise N, Cheung YK et al. Effect of depression screening after acute coronary syndromes on quality of life: The CODIACS-QoL randomized clinical trial. JAMA Intern Med 2019 Oct 21; PMID: https://www.ncbi.nlm.nih.gov/pubmed/31633746
- ↑ ARUP Consult: Acute Coronary Syndrome - Ischemic Heart Disease The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/acute-coronary-syndrome
- ↑ 46.0 46.1 Gimbel M, Qaderdan K, Willemsen L et al. Clopidogrel versus ticagrelor or prasugrel in patients aged 70 years or older with non-ST-elevation acute coronary syndrome (POPular AGE): The randomised, open-label, non-inferiority trial. Lancet 2020 Apr 25; 395:1374. PMID: https://www.ncbi.nlm.nih.gov/pubmed/32334703 https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(20)30325-1.pdf
- ↑ 47.0 47.1 NEJM Knowledge+ Question of the Week. June 2, 2020 https://knowledgeplus.nejm.org/question-of-week/52/
de Zwaan C et al. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J 1982 Apr 1; 103:730 PMID: https://www.ncbi.nlm.nih.gov/pubmed/17679616
Anderson JL, Adams CD, Antman EM et al ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation. 2007 Aug 14;116(7):e148-304. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17679616 - ↑ 48.0 48.1 48.2 Menichelli M, Neumann FJ, Ndrepepa G et al Age- and Weight-Adapted Dose of Prasugrel Versus Standard Dose of Ticagrelor in Patients With Acute Coronary Syndromes. Results From a Randomized Trial. Annals of Internal Medicien, July 21, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32687741 https://www.acpjournals.org/doi/10.7326/M20-1806
Conen D, Devereaux PJ The Value of Large Randomized Trials of Two Active Interventions to Define the Optimal Treatment in Patients With Acute Coronary Syndrome. Annals of Internal Medicien, July 21, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/32687738 https://www.acpjournals.org/doi/10.7326/M20-4770 - ↑ Schupke S, Neumann FJ, Menichelli M; ISAR-REACT 5 Trial Investigators. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2019 Oct 17;381(16):1524-1534. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31475799 https://www.nejm.org/doi/10.1056/NEJMoa1908973
- ↑ 50.0 50.1 Kawatkar AA et al. Early noninvasive cardiac testing after emergency department evaluation for suspected acute coronary syndrome. JAMA Intern Med 2020 Oct 5; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33031502 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2771506
- ↑ 51.0 51.1 You SC et al. Association of ticagrelor vs clopidogrel with net adverse clinical events in patients with acute coronary syndrome undergoing percutaneous coronary intervention. JAMA 2020 Oct 27; 324:1640. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33107944 https://jamanetwork.com/journals/jama/article-abstract/2772280
Bates ER. Net adverse clinical events with antiplatelet therapy in acute coronary syndromes. JAMA 2020 Oct 27; 324:1613. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33107925 https://jamanetwork.com/journals/jama/article-abstract/2772255 - ↑ 52.0 52.1 Chew DP, Hyun K, Morton E et al Objective Risk Assessment vs Standard Care for Acute Coronary Syndromes. A Randomized Clinical Trial. JAMA Cardiol. Published online December 9, 2020 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33295965 https://jamanetwork.com/journals/jamacardiology/fullarticle/10.1001/jamacardio.2020.6314
- ↑ 53.0 53.1 Gray AJ, Roobottom C, Smith JE et al. Early computed tomography coronary angiography in patients with suspected acute coronary syndrome: Randomised controlled trial. BMJ 2021 Sep 29; 374:n2106. PMID: https://www.ncbi.nlm.nih.gov/pubmed/34588162 PMCID: PMC8479591 Free PMC article https://www.bmj.com/content/374/bmj.n2106
- ↑ Bhatt DL, Lopes RD, Harrington RA. Diagnosis and Treatment of Acute Coronary Syndromes. A Review. JAMA. 2022;327(7):662-675. February 15. PMID: https://www.ncbi.nlm.nih.gov/pubmed/35166796 https://jamanetwork.com/journals/jama/fullarticle/2789023
- ↑ 55.0 55.1 Zhou S, Xiao Y, Zhou C et al Effect of Rivaroxaban vs Enoxaparin on Major Cardiac Adverse Events and Bleeding Risk in the Acute Phase of Acute Coronary Syndrome. The H-REPLACE Randomized Equivalence and Noninferiority Trial. JAMA Netw Open. 2023;6(2):e2255709 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36763358 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2801235
- ↑ 56.0 56.1 56.2 56.3 56.4 56.5 56.6 NEJM Knowledge+ Cardiology
Amsterdam EA, Wenger NK, Brindis RG et al 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Dec 23;64(24):e139-e228. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25260718 Free article. - ↑ 57.0 57.1 57.2 Dai X, Busby-Whitehead J, Alexander KP. Acute coronary syndrome in the older adults. J Geriatr Cardiol. 2016 Feb;13(2):101-8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27168733 PMCID: PMC4854946 Free PMC article.
- ↑ 58.0 58.1 58.2 McGarry M, Shenvi CL. Identification of Acute Coronary Syndrome in the Elderly. Emerg Med Clin North Am. 2021 May;39(2):339-346. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33863463 Review.