1. Ischaemic Heart Disease Acute Coronary Syndrome

8. Desired Outcomes Prevent acute coronary syndrome and death
Alleviate acute symptoms of myocardial ischemia
Prevent recurrent symptoms of myocardial ischemia
Prevent progression of the disease
Reduce complications of IHD
Avoid or minimize adverse treatment effects

9. FIGURE 7–5. The treatment algorithm for ischemic heart disease
FIGURE 7–5. The treatment algorithm for ischemic heart disease. It begins at the top (blue section), which suggests risk factor modifications as the first treatment modality. Moving down to the green section, appropriate antiplatelet therapy is selected. The purple section identifies patients at high risk for major adverse cardiac events (MACE) and suggests appropriate drug therapy to decrease cardiovascular risk. The orange section at the bottom recommends appropriate antianginal therapy. aThe minimum duration of clopidogrel therapy following intracoronary stent placement is as follows: at least 1 month for bare metal stents and at least 12 months for drug-eluting stents.
(ACE-I, angiotensin-converting enzyme inhibitor; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; BMS, bare metal stent; BP, blood pressure; CABG, coronary artery bypass graft; CCB, calcium channel blocker; DES, drug-eluting stent; HR, heart rate; IR, immediate release; LA, long acting; LDL, low-density lipoprotein; LV, left ventricular; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SL, sublingual.)

17. Acute Coronary Syndrome

18. ACS ACS Spectrum STEMI NSTE-ACS NSTEMI UA Troponin
From acute myocardial ischemia to MI resulting from an imbalance between myocardial oxygen demand and supply
results primarily from diminished myocardial blood flow secondary to an occlusive or partially occlusive coronary artery thrombus
ACS
STEMI
NSTE-ACS
NSTEMI
Troponin UA

20. Risk Stratification GRACE TIMI ACS NSQIP ACC/AHA
TIMI
ACS NSQIP
ACC/AHA

21. Desired Outcomes Short-term: Long-term:
early restoration of blood flow to the infarct-related artery to prevent infarct expansion (in the case of MI) or prevent complete occlusion and MI (in UA);
prevention of death and other MI complications;
prevention of coronary artery reocclusion;
relief of ischemic chest discomfort; and
resolution of ST segment and T-wave changes on the ECG
Long-term:
control of CV risk factors,
prevention of additional CV events, including reinfarction, stroke, and HF, and
improvement in quality of life

23. FIGURE 8–2. Initial pharmacotherapy for ST-segment elevation myocardial infarction. See Table 8–3 for dosing recommendations and contraindications to specific therapies.
a Options after coronary angiography also include medical management alone or CABG surgery.
b Clopidogrel preferred P2Y12 when fibrinolytic therapy is utilized. No loading dose recommended if age older than 75 years.
c Given for up to 48 hours or until revascularization.
d Given for the duration of hospitalization, up to 8 days or until revascularization.
e If pretreated with UFH, stop UFH infusion for 30 minutes prior to administration of bivalirudin (bolus plus infusion).
f In patients with STEMI receiving a fibrinolytic or who do not receive reperfusion therapy, administer clopidogrel for at least 14 days and ideally up to 1 year.
(ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; ASA, aspirin; CI, contraindication; FMC, first medical contact; GPI, glycoprotein IIb/IIIa inhibitor; IV, intravenous; MI, myocardial infarction; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin.)

24. FIGURE 8–3. Initial pharmacotherapy for non–ST-segment elevation (NSTE) ACS. See Table 8–3 for dosing recommendations and contraindications to specific therapies.
A Reasonable to choose ticagrelor over clopidogrel for maintenance P2Y12 for NSTE-ACS patients treated with an early invasive or ischemia-guided strategy.
B Reasonable to choose prasugrel over clopidogrel for maintenance P2Y12 for NSTE-ACS patients undergoing PCI who are not at high risk for bleeding. Do not use if prior history of stroke/transient ischemic attack (TIA), age older than 75 years, or body weight less than or equal to 60 kg (132 lb).
C May require IV supplemental dose of enoxaparin; see Table 8–2.
D Not to be used as the sole anticoagulant during PCI. Give additional 85 units/kg IV without GPI and 60 Units/kg IV with GPI.
E If pretreated with UFH, stop UFH infusion for 30 minutes prior to administration of bivalirudin bolus plus infusion.
(ACE, angiotensinconverting enzyme; ACS, acute coronary syndrome; ARB, angiotensin receptor blocker; ASA, aspirin; CABG, coronary artery bypass graft; CI, contraindication; DES, drug-eluting stent; GPI, glycoprotein IIb/IIIa inhibitor; IV, intravenous; NTG, nitroglycerin; PCI, percutaneous coronary intervention; SC, subcutaneous; SL, sublingual; UFH, unfractionated heparin).