Update on the Medical

Management of
Acute Coronary Syndrome
 Worldwide Statistics

Each year:
> 4 million patients are admitted
with unstable angina and acute MI
> 900,000 patients undergo PTCA
with or without stent
 Myocardial Ischemia

Spectrum of presentation
silent ischemia
exertion-induced angina
unstable angina
acute myocardial infarction
Cumulative 6-month mortality
from ischemic heart disease
25
Deaths / 100 pts / month

N = 21,761; 1985-1992
20
Diagnosis on adm to hosp
15
Acute MI
10 Unstable angina
Stable angina
5

0 1 2 3 4 5 6
Months after hospital admission

Duke Cardiovascular Database

 Ischemic Heart Disease
evaluation
Based on the patients
history / physical exam
electrocardiogram
Patients are categorized into 3 groups
non-cardiac chest pain
unstable angina
myocardial infarction
 Acute Coronary Syndrome
Ischemic Discomfort History
Unstable Symptoms Physical Exam

No ST-segment ST-segment
ECG
elevation elevation

Unstable Non-Q Q-Wave Acute

angina AMI AMI Reperfusion
 Acute Coronary Syndrome
The spectrum of clinical conditions
ranging from:
unstable angina
non-Q wave MI
Q-wave MI
characterized by the common
pathophysiology of a disrupted
atheroslerotic plaque
 Unstable Angina
Anti-coagulant Therapy
Heparin
recommendation is based on documented
efficacy in many trials of moderate size
meta-analyses (1,2) of six trials showed a
33% risk reduction in MI and death, but with
a two fold increase in major bleeding
titrate PTT to 2x the upper limits of normal

1. Circulation 1994;89:81-88
2. JAMA 1996;276:811-815
 Unstable Angina
Anti-coagulant Therapy
Low-molecular-weight heparin
advantages over heparin:
better bio-availability
higher ratio (3:1) of anti-Xa to anti-IIa activity
longer anti-Xa activity, avoid rebound
induces less platelet activation
ease of use (subcutaneous - qd or bid)
no need for monitoring