CHAPTER 16 Acute Coronary Syndromes
Acute coronary syndrome (ACS) is the clinical manifestation of the critical phase of coronary artery disease (CAD). Based on electrocardiogram (ECG) and biochemical markers it is distinguished from ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. The common underlying pathophysiology is related to plaque rupture or erosion with subsequent thrombus formation. Despite the decreasing age-adjusted mortality for myocardial infarction, the disease prevalence for non-fatal components of ACS remains high and the economic costs are immense. Treatment of patients presenting with an ACS aims at immediate relief of ischaemia and the prevention of serious adverse events, including death, myocardial (re)infarction, and life-threatening arrhythmias. The general management is predominately guided by the ECG and biomarkers. All patients should be admitted to an inpatient unit with careful observation for recurrent ischaemia, ECG monitoring, and frequent assessment of vital signs. The implementation of chest pain units and treatment networks with standardized care improve delivery of best management. In general, treatment options include antiplatelet therapy, antithrombins, fibrinolytics, percutaneous coronary interventions (PCI), and cardiac surgery. In patients with persistent ST-segment elevation rapid (within 6 hours after onset of pain) and sustained reperfusion of the infarct related artery by primary PCI or fibrinolysis improves early and long-term outcome. In patients presenting without ST-segment elevation (NSTE-ACS) the further management is guided by risk stratification (troponin, ECG, risk scores etc.). High-risk patients benefit from an early (<72 hours) invasive strategy. It is well established that adherence to guidelines recommended therapy reduces mortality and morbidity in this high risk population.
Chapter 28)
