Acute Coronary Syndrome

MDNG Primary CareNovember 2010
Volume 12
Issue 11

Medical WebsitesACS: Chest Pain and Acute Coronary Syndrome, Diagnosis and Treatment

This Institute for Clinical Systems Improvement guideline is designed to provide for clinicians an “analytical framework for the evaluation and treatment” of adults presenting with past or present symptoms of chest pain and/or indications of acute coronary syndrome (ACS). The goals of the guidelines are to: improve the success of emergency intervention for patients with chest pain symptoms; minimize the delay in administering fibrinolysis or angioplasty to patients with acute myocardial infarction (AMI); increase the timely initiation of treatment to reduce postinfarction mortality in patients with AMI; and increase the number of AMI patients who receive tobacco cessation advice, and who use appropriate cardiac rehabilitation postdischarge.

Diagnosis of Acute Coronary Syndrome

Originally published in American Family Physician in 2005, this article comprehensively explores the diagnosis of acute coronary syndrome, a term that “encompasses a range of thrombotic coronary artery diseases, including unstable angina and both ST-segment elevation and non—ST-segment elevation myocardial infarction. Topics addressed include physical examination of patients, interpretation of electrocardiogram results, risk stratification to determine the likelihood of ACS, characteristics of serum cardiac markers for the diagnosis of acute myocardial infarction, and a protocol that can be used by family physicians to evaluate patients with chest pain or symptoms suggesting ACS.

The Educated PatientAHA: Get Yourself Moving

Direct patients with acute coronary syndrome and other cardiac conditions to this American Heart Association (AHA) site, where they can access heart-healthy recipes; learn how to more effectively manage weight and prevent obesity; read the AHA Guidelines for Physical Activity and obtain fitness tips; learn how to better manage stress; obtain information on selecting healthy fats and oils; get tips on how to quit smoking. Of the many resources offered at this site, one that might strike a chord with children and adults alike is the guide to Wii games for the Heart.


This resource from the National Library of Medicine offers three different ways for users to learn about echocardiograms; visitors can watch an interactive multimedia tutorial, view a self-guided presentation, or opt for the text version. The content remains the same throughout; easy-to-understand text and colored diagrams are used to explain how the different chambers of the heart work, how disease and certain events can affect heart function and quality of life, how an echocardiography works, and what happens during and after an echocardiography.

CMEChest Pain: What to Do with ACS?Credits: 0.75

Fee: None

Expires: August 1, 2012

Multimedia: Audio/Video

In this video lecture—the first in a educational series on acute coronary syndrome—Jasen Gundersen, MD, aims to provide foundation for primary care physicians by reviewing the pathophysiology and prevalence of ACS, the differential diagnosis and risk stratification, and evidence-based strategies for acute and post-ACS management. The course will also cover communication with patients concerning their ACS risk, presentation of ACS, and the importance of compliance with recommended treatment.

Antiplatelet Therapy in ACS: What’s Best Practice?Credits: 1.25

Fee: None

Expires: October 15, 2012

Multimedia: Audio/Video

Despite guideline recommendations, only three-quarters of ACS patients are administered antiplatelet and anticoagulation therapy upon hospital discharge. In this video lecture, Clare Hawkins, MD, and Kim Eagle, MD, discuss the evidence-based recommendations for antiplatelet therapy over the continuum of care, and address common challenges facing family physicians. They also explore factors contributing to suboptimal management of ACS, including unfamiliarity with the guidelines, as well as “the relative novelty of some agents and concerns about their benefit-to-risk ratio and cost.”

Clinical TrialsMulti-Markers in the Diagnosis of Acute Coronary SyndromeStudy Type: Observational

Age/Gender Requirements: 19 years (male/female)

Sponsor: Biosite

Purpose: In this study, investigators will procure four blood samples from patients who present to the emergency department with suspected ACS, and will collect data on the patient’s health history, hospital procedures, and final diagnosis. Blood samples will be sent to the sponsor organization for long-term storage and analysis in the future for novel blood markers as they become available.

A Study Assessing the REG1 Anticoagulation System Compared Heparin in Subjects with Acute Coronary Syndrome (RADAR)Study Type: Interventional

Age/Gender Requirements: 18-80 years (male/female)

Sponsor: Regado Biosciences, Inc.

Purpose: This randomized, multi-center study is being conducted to evaluate the safety and efficacy of the REG1 anticoagulation system compared to unfractionated heparin or low molecular heparin in acute coronary syndrome patients undergoing cardiac catheterization. To become eligible, patients must have been experiencing chest pain or other ischemic symptoms for a minimum of 10 minutes duration within 72 hours before anticipated cardiac catheterization.

eAbstractsAntiplatelet Therapy in Acute Coronary Syndrome: Applying New Science to Clinical DecisionsJournal: American Journal of Cardiology (October 15, 2010)

Authors: Becker R, Gibson C, Jennings L, Morrow D

Purpose: Although current guidelines recommend combination antiplatelet therapies for patients with unstable angina or non-ST elevation myocardial infarctions, “there remains a significant incidence of arterial thrombosis in patients receiving currently available antiplatelet therapy, indicating the need for improved and/or alternative agents and targets.”

Results: Data from recent clinical trials show that new oral antiplatelet therapies, including the thienopyridine prasugrel and the investigational reversible oral adenosine diphosphate antagonist ticagrelor, “have a faster onset of action, result in a more predictable response, and provide improved efficacy compared to clopidogrel, the current standard of care.” The question remains, however, as to whether improved prevention and treatment of thrombosis can be separated from an increase in hemorrhage or bleeding. Therefore, “clinicians must continue to consider the potential risks and benefits when individualizing antiplatelet therapy for patients with ACS,” the authors wrote.

Quality of Life after Percutaneous Coronary Intervention in the Elderly with Acute Coronary SyndromeJournal: International Journal of Cardiology (October 19, 2010)

Authors: Li R, Yan B, Dong M et al

Purpose: To explore the impact of percutaneous coronary intervention (PCI) on health-related quality of life (HRQoL), “an important but often neglected outcome measure,” in elderly patients with acute coronary syndrome.

Results: Using data obtained from a Short Form-36 health survey at baseline and six months, researchers determined that baseline HRQoL decreased with advancing age. However, elderly patients who underwent PCI experienced the most improvement in physical health compared to younger patients. Therefore, age alone “should not deter against revascularization because of potential benefits in HRQoL.”

What Predicts Depression in Cardiac Patients: Sociodemographic Factors, Disease Severity or Theoretical Vulnerabilities?Journal: Psychology & Health (November 2010)

Authors: Doyle F, McGee H, Conroy R, Delaney M

Purpose: Depression is associated with increased cardiovascular risk in acute coronary syndrome patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. To assess depression and psychosocial vulnerabilities, a group of ACS patients completed questionnaires assessing depression and psychosocial vulnerabilities.

Results: Investigators found that theoretical vulnerabilities predicted depression status more effectively than either demographic or disease indices. “The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity,” they wrote.

Pharma Focus

Xarelto (rivaroxaban)

An Efficacy and Safety Study for Rivaroxaban in Patients with Acute Coronary SyndromeStudy Type: Interventional

Age/Gender Requirements: 18 years (male/female)

Sponsor: Johnson & Johnson Pharmaceutical Research & Development, LLC

Purpose: The purpose of this study is to determine whether rivaroxaban in addition to standard care reduces the risks of cardiovascular death, myocardial infarction, and stroke in patients with acute coronary syndrome compared with placebo. Participants will be given rivaroxaban (2.5 mg twice daily or 5 mg twice daily) or placebo (twice daily) in addition to standard care.

Role of Orally Available Antagonists of Factor Xa in the Treatment and Prevention of Thromboembolic Disease: Focus on RivaroxabanJournal: Journal of Clinical Pharmacology (September 2010)

Authors: Morell J, Sullivan B, Khalabuda M, McBride, BF

Purpose: Researchers reviewed data on seven compounds—including rivaroxaban, apixaban, betrixaban, and eribaxaban—that are orally available direct inhibitors of activated factor X currently in development for the prevention and treatment of venous thromboembolism (VTE) and for thromboprophylaxis in patients with atrial fibrillation (AF) or following an acute coronary syndrome.

Results: “At doses used in phase 2 and 3 clinical trials, rivaroxaban and apixaban demonstrated a predictable onset of effect, maximal plasma concentration, and half-life that was unaffected by age, renal, or hepatic disease,” they wrote. In clinical trials for the treatment and prevention of VTE, rivaroxaban and apixaban yielded equivalent or superior reductions in the development or progression of VTE compared with either low molecular weight heparin or warfarin. Trials comparing the efficacy of rivaroxaban or apixaban to standard therapy for stroke prophylaxis in patients with AF are in process.

From the Network

American Journal of Managed Care

Pharmacy Cost Sharing, Antiplatelet Therapy Utilization, and Health Outcomes for Patients with Acute Coronary SyndromeIn this retrospective outcomes study, Tomas J. Philipson, PhD, and colleagues determined that “higher copayments for prescription drugs are associated with lower utilization of antiplatelet therapy and with higher likelihood of rehospitalization among patients with ACS.”

Pharmacy Times

Dose Comparisons of Clopidogrel and Aspirin in Acute Coronary SyndromesIn patients who have acute coronary syndrome or undergoing percutaneous coronary intervention, there was no significant difference between a seven-day double-dose clopidogrel regimen and the standard-dose regimen, or between higher-dose aspirin and lower-dose aspirin, according to a recent study.

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