Contemporary Approach to the Diagnosis and Management of Non-ST-Segment Elevation Acute Coronary Syndromes
Department of Medicine, Duke University, Durham, North Carolina, United StatesProgress in cardiovascular diseases (Impact Factor: 4.25). 03/2008; 50(5):311-51. DOI: 10.1016/j.pcad.2007.11.003
The management of patients with acute coronary syndromes (ACS) has evolved dramatically over the past decade and, in many respects, represents a rapidly moving target for the cardiologist and internist who seek to integrate these recent advances into contemporary clinical practice. Unstable angina and non-ST-segment elevation myocardial infarction (MI) comprise a growing percentage of patients with ACS and is emerging as a major public health problem worldwide, especially in Western countries, despite significant improvements and refinements in management over the past 20 years. Against this backdrop of a multitude of randomized, controlled clinical trials that have established the scientific foundation upon which evidence-based treatment strategies have emerged and become increasingly refined, the clinician is frequently confronted with panoply of choices that can create uncertainty or confusion regarding "optimal management". While the debate about the ideal approach to the management of non-ST-segment elevation (NSTE) ACS (i.e., routine "early invasive strategy" versus an "ischemia-guided", or "conservative", strategy) has been ongoing for over a decade, clinical trials results provide compelling evidence that intermediate- and high-risk ACS patients derived significant reductions in both morbidity and mortality with mechanical or surgical intervention, especially when revascularization is coupled with aggressive, multifaceted (anti-platelet, antithrombin, anti-ischemic and anti-atherogenic) medical therapy along with risk factor modification. For these reasons, it seems especially timely and appropriate to present a state-of-the-art paper that reviews the latest advances in the management of NSTE ACS, mindful of the fact that even this noble effort to synthesize and integrate a prodigious amount of scientific information and cardiovascular therapeutics is destined to evolve still further as our full-scale assault on optimizing clinical outcomes by harmonizing the advances in mechanical and pharmacologic interventions continues unabated.
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- "The cardiac specific troponins are detectable in the serum within 4 to 12 h after the onset of myocardial necrosis, and depending on the duration of ischaemia and reperfusion status, peak values occur 12 to 48 h from symptom onset. cTns offer a wide temporal diagnostic window (4 h to 14 days); their levels remain elevated in the serum for up to 14 days after myocardial injury, allowing for diagnostic confirmation even when patients delay their presentation to medical care after onset of symptom67. "
ABSTRACT: Background & objectives: Accurate and rapid diagnosis of acute myocardial infarction (MI) is of major clinical significance. The troponin is the biomarker of choice for detection of cardiac injury. The objective of this study was to identify salivary levels of cardiac troponin I (cTnI) in patients with acute MI. Methods: Thirty patients with acute MI and 28 normal healthy individuals were included in the study. cTnI levels were assayed in serum and saliva 12 and 24 h of acute MI by ELISA method. Results: In patients with acute MI, the serum and resting (unstimulated) saliva concentrations of cTnI, but not stimulated saliva cTnI, at both 12 and 24 h of onset of MI, were significantly higher than in controls. Resting saliva cTnI concentrations correlated significantly with serum cTnI levels (spearman rho = 0.34 and 0.45 in the total individuals and in the MI patients respectively). Interpretation & conclusions: The present results suggest that saliva can be an analytical matrix for measurement of cTnI in patients with acute MI. Further studies may reveal capability of salivary cTnI for being used for developing point-of-care testing for early detection of MI in pre-clinical settings.
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ABSTRACT: The spectrum of acute coronary syndromes (ACS) encompasses a broad array of clinical characteristics and risk strata, ranging from unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI) to ST-segment elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). In this article, UA and NSTEMI will be considered together as non-ST-segment elevation acute coronary syndromes (NSTE-ACS), reflecting the similarity in the pathogenesis and management of these entities. Despite the significant advances that have been made in diagnostic technologies, the availability of newer therapeutic agents, and greater access to invasive therapies, as well as the burgeoning body of clinical trial and registry data linking specific treatment paradigms with improved clinical outcomes, many challenges remain in the management of NSTE- ACS. The dynamic nature of ACS presentation often confounds accurate risk stratification, with a resultant impact on early use of proven therapies. Hospital-specific resource limitations and uncertainties arising from the timing and use of invasive cardiac diagnostics and revascularization also often complicate management. The consistent observation that patients with NSTE-ACS, who make up the greatest proportion of ACS patients overall, suffer equal or higher rates of one- year mortality than STEMI patients underscores the need for further clarification and continued progress in this area of cardiovascular medicine. 1,2
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ABSTRACT: Percutaneous coronary intervention with stent placement is widely used to achieve revascularization of the myocardium, especially in acute coronary syndrome. There is increasing number of reports published concerning stent thrombosis both in bare metal stents as in drug eluting stents. According to the newest ACC/AHA/SCAI 2007th guidelines, bare-metal stent or balloon angioplasty is recommended as an optimal solution if surgery is to be performed in 6-12 months time after stent placement. We present a case of a 56-year-old male with colon carcinoma who suffered from post-operational myocardial infarction due to bare metal stent thrombosis, while the drug eluting stent remained patent. Currently, in our opinion, high level evidence is lacking in the literature in support for recommendations published in current ACC, AHA and SCAI 2007th guidelines regarding the choice of stent, antiaggregation and anticoagulation therapy. This case, together with others previously published suggests a need for development of an applicable strategy for selection and treatment of patients with increased perioperative risk of in-stent thrombosis in order to ensure optimal medical treatment.
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