Chapter 19: Evaluation and Management of Non–ST-Segment Elevation Acute Coronary Syndromes

Content Update

BIOVASC: Immediate Versus Staged Complete Revascularization in ACS and Multivessel Disease

The BIOVASC trial was a prospective, open-label, non-inferiority, randomized, multinational clinical trial designed to assess whether immediate versus staged (within 6 weeks after the index procedure) complete revascularization improves outcomes in patients with acute coronary syndromes (ACS) and multivessel coronary disease. Read More

Content Update

SECURE Trial

The SECURE trial is an open-label, multinational trial that randomized 2,499 patients aged ≥65 years with a prior type 1 myocardial infarction (MI) within the 6 months preceding enrollment to a polypill-based strategy with a single pill containing aspirin (100 mg), ramipril (2.5, 5 or 10 mg) and atorvastatin (20 or 40 mg), or to usual care. Read More

Content Update

PACMAN-AMI: Effects of the PCSK9 Antibody Alirocumab on Coronary Atherosclerosis in Patients with Acute Myocardial Infarction

The PACMAN-AMI trial sought to evaluate effects of PCSK9 inhibition on atherosclerotic plaque progression via serial intracoronary imaging of non-culprit plaques in patients presenting with acute myocardial infarction (MI) on high-intensity statin therapy. Read More

Chapter Summary

This chapter discusses the pathophysiology, epidemiology, diagnosis, and treatment of non–ST-segment elevation acute coronary syndromes (see Fuster and Hurst’s Central Illustration). The most common etiology is disruption of an atherosclerotic coronary artery plaque with subsequent platelet-rich thrombus formation that may be flow limiting, but usually does not completely occlude the coronary lumen. Downstream microembolization of platelet aggregates and components of the disrupted plaque are likely responsible for the release of myocardial injury biomarkers. The clearest separation between unstable angina (UA) and non–ST-segment elevation myocardial infarction (NSTEMI) is the absence or presence of abnormal concentrations of myocardial biomarkers. The aims of therapy are to relieve ischemia, control symptoms, and prevent complications. Nitrates, β-blockers, and calcium channel blockers reduce the risk of recurrent ischemia. The risk of progression to myocardial infarction (MI), or recurrent MI, is diminished by antiplatelet and antithrombotic drugs and by revascularization of the culprit lesion, usually with percutaneous coronary intervention (PCI). Hospitalized patients should be treated with ASA, a platelet P2Y₁₂ receptor inhibitor, antithrombin therapy, a β-blocker, an angiotensin-converting enzyme (ACE) inhibitor, and a high-intensity statin. Outpatient therapy includes lifestyle interventions, risk factor control, and education about the importance of medication adherence. Discharge planning protocols and cardiac rehabilitation programs are the best way to achieve these goals.