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Media Gallery

Pathogenesis of acute coronary syndromes.
Thrombolysis in Myocardial Infarction (TIMI) Risk Score correlates with major adverse outcome and effect of therapy with low-molecular-weight heparin. ARD = absolute risk difference; ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; No. = number; NNT = number needed to treat.
Algorithm for initial invasive strategy. ASA = acetylsalicylic acid (aspirin); GP IIb/IIIa= glycoprotein IIb/IIIa; IV = intravenous; LOE = level of evidence; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction; UFH = unfractionated heparin. (Adapted from 2007 ACC/AHA UA/NSTEMI Guidelines.)
Algorithm for initial conservative strategy. ASA = acetylsalicylic acid (aspirin); EF = ejection fraction; GP IIb/IIIa= glycoprotein IIb/IIIa; IV = intravenous; LOE = level of evidence; LVEF = left ventricular ejection fraction; UA/NSTEMI = unstable angina/non–ST-segment elevation myocardial infarction. (Adapted from 2007 ACC/AHA UA/NSTEMI Guidelines.)
Rate and timing of revascularization for patients with unstable angina using invasive versus conservative approach (FRagmin during InStability in Coronary artery disease [FRISC] II).
Time course of elevations of serum markers after acute myocardial infarction. CK = creatine kinase; CK-MB = creatine kinase MB fraction; LDH = lactate dehydrogenase.

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Table 1. Patient Characteristics, GUARANTEE Versus CRUSADE Trials

Characteristics	GUARANTEE, 1995-96 ^[12]	CRUSADE, 2001-06 ^[13]
Mean age (y)	62	69
Patients >65 y (%)	44	–
Female (%)	39	40
Hypertension (%)	60	73
Diabetes mellitus (%)	26	33
Current smoker (%)	25	–
Hypercholesterolemia (%)	43	50
Previous stroke (%)	9	–
Previous MI (%)	36	30
Previous angina (%)	66	–
CHF (%)	14	18
Previous coronary intervention (%)	23	21
Previous coronary bypass surgery (%)	25	19
CHF = congestive heart failure; CRUSADE = Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines; GUARANTEE = Global Unstable Angina Registry and Treatment Evaluation; MI = myocardial infarction.

Table 2. Demographic Characteristics of Patients in International OASIS-2 Registry

Characteristics ^[15]		Australia	Brazil	Canada	Hungary	Poland	United States
General	Number of patients	1899	1478	1626	931	1135	918
	Mean age (y)	65	62	66	65	63	66
	Women (%)	37	42	37	45	40	37
Clinical	NQMI presentation (%)	7	7	14	22	17	16
Clinical	Abnormal ECG (%)	74	91	82	95	97	87
Select treatments	Beta blocker (%)	67	53	73	67	59	57
Select treatments	Calcium blocker (%)	59	51	53	52	43	59
Invasive procedures (index hospitalization)	Cardiac catheterization (%)	24	69	43	20	7	58
	PCI (%)	7	19	16	5	0.4	24
	CABG (%)	4	20	10	7	0.4	17
CABG = coronary artery bypass grafting; ECG = electrocardiographic; NQMI = non-Q wave myocardial infarction; OASIS = Organization to Assess Strategies for Ischemic Syndromes; PCI = percutaneous coronary intervention.

Table 3. Thirty-Day Clinical Outcome in Patients With Acute Coronary Syndromes in Clinical Trials

Study	Year	Number of Patients	Death (%)	Myocardial Infarction (%)	Major Bleed (%)
TIMI-3	1994	1,473	2.5	9.0	0.3
GUSTO-IIb	1997	8,011	3.8	6.0	1.0
ESSENCE	1998	3,171	3.3	4.5	1.1
PARAGON-A	1998	2,282	3.2	10.3	4.0
PRISM	1998	3,232	3.0	4.2	0.4
PRISM-PLUS	1998	1,915	4.4	8.1	1.1
PURSUIT	1998	10,948	3.6	12.9	2.1
TIMI-11B	1999	3,910	3.9	6.0	1.3
PARAGON-B	2000	5,225	3.1	9.3	1.1
Pooled		40,167	3.5	8.5	1.5
ESSENCE = Efficacy and Safety of Subcutaneous Enoxaparin in Non–Q-wave Coronary Events; GUSTO-IIb = Global Utilization of Streptokinase and TPA (tissue plasminogen activator) for Occluded Coronary Arteries; PARAGON-A = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PARAGON-B = Platelet IIb/IIIa Antagonism (lamifiban) for the Reduction of Acute Coronary Syndrome Events in a Global Organization Network; PRISM = Platelet Receptor Inhibition in Ischemic Syndrome Management; PRISM-PLUS = Platelet Receptor Inhibition in Ischemic Syndrome Management in Patients Limited by Unstable Angina Signs and Symptoms; PURSUIT = Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy; TIMI-11B = Thrombolysis in Myocardial Infarction Clinical Trial 11B; TIMI-3 = Thrombolysis in Myocardial Infarction Clinical Trial 3.

Table 4. Braunwald Classification of Unstable Angina

Characteristic	Class/Category	Details
Severity	I	Symptoms with exertion
	II	Subacute symptoms at rest (2-30 days prior)
	III	Acute symptoms at rest (within prior 48 hr)
Clinical precipitating factor	A	Secondary
	B	Primary
	C	Postinfarction
Therapy during symptoms	1	No treatment
	2	Usual angina therapy
	3	Maximal therapy

Table 5. Recommendations for Selection of Preferred Management Strategy

Preferred Strategy	Patient Characteristic/Clinical Risk
Immediate Invasive Strategy (< 2 hours)	Refractory angina
	Signs/symptoms of heart failure or new or worsening mitral regurgitation
	Hemodynamic instability or cardiogenic shock
	Recurrent angina/ischemia at rest or with low-level activities despite intensive medical therapy
	Sustained ventricular tachycardia or ventricular fibrillation
Ischemia-Guided Strategy	Low-risk score (eg, TIMI 0 or 1, GRACE < 109)
	Low-risk Tn-negative female
	Patient or physician preference in the absence of high-risk features
Early Invasive Strategy (< 24 hours)	GRACE score >140
	Rise or fall in Tn compatible with myocardial infarction
	New or presumably new ST-segment depression
Delayed Invasive Strategy (24-72 hours)	Diabetes mellitus
	Renal insufficiency (GFR < 60 mL/min/1.73m²)
	Reduced LV systolic function (LVEF < 40%)
	Early postinfarction angina
	PCI within 6 months
	Prior CABG
	GRACE score 109-140; TIMI Score ≥2
ACC/AHA = American College of Cardiology/American Heart Association; CABG = coronary artery bypass grafting; GFR = glomerular filtration rate; GRACE = Global Registry of Acute Coronary Events; LV = left ventricle; LVEF = left ventricular ejection fraction; PCI = percutaneous coronary intervention; TIMI = Thrombolysis in Myocardial Infarction Clinical Trial; Tn = troponin.

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Author

Walter Tan, MD, MS Associate Professor of Medicine, Wake Forest University School of Medicine; Director of Cardiac Cath Labs, Wake Forest Baptist Medical Center

Walter Tan, MD, MS is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American Heart Association, American Stroke Association, National Stroke Association, Society for Vascular Medicine, Society of Interventional Radiology

Disclosure: Nothing to disclose.

Coauthor(s)

David J Moliterno, MD Professor of Medicine, Jefferson Morris Gill Professor of Cardiology, Chief, Division of Cardiovascular Medicine, University of Kentucky; Vice Chairman of Internal Medicine, Chandler Medical Center; Medical Director, Gill Heart Institute

David J Moliterno, MD is a member of the following medical societies: American College of Cardiology, European Society of Cardiology, Association of Professors of Cardiology, American College of Physicians, American Heart Association, American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Chief Editor

Eric H Yang, MD Associate Professor of Medicine, Director of Cardiac Catherization Laboratory and Interventional Cardiology, Mayo Clinic ArizonA

Eric H Yang, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Acknowledgements

Steven James Filby, MD Fellow in Interventional Cardiology, The Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Director of Cardiology Quality Program KMC, Dartmouth-Hitchcock Medical Center, Dartmouth Medical School

Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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