Acute Coronary Syndrome covers the spectrum of clinical conditions ranging from unstable angina to non-ST elevation myocardial infarction and ST elevation myocardial infarction. These life-threatening disorders are a major cause of emergency medical care, hospitalization and mortality. Management of Acute Coronary Syndromes is designed to provide busy clinicians with a comprehensive guide to the investigation, diagnosis and treatment of these syndromes. It encompasses the latest technologies, including the use of biomarkers and non-invasive imaging procedures. For each condition, the reader…mehr
Acute Coronary Syndrome covers the spectrum of clinical conditions ranging from unstable angina to non-ST elevation myocardial infarction and ST elevation myocardial infarction. These life-threatening disorders are a major cause of emergency medical care, hospitalization and mortality. Management of Acute Coronary Syndromes is designed to provide busy clinicians with a comprehensive guide to the investigation, diagnosis and treatment of these syndromes. It encompasses the latest technologies, including the use of biomarkers and non-invasive imaging procedures.
For each condition, the reader is taken through all of the therapeutic options available; in each case the indications and contraindications are evaluated in the light of the latest clinical trials. Potential complications are dealt with in a similar fashion, permitting the reader to anticipate and manage problems as they arise. The authors also present evidence-based recommendations for long-term care of at-risk patients, encompassing pharmacologic therapies and lifestyle management.
The book concludes with a comprehensive collection of appendices that include treatment algorithms, risk scores and a summary of the latest management guidelines.
Management of Acute Coronary Syndromes is the most up to date and comprehensive evidence-based guide to managing acute coronary syndromes, in a compact and usable format. It will be of interest to busy specialist physicians in cardiovascular medicine, cardiac and vascular surgery, and critical care, as well as primary care physicians and hospitalists who care for patients with these syndromes.Hinweis: Dieser Artikel kann nur an eine deutsche Lieferadresse ausgeliefert werden.
Dr. Eli Gelfand is a clinical cardiologist, who provides comprehensive care for patients with a full range of heart and vascular problems at the Beth Israel Deaconess Medical Center. He is the Director of the Vascular Diagnostic Laboratory, Harvard Medical School and is the , Harvard Medial School and is the Associate Cardiovascular Fellowship Director at Beth Israel Deaconess Medical Center. Dr. Christopher P. Cannon, is an Associate Professor of Medicine at Harvard Medical School and an Associate Physician in the Cardiovascular Division at Brigham and Women's Hospital in Boston, Massachusetts. He is a senior investigator of the Thrombolysis in Myocardial Infarction (TIMI) Study Group. Dr. Cannon has published more than 500 original articles, reviews, editorials, book chapters, and electronic publications in the field of acute coronary syndromes. Dr. Cannon has received numerous awards including the Alfred Steiner Research Award, Upjohn Achievement in Research Award, and Robert F. Loeb Award for Excellence in Clinical Medicine. He is a Fellow of the American Heart Association and of the American College of Cardiology.
Inhaltsangabe
List of contributors xiii Foreword xv Eugene Braunwald Chapter 1 Pathophysiology of acute coronary syndromes 1 Alisa B. Rosen and Eli V. Gelfand Introduction 1 Formation of atherosclerotic plaque 2 Plaque instability and the development of ACS 5 Myocardial ischemia 7 Thrombus formation 7 Platelets 7 Secondary hemostasis 9 Dynamic obstruction 10 Progressive mechanical obstruction 10 Inflammation 11 Secondary unstable angina 11 References 11 Chapter 2 Diagnosis of acute coronary syndrome 13 Eli V. Gelfand and Alisa B. Rosen Introduction 13 Definition of myocardial infarction 13 History 14 Risk factors 17 Physical examination 17 Electrocardiography 19 The pathophysiologic basis of ST segment changes during ischemia 19 Electrocardiography in ST-elevation MI and identification of the infarct-related artery 20 Electrocardiography in unstable angina and NSTEMI 26 Cardiac biomarkers 26 Noninvasive imaging 29 Echocardiography 29 Myocardial perfusion imaging 30 Coronary computed tomography 30 Cardiovascular magnetic resonance imaging 31 Stress testing for diagnosis of ACS 32 Overall diagnostic pathway for ACS 32 References 34 Chapter 3 Unstable angina and non-ST-elevation myocardial infarction 37 Eli V. Gelfand and Christopher P. Cannon Introduction 37 Causes of UA/NSTEMI 37 Presentation of UA/NSTEMI 38 General strategies in management of UA/NSTEMI 39 Risk stratification of patients with UA/NSTEMI 40 Initial management of UA/NSTEMI in the emergency department 42 Pharmacologic treatment of ischemia in UA/NSTEMI 43 Beta-blockers 44 Nitrates 44 Calcium channel blockers 45 Angiotensin-converting enzyme inhibitors 45 Morphine 46 Oxygen 46 Invasive versus conservative strategy 46 Antiplatelet therapy in UA/NSTEMI 49 Aspirin 54 Clopidogrel 55 Prasugrel 57 Glycoprotein IIb/IIIa inhibitors 58 Anticoagulant therapy in UA/NSTEMI 61 Unfractionated heparin 61 Enoxaparin 62 Direct thrombin inhibitors 65 Fondaparinux 66 Oral anticoagulation in UA/NSTEMI 67 Fibrinolysis in UA/NSTEMI 68 Early lipid-lowering therapy in patients with UA/NSTEMI 68 Predischarge noninvasive risk stratification after UA/NSTEMI 69 Overall management of UA/NSTEMI 71 References 71 Chapter 4 ST-segment-elevation myocardial infarction 79 Eli V. Gelfand and Christopher P. Cannon Introduction 79 Global treatment goals in STEMI 79 Prehospital management and triage 80 Transport decisions 82 Management prior to reperfusion 82 Primary reperfusion therapy for STEMI 83 Fibrinolysis 83 Combination fibrinolysis 86 Markers of fibrinolysis effectiveness 86 Complications of fibrinolysis 88 Primary percutaneous coronary intervention 88 Comparison of PCI with fibrinolysis 90 Timing of primary PCI 91 PCI following fibrinolytic therapy 94 Rescue PCI 94 Facilitated PCI 94 Routine PCI after successful fibrinolysis 96 Overall reperfusion strategy 97 Coronary artery bypass grafting for treatment of STEMI 98 Adjunctive pharmacologic treatment of STEMI 98 Antiplatelet agents 98 Anticoagulation therapy 101 Other adjunctive therapy 105 Hospital care following successful reperfusion 110 References 114 Chapter 5 Special considerations in acute coronary syndromes 123 Jason Ryan and Eli V. Gelfand Secondary unstable angina 123 Acute coronary syndrome in patients with diabetes mellitus 123 General considerations 123 Primary ACS therapy in diabetics 124 Glycemic control in diabetics with ACS 125 Coronary revascularization in diabetics 126 Metabolic syndrome and ACS 127 Chronic kidney disease in ACS 127 Young patients with ACS 130 ACS in the setting of cocaine use 130 ACS in patients with normal coronary arteries or mild CAD 132 Myocarditis 132 Acute transient apical ballooning syndrome 133 Postoperative ACS 134 ACS in a pregnant woman 135 Hyperthyroidism and ACS 136 ACS in patients exposed to radiation 137 Trauma and ACS 137 References 137 Chapter 6 Complications of acute coronary syndrome 141 Jan M. Pattanayak and Eli V. Gelfand Introduction 141 Pump failure 141 General principle 141 Clinical presentation 142 Prognosis 144 Treatment 144 Right ventricular infarction 148 Introduction 148 Clinical presentation 148 Diagnosis 149 Management 150 Prognosis 152 Mechanical complications of ACS 152 Introduction 152 Left ventricular free wall rupture 152 Ventricular septal rupture 153 Acute mitral regurgitation 154 Left ventricular aneurysm 155 Left ventricular pseudoaneurysm 157 Pericardial complications 157 Arrhythmic complications of ACS 159 Bradyarrhythmias 159 Atrial fibrillation 163 Ventricular tachycardia and fibrillation 163 Complications involving bleeding 164 Complications of percutaneous coronary intervention 165 References 170 Chapter 7 Post-hospitalization care of patients with acute coronary syndrome 173 Jersey Chen and Eli V. Gelfand Introduction 173 Pharmacologic measures 173 Aspirin 173 Clopidogrel 174 Beta adrenergic blockade 177 Renin-angiotensin-aldosterone inhibitors 179 Lipid-lowering therapy 185 Warfarin 189 Influenza vaccination 192 Medications of limited benefit to patients following ACS 192 Vitamins/antioxidants 192 Estrogen replacement therapy 192 Nonsteroidal anti-inflammatory agents and related compounds 194 Nonpharmacologic measures 195 Antiarrhythmic devices 195 Therapy of comorbidities following ACS 198 Diabetes mellitus 198 Hypertension 199 Depression 199 Lifestyle recommendations following ACS 200 General physical activity and structured cardiac rehabilitation 200 Sexual activity after ACS 201 Smoking cessation 201 Diet/nutrition and weight loss 202 References 204 Appendix 209 Index 217
List of contributors xiii Foreword xv Eugene Braunwald Chapter 1 Pathophysiology of acute coronary syndromes 1 Alisa B. Rosen and Eli V. Gelfand Introduction 1 Formation of atherosclerotic plaque 2 Plaque instability and the development of ACS 5 Myocardial ischemia 7 Thrombus formation 7 Platelets 7 Secondary hemostasis 9 Dynamic obstruction 10 Progressive mechanical obstruction 10 Inflammation 11 Secondary unstable angina 11 References 11 Chapter 2 Diagnosis of acute coronary syndrome 13 Eli V. Gelfand and Alisa B. Rosen Introduction 13 Definition of myocardial infarction 13 History 14 Risk factors 17 Physical examination 17 Electrocardiography 19 The pathophysiologic basis of ST segment changes during ischemia 19 Electrocardiography in ST-elevation MI and identification of the infarct-related artery 20 Electrocardiography in unstable angina and NSTEMI 26 Cardiac biomarkers 26 Noninvasive imaging 29 Echocardiography 29 Myocardial perfusion imaging 30 Coronary computed tomography 30 Cardiovascular magnetic resonance imaging 31 Stress testing for diagnosis of ACS 32 Overall diagnostic pathway for ACS 32 References 34 Chapter 3 Unstable angina and non-ST-elevation myocardial infarction 37 Eli V. Gelfand and Christopher P. Cannon Introduction 37 Causes of UA/NSTEMI 37 Presentation of UA/NSTEMI 38 General strategies in management of UA/NSTEMI 39 Risk stratification of patients with UA/NSTEMI 40 Initial management of UA/NSTEMI in the emergency department 42 Pharmacologic treatment of ischemia in UA/NSTEMI 43 Beta-blockers 44 Nitrates 44 Calcium channel blockers 45 Angiotensin-converting enzyme inhibitors 45 Morphine 46 Oxygen 46 Invasive versus conservative strategy 46 Antiplatelet therapy in UA/NSTEMI 49 Aspirin 54 Clopidogrel 55 Prasugrel 57 Glycoprotein IIb/IIIa inhibitors 58 Anticoagulant therapy in UA/NSTEMI 61 Unfractionated heparin 61 Enoxaparin 62 Direct thrombin inhibitors 65 Fondaparinux 66 Oral anticoagulation in UA/NSTEMI 67 Fibrinolysis in UA/NSTEMI 68 Early lipid-lowering therapy in patients with UA/NSTEMI 68 Predischarge noninvasive risk stratification after UA/NSTEMI 69 Overall management of UA/NSTEMI 71 References 71 Chapter 4 ST-segment-elevation myocardial infarction 79 Eli V. Gelfand and Christopher P. Cannon Introduction 79 Global treatment goals in STEMI 79 Prehospital management and triage 80 Transport decisions 82 Management prior to reperfusion 82 Primary reperfusion therapy for STEMI 83 Fibrinolysis 83 Combination fibrinolysis 86 Markers of fibrinolysis effectiveness 86 Complications of fibrinolysis 88 Primary percutaneous coronary intervention 88 Comparison of PCI with fibrinolysis 90 Timing of primary PCI 91 PCI following fibrinolytic therapy 94 Rescue PCI 94 Facilitated PCI 94 Routine PCI after successful fibrinolysis 96 Overall reperfusion strategy 97 Coronary artery bypass grafting for treatment of STEMI 98 Adjunctive pharmacologic treatment of STEMI 98 Antiplatelet agents 98 Anticoagulation therapy 101 Other adjunctive therapy 105 Hospital care following successful reperfusion 110 References 114 Chapter 5 Special considerations in acute coronary syndromes 123 Jason Ryan and Eli V. Gelfand Secondary unstable angina 123 Acute coronary syndrome in patients with diabetes mellitus 123 General considerations 123 Primary ACS therapy in diabetics 124 Glycemic control in diabetics with ACS 125 Coronary revascularization in diabetics 126 Metabolic syndrome and ACS 127 Chronic kidney disease in ACS 127 Young patients with ACS 130 ACS in the setting of cocaine use 130 ACS in patients with normal coronary arteries or mild CAD 132 Myocarditis 132 Acute transient apical ballooning syndrome 133 Postoperative ACS 134 ACS in a pregnant woman 135 Hyperthyroidism and ACS 136 ACS in patients exposed to radiation 137 Trauma and ACS 137 References 137 Chapter 6 Complications of acute coronary syndrome 141 Jan M. Pattanayak and Eli V. Gelfand Introduction 141 Pump failure 141 General principle 141 Clinical presentation 142 Prognosis 144 Treatment 144 Right ventricular infarction 148 Introduction 148 Clinical presentation 148 Diagnosis 149 Management 150 Prognosis 152 Mechanical complications of ACS 152 Introduction 152 Left ventricular free wall rupture 152 Ventricular septal rupture 153 Acute mitral regurgitation 154 Left ventricular aneurysm 155 Left ventricular pseudoaneurysm 157 Pericardial complications 157 Arrhythmic complications of ACS 159 Bradyarrhythmias 159 Atrial fibrillation 163 Ventricular tachycardia and fibrillation 163 Complications involving bleeding 164 Complications of percutaneous coronary intervention 165 References 170 Chapter 7 Post-hospitalization care of patients with acute coronary syndrome 173 Jersey Chen and Eli V. Gelfand Introduction 173 Pharmacologic measures 173 Aspirin 173 Clopidogrel 174 Beta adrenergic blockade 177 Renin-angiotensin-aldosterone inhibitors 179 Lipid-lowering therapy 185 Warfarin 189 Influenza vaccination 192 Medications of limited benefit to patients following ACS 192 Vitamins/antioxidants 192 Estrogen replacement therapy 192 Nonsteroidal anti-inflammatory agents and related compounds 194 Nonpharmacologic measures 195 Antiarrhythmic devices 195 Therapy of comorbidities following ACS 198 Diabetes mellitus 198 Hypertension 199 Depression 199 Lifestyle recommendations following ACS 200 General physical activity and structured cardiac rehabilitation 200 Sexual activity after ACS 201 Smoking cessation 201 Diet/nutrition and weight loss 202 References 204 Appendix 209 Index 217
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