Management of Acute Coronary Syndromes. Contemporary Cardiology

798 Pages·2003·10.43 MB·English

by  Kevin T. McVary

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M A C S
ANAGEMENT OF CUTE ORONARY YNDROMES
ii
C C
ONTEMPORARY ◊ ARDIOLOGY
Christopher P. Cannon, Series Editor
Management of Acute Coronary Syndromes, Second Edition, edited by Christopher P. Cannon, MD 2003
Aging, Heart Disease, and Its Management: Facts and Controversies, edited by Niloo M. Edwards,
MD, Mathew S. Maurer, MD, and Rachel B. Wellner, MPH, 2003
Peripheral Arterial Disease: Diagnosis and Treatment, edited by Jay D. Coffman, MD and Robert
T. Eberhardt, MD, 2003
Cardiac Repolarization: Basic and Clinical Research, edited by Ihor Gussak, MD,PhD, Charles
Antzelevitch,PhD, Stephen C. Hammill, MD, Win K. Shen, MD, and Preben Bjerregaard, MD,
DMSc, 2003
Essentials of Bedside Cardiology: With a Complete Course in Heart Sounds and Murmurs on
CD, Second Edition, byJules Constant, MD, 2003
Primary Angioplasty in Acute Myocardial Infarction, edited by James E. Tcheng, MD, 2002
Cardiogenic Shock: Diagnosis and Treatment, edited by David Hasdai, MD, Peter B. Berger, MD,
Alexander Battler, MD, and David R. Holmes, Jr., MD, 2002
Management of Cardiac Arrhythmias, edited by Leonard I. Ganz, MD, 2002
Diabetes and Cardiovascular Disease, edited by Michael T. Johnstone, MD and Aristidis Veves, MD,
DSC, 2001
Blood Pressure Monitoring in Cardiovascular Medicine and Therapeutics,edited by William B.
White,MD, 2001
Vascular Disease and Injury: Preclinical Research, edited by Daniel I. Simon, MD, and Campbell
Rogers,MD 2001
Preventive Cardiology: Strategies for the Prevention and Treatment of Coronary Artery Disease, edited
byJoAnne Micale Foody, MD, 2001
Nitric Oxide and the Cardiovascular System,edited by Joseph Loscalzo, MD,PhD and Joseph A.
Vita,MD, 2000
Annotated Atlas of Electrocardiography: A Guide to Confident Interpretation, byThomas M.
Blake,MD, 1999
Platelet Glycoprotein IIb/IIIa Inhibitors in Cardiovascular Disease,edited by A. Michael
Lincoff,MD, and Eric J. Topol, MD, 1999
Minimally Invasive Cardiac Surgery,edited by Mehmet C. Oz, MD and Daniel J. Goldstein, MD, 1999
Management of Acute Coronary Syndromes,edited by Christopher P. Cannon, MD, 1999
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M A
ANAGEMENT OF CUTE
C S
ORONARY YNDROMES
Second Edition
Edited by
C P. C ,
HRISTOPHER ANNON MD
Brigham and Women’s Hospital, Boston, MA
Foreword by
E B ,
UGENE RAUNWALD MD
Brigham and Women’s Hospital, Boston, MA
H P
UMANA RESS
T , N J
OTOWA EW ERSEY
iv
© 2003 Humana Press Inc.
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Library of Congress Cataloging-in-Publication Data
Management of acute coronary syndromes / edited by Christopher P. Cannon; foreword by Eugene Braunwald.--2nd ed.
p.;cm.–(Contemporary cardiology)
ISBN 1-58829-130-8 (alk. paper) (hb); 1-58829-309-2 (pb)
Includes bibliographical references and index.
1. Coronary heart disease. 2. Myocardial infarction. I. Cannon, Christopher P. II. Contemporary cardiology
(Totowa, N.J.: unnumbered)
[DNLM: 1. Coronary Disease–therapy, 2. Acute Disease–therapy. WG 300 M2656 2003]
RC685.C6 M33 2003
616.1'23–dc21 2002068765
v
F
OREWORD
Coronary artery disease, the great scourge of our times, may express itself in two major
clinicopathologic forms. The chronic form is caused by progressive atherosclerotic narrow-
ing of the coronary arterial bed and usually presents as angina secondary to ischemia
precipitated by increased myocardial oxygen demand, i.e., “demand ischemia.” Treatment
consists of pharmacological agents and other measures to reduce oxygen demand, and
when this approach is inadequate, surgical or catheter-based revascularization. The acute
form, on the other hand, results form a sudden reduction in myocardial oxygen supply
caused, most commonly, by a thrombus on a fissured or eroded coronary atherosclerotic
plaque that previously had not caused critical obstruction. This causes “supply ischemia,”
which may result in a variety of clinical syndromes, including unstable angina, non-Q-wave
myocardial infarction, and Q-wave myocardial infarction. These acute coronary syndromes
are responsible for more than half a million deaths and a million hospitalizations each year
in the United States. The incidence is similar in other developed nations and it is rising at
an alarming rate in portions of the world.
The management of patients with acute coronary syndromes represents one of the
critical challenges to contemporary cardiology. This field has been the subject of inten-
sive investigation that has led to major advances in our understanding of the pathophysi-
ology, as well as in the diagnosis and management, of patients with these conditions.
Management of Acute Coronary Syndromes, Second Edition captures the many
important recent developments in this rapidly moving area of cardiology. Dr. Cannon
deserves thanks and congratulations for having organized a group of experienced clini-
cians and clinical investigators who present a comprehensive, up-to-date, and eminently
readable picture of the field. This book is certain to aid cardiologists, internists, and
emergency physicians in their management of patients with acute coronary syndromes.
Eugene Braunwald, MD
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P
REFACE
Over the past decade, there has been a revolution in our understanding of both the
pathophysiology and the management of acute coronary syndromes (ACS). The conver-
sion of a stable atherosclerotic lesion to a ruptured plaque with thrombosis has provided
a unifying hypothesis for the etiology of acute coronary syndromes. From this, the
concept of a “spectrum” of myocardial ischemia has provided a framework for under-
standing the pathogenesis, clinical feature, treatment, and outcome of patients across the
spectrum of myocardial ischemia.
Furthermore, a new paradigm for acute coronary syndromes has emerged with the
results of the Thrombolysis in Myocardial Ischemia (TIMI) IIIB trial: Though throm-
bolytic therapy has proven clearly beneficial in patients with ST segment elevation, no
benefit has been observed in patients with unstable angina or non-ST elevation MI.
Angiographic studies, including TIMI I and TIMI IIIA, have shown that this difference
in outcome results from the initial status of the infarct-related artery, which usually
demonstrates 100% coronary occlusion in ST elevation MI, in contrast to a patent, but
stenotic coronary lesion in unstable angina and not-ST elevation MI. Thus, a classifica-
tion of ST elevation MI vs non-ST segment elevation ACS provides the critical informa-
tion regarding the pathophysiology and acute management of the patient.
Accordingly,Management of Acute Coronary Syndromes, now in its Second Edition,
is the first book to approach the management of acute coronary syndromes based on this
new paradigm. The initial sections are devoted to understanding the pathophysiology of
ACS, as well as the diagnostic tools for assessing patients. There are then two separate
sections, one for ST elevation MI and the other for non-ST elevation ACS, which discuss
the state-of-the-art management of these two groups of patients. I have felt privileged to
have colleagues who are each world-renowned experts in their fields to provide concise,
evidence-based recommendations on the optimal management of patients. The latest
clinical trial data with numerous figures and tables are provided so that the reader will
be able to have quickly available the key information that supports the recommended
therapies. It is hoped that this compilation of the latest information will facilitate im-
provement in the management of patients with acute coronary syndromes.
On a personal level, my interest in acute coronary syndromes grew from many sources.
First and foremost in guiding me has been my father, Paul Cannon, whose dedication to
medicine and science has been a strong role model for me. His initial work in the mea-
surement of coronary blood flow with radionuclide imaging two decades ago helped
define the very basic pathophysiology of angina pectoris. He has also been one of my
clinical teachers, as he has for many others at Columbia University College of Physicians
and Surgeons over the past 30 years, teaching the students, housestaff, and fellows about
the clinical presentation of angina to the acute management of myocardial infarction in
the coronary care unit. The second major influence came from the writings of Fuster,
Willerson, Braunwald, and others, on the emerging understanding of plaque rupture and
coronary thrombosis in the pathophysiology of unstable angina. The new and rapidly
vii
viii Preface
emerging field sparked both my interest and enthusiasm to focus on acute coronary
syndromes where new treatments might be of benefit to patients. Next, beginning with
my fellowship at the Brigham, it has been my privilege to work with Eugene Braunwald,
for nearly a decade in conducting the Thrombosis in Myocardial Infarction (TIMI) trials.
His expertise, insight, innovation, and judgment have been the greatest example any
student of medicine could hope for. His support and teaching throughout has fueled my
enthusiasm for design and participation in clinical trials and scientific research studies,
with the goal of improving patient care. Finally, my numerous other colleagues in the
TIMI Group, notably Carolyn McCabe, Michael Gibson, and Elliott Antman, and in the
entire cardiology community have been a constant inspiration to delve deeper into trying
to understand and improve the management of patients with acute coronary syndromes.
Christopher P. Cannon, MD
ix
C
ONTENTS
Foreword ........................................................................................................................v
Preface......................................................................................................................... vii
Contributors................................................................................................................ xiii
Part I Pathophysiology
1 The Spectrum of Myocardial Ischemia:
The Paradigm of Acute Coronary Syndromes.............................3
Christopher P. Cannon and Eugene Braunwald
2 Linking Biochemistry, Vascular Biology, and Clinical Events
in Acute Coronary Syndromes...................................................19
Richard C. Becker and Annemarie Armani
3 Triggers of Acute Coronary Syndromes ........................................61
Peter M. Sapin and James E. Muller
4 Insights into the Pathophysiology of Acute Ischemia Syndromes
Using the TIMI Flow Grade, TIMI Frame Count, and TIMI
Myocardial Perfusion Grade ........................................................95
C. Michael Gibson, Sabina A. Murphy,
and Jeffrey J. Popma
Part II Diagnosis
5 Emergency Department Presentations
of Acute Cardiac Ischemia.......................................................121
J. Hector Pope and Harry P. Selker
6 Early Identification and Treatment of Patients
with Acute Coronary Syndromes.............................................157
Mary M. Hand and Costas T. Lambrew
7 Serum Markers for Diagnosis and Risk Stratification
in Acute Coronary Syndromes.................................................183
L. Kristin Newby, W. Brian Gibler, Robert H. Christenson,
and E. Magnus Ohman
8 Technologies to Diagnose Acute Ischemia..................................211
Robert J. Zalenski, Joseph Lau, and Harry P. Selker
ix