Pharmacoinvasive Management of Acute Coronary Syndrome: Incorporating the 2007 ACC/AHA Guidelines

High-risk features and treatment trigger criteria for acute coronary syndromes: Risk-directed therapy and the sliding scale and hierarchy of care options.
Comparison between ACC/AHA non-ST-elevation myocardial infarction and ESC non-ST-segment elevation acute coronary syndrome criteria
Current bleeding definitions according to clinical studies using antithrombins.
“Major” bleeding in ACS trials and community populations. Bleeding events are more prevalent than other adverse events, e.g., MI, CHF, and death [Moscucci, 2003; Alexander, 2005; Ferguson, 2004; Cohen, 1997; Peterson, 2004; PURSUIT, 1998; Boersma, 2002; P
Figure 2. Excessive dosing of anticoagulants by age. LMVW = low-molecular-weight; UF = unfractionated; GP IIb/IIIa = glycoprotein IIb/IIIa inhibitor.
The CATH Clinical Consensus Panel Report - III
The CATH Clinical Consensus Panel Report - III (Cont.)
Author(s): 

aMarc Cohen, MD, bJosé Diez, MD, bGlenn N. Levine, MD, cJames J. Ferguson III, MD,
dDavid A. Morrow, MD, MPH, eSunil V. Rao, MD, eJames P. Zidar, MD

Every year, more than 1 million patients are admitted to a hospital with a diagnosis of unstable angina or non-ST-elevation myocardial infarction (UA/NSTEMI).1 Relative to acute ST-elevation myocardial infarction (STEMI), patients with UA/NSTEMI have a slightly higher 1-year mortality rate,2 and constitute a significantly larger proportion of patients with acute coronary syndromes (ACS).3 During the course of their hospitalization, these patients will interact with many different healthcare professionals, be subjected to many different drugs, diagnostic and invasive procedures, and be moved through several different hospital units before being discharged on multiple different medications. While the 2002 American College of Cardiology/American Heart Association Guidelines (ACC/AHA) provided a foundation for management of patients with UA/NSTEMI, a host of recent, prospective, randomized, clinical therapeutic trials of some already-approved antithrombotics as well as newer agents have been published or presented at international meetings involving more than 75,000 patients. In recognition of the fast-moving pace of scientific discovery, the 2002 guidelines were updated and published in late 2007.4 In addition, several recent large clinical trials have presented new options above and beyond those presented in the 2004 American College of Cardiology/American Heart Association Guidelines (ACC/AHA) for the management of patients with STEMI.5
However, despite the new information and updated guidelines, substantial challenges remain in identifying the optimal combination of therapeutic agents that will maximize benefits while minimizing drug-related adverse events in the individual patient with NSTEMI. The decision-making process in terms of choosing among the spectrum of pharmacologic options (e.g., low-molecularweight heparins (LMWHs), unfractionated heparin [UFH], direct antithrombins [DTI], indirect factor-Xa inhibitors, P2Y12 – adenosine diphosphate (ADP) receptor blockers and glycoprotein [GP] IIb/IIIa inhibitors), and the optimal timing for invasive catheterization and percutaneous interventional (PCI) approaches is complicated by the large number of “stakeholders”: emergency physicians, medical cardiologists, interventionalists, cardiac surgeons, nurse practitioners and nurses. Not infrequently, the choices appealing to emergency department providers may be different from the choices interventional cardiologists will make.

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