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Upon completion of the chapter, the reader will be able to:

  1. Define the role of atherosclerotic plaque, platelets, and the coagulation system in an acute coronary syndrome (ACS).

  2. List key electrocardiogram (ECG) and clinical features identifying a patient with non-ST-segment elevation (NSTE) ACS who is at high risk of myocardial infarction (MI) or death.

  3. Devise a pharmacotherapy treatment plan for a patient undergoing primary percutaneous coronary intervention (PCI) in ST-segment elevation (STE) MI and NSTE ACS given patient-specific data.

  4. Compare and contrast the pharmacokinetics, antiplatelet effects, adverse effects, and drug–drug interactions between clopidogrel, prasugrel, and ticagrelor.

  5. Devise a pharmacotherapy treatment plan for a patient with NSTE ACS given patient-specific data.

  6. Develop a pharmacotherapy and risk-factor modification treatment plan for secondary prevention of coronary heart disease events in a patient following MI.

  7. Identify the characteristics of patients who are ideal candidates for mineralocorticoid receptor antagonist therapy following MI.

  8. Formulate a treatment and monitoring plan for a patient with STE MI or NSTE ACS.

  9. List the quality performance measures of care for MI.




  • Image not available. The cause of an acute coronary syndrome (ACS) is the rupture of an atherosclerotic plaque with subsequent platelet adherence, activation, and aggregation, and the activation of the clotting cascade. Ultimately, a clot forms composed of fibrin and platelets.

  • Image not available. The American College of Cardiology Foundation (ACCF), American Heart Association (AHA), and Society for Cardiovascular Angiography and Interventions (SCAI) recommend strategies, or guidelines, for ACS patient care for ST-segment elevation (STE) myocardial infarction (MI) and non-ST-segment elevation (NSTE) ACS, including guidelines for patients undergoing percutaneous coronary intervention (PCI).

  • Image not available. Patients with ischemic chest discomfort and suspected ACS are risk stratified based on a 12-lead electrocardiogram (ECG), past medical history, and results of the troponin and creatine kinase (CK) myocardial band (MB) tests. The diagnosis of myocardial infarction (MI) is confirmed based on the results of the CK MB and troponin biochemical marker tests.

  • Image not available. Early reperfusion therapy with primary PCI of the infarct artery is the recommended therapy for patients presenting with STE MI within 12 hours of symptom onset.

  • Image not available. The most recent PCI ACCF/AHA/SCAI clinical practice guidelines recommend coronary angiography with either PCI or coronary artery bypass graft (CABG) surgery revascularization as an early treatment (early invasive strategy) for patients with NSTE ACS at an elevated risk for death or MI, including those with a high risk score or patients with refractory angina, acute heart failure, other symptoms of cardiogenic shock, or arrhythmias.

  • Image not available. In addition to reperfusion therapy, other early pharmacotherapy that all patients with STE MI and without contraindications should receive within the first day of hospitalization, and preferably in the emergency department, are intranasal oxygen (if oxygen saturation is low), sublingual (SL) nitroglycerin (NTG), aspirin (ASA), a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor depending on reperfusion strategy), and anticoagulation with bivalirudin, unfractionated heparin (UFH), or enoxaparin (agent dependent on reperfusion strategy). A glycoprotein (GP) IIb/IIIa inhibitor should be administered ...

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