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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 electrocardiographic and clinical features identifying a patient with non–ST-segment elevation (NSTE), ACS, and ST-segment elevation myocardial infarction (STEMI).

  3. Devise a pharmacotherapy treatment and monitoring plan for a patient undergoing percutaneous coronary intervention (PCI) in NSTE-ACS and STEMI given patient-specific data.

  4. Devise a pharmacotherapy treatment and monitoring plan for a patient with NSTE-ACS or STEMI not undergoing PCI given patient-specific data.

  5. Develop a pharmacotherapy and risk factor modification treatment plan for secondary prevention of coronary heart disease (CHD) events in a patient following NSTE-ACS or STEMI.


Cardiovascular disease (CVD) is the leading cause of death in the United States and one of the major causes of death worldwide. Acute coronary syndromes (ACS), including unstable angina (UA) and myocardial infarction (MI), are a form of coronary heart disease (CHD) that comprises the most common cause of CVD death.1 KEY CONCEPT ACS is primarily caused by rupture of an atherosclerotic plaque with subsequent platelet adherence, activation, aggregation, and the activation of the clotting cascade. Ultimately, a thrombus composed of fibrin and platelets may develop, resulting in incomplete or complete occlusion of a coronary artery.2 The American Heart Association (AHA) and the American College of Cardiology Foundation (ACCF) recommend strategies or guidelines for ACS patient care for ST-segment elevation MI (STEMI) and Non-ST-segment elevation (NSTE)-ACS which includes both UA and non–ST-elevation MI (NSTEMI). In collaboration with the Society for Cardiovascular Angiography and Interventions (SCAI), the ACCF and AHA issue joint guidelines for percutaneous coronary intervention (PCI), including PCI in the setting of ACS. These practice guidelines are based on a review of available clinical evidence, have graded recommendations based on evidence and expert opinion, and are updated periodically. These guidelines form the cornerstone for quality care of the ACS patient.3,4,5


Each year, approximately 620,000 Americans will have a new “coronary attack,” a first hospitalized MI or CHD death, while 295,000 will have a recurrent event.1 The risks of CHD events, such as death, recurrent MI, and stroke, are higher for patients with established CHD and a history of MI than for patients with no known CHD.

The incidence rates of MIs in the United States have been decreasing.1 In particular, the number of patients presenting with STEMI has significantly decreased (from 133 to 50 cases per 100,000 person-years). Nevertheless, 122,071 Americans died of an MI in 2010.1 One in six deaths is secondary to CHD, which is the leading cause of hospitalization in the United States, with 1,346,000 hospitalizations listing it as the first cause of hospitalization ...

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