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

  3. Devise an initial, early pharmacotherapy treatment and monitoring plan for a patient presenting with either NSTE-ACS or STEMI given patient-specific data.

  4. Devise an antithrombotic pharmacotherapy treatment and monitoring plan for a patient with NSTE-ACS or STEMI undergoing percutaneous coronary intervention (PCI) given patient-specific data.

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

  6. 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.1 Acute coronary syndromes (ACSs), 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 image 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 ACS is a spectrum of disease encompassing ST-segment elevation MI (STEMI) or non–ST-segment elevation (NSTE)-ACS, which are classified according to electrocardiogram (ECG) changes and underlying pathophysiology.3,4 The American Heart Association (AHA), American College of Cardiology (ACC), and American College of Cardiology Foundation (ACCF) recommend strategies or guidelines for ACS patient care for STEMI and NSTE-ACS which include 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. In the United States, these guidelines form the cornerstone for quality care of the ACS patient.3-5


Each year, approximately 720,000 Americans will have a new coronary event, defined as a first hospitalization for MI or CHD death, while 335,000 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 without CHD.

The incidence rate of MI in the United States has been decreasing since 2007.1 Particularly, patients presenting with STEMI have significantly decreased (from 133 to 50 cases per 100,000 person-years). Nevertheless, 110,346 Americans died ...

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