What’s new in Acute Coronary Syndrome 2005? Songsak Kiatchoosakun M.D. Division of Cardiology Department of Medicine Khon Kaen University

Coronary Artery Disease HT, smoking, dyslipidemia, DM Unstable angina NSTE MI STE MI Note: Plavix® (clopidogrel bisulfate) is not indicated for all the conditions listed on this slide. Vascular disease is the common underlying disease process for MI, ischemia and vascular death. Acute coronary syndrome (ACS) is a classic example of the progression of vascular disease to an ischemic event. ACS (in common with ischemic stroke and critical leg ischemia) is typically caused by rupture or erosion of an atherosclerotic plaque followed by formation of a platelet-rich thrombus. Atherosclerosis is an ongoing process affecting mainly large and medium-sized arteries, which can begin in childhood and progress throughout a person’s lifetime. Stable atherosclerotic plaques may encroach on the lumen of the artery and cause chronic ischemia, resulting in (stable) angina pectoris or intermittent claudication, depending on the vascular bed affected. Unstable atherosclerotic plaques may rupture, leading to the formation of a platelet-rich thrombus that partially or completely occludes the artery and causes acute ischemic symptoms.

Acute Coronary Syndrome (ACS) The spectrum of clinical conditions ranging from: Unstable angina Non-ST elevation MI ST elevation MI Characterized by the common pathophysiology of a disrupted atheroslerotic plaque

Pathogenesis of ACS Unstable angina NSTE MI STEMI Incomplete occlusion Distal embolization Platelet aggregation Thrombus formation Vasospasm Unstable angina NSTE MI Vulnerable Plaque Plaque rupture (55-80%) Exertion BP, HR Vasoconstriction Complete occlusion STEMI

Acute Coronary Syndrome : Clinical Perspective 1772: Clinical description of progression of angina symptoms to myocardial infarction and death 1910: Pre-infarction angina 1971: Introduction of terminology of unstable angina 1988: Concept of acute coronary syndrome 1990-95: Risk stratification-Troponins

Mortality Rate in Thai ACS Registry % GRACE Am J Cardiology 2002;90:358-363

Clinical Trials Update in ACS HELVETICA INTERACT RITA PERSUIT EPIC EPILOG PROTECT CARDILAC FRIC EPISTENT CURE ESSENCE CREDO TARGET ESPRIT REPLACE-2 GUSTO I-V TACTIC OASIS-2 A-Z TIMI 11 B FRAXIS PRISM -PLUS SYNERGY

Acute Coronary Syndrome = Acute Confusional State Eric Topol. J Am Coll Cardiol 2003;41:123S

Milestones in Management of Acute Coronary Syndrome 1983:Aspirin therapy 1985: Thrombolytic therapy 1988: Aspirin and heparin 1997: Low molecular weight heparin 1998: GPIIb/IIIa and aspirin and heparin 1999: Catheter based/ Invasive treatment (PCI/CABG) 2001: Clopidogrel with aspirin 2005: What’s new??