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

2. 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.

3. 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

4. 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

5. 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
: Risk stratification-Troponins

6. Mortality Rate in Thai ACS Registry%
GRACE Am J Cardiology 2002;90:

7. 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

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

9. 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??