Acute coronary syndromes treatment

Goodman SG, Fitchett D, Armstrong PW, et al., for the Integrilin and Enoxaparin Ftandomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial investigators. Randomized... 

Fondaparinux, the factor Xa-binding pentasaccharide (Arixtra, MW 1,728 Da), is prepared synthetically, unlike UFH, LMWH and danaparoid, which are obtained from animal sources. Despite only inactivating free factor Xa, clinical trials indicate that fondaparinux is an effective antithrombotic agent, both for venous thromboembolism prophylaxis and treatment, as well as for acute coronary syndrome and ST elevation myocardial infarction [4]. 

The major goals for the treatment of ischemic heart disease are to prevent acute coronary syndromes and death, alleviate acute symptoms of myocardial ischemia, prevent recurrent symptoms of myocardial ischemia, and avoid or minimize adverse treatment effects. 

Devise a pharmacotherapy treatment and monitoring plan for a patient with non-ST-segment elevation acute coronary syndrome given patient-specific data. 

The safety of G-CSF stimulation in patients with CAD has been questioned in two recent studies. Hill et al. [138] report the results of administration of 10 mcg/kg/day of G-CSF for 5 days in patients with chronic CAD n = 16). There was no clinical benefit as assessed by exercise stress testing and dobuta-mine cardiac MRI. Additionally two patients in the G-CSF group developed serious adverse events related to the therapy (one non-ST elevation MI one MI causing death). Zbinden et al. [139] also tested the efficacy of the same G-CSF dose in patients with chronic CAD ( = 7). The invasive endpoint collateral flow index was significantly better in the G-CSF treated patients when compared to the placebo group. However, two patients in the G-CSF treated group developed acute coronary syndrome during treatment. 

According to recent ACC/AHA/ESC Guidelines (see Zipes et al., 2006), in patients with sutained VT, direct-current cardioversion is appropriate and most effective, and also intravenous procainamide (or ajmaline in some European countries) is recommended as a reasonable choice for initial treatment for sustained monomorphic VT in patients with acute coronary syndrome. Intravenous amiodarone or lidocaine may be reasonable chose as alternative treatment. 

Indications Treatment of patients with acute coronary syndrome, including patients who are to be managed medically and those undergoing percutaneous coronary intervention (PCI). 

Alexander KP Chen AY Roe MT et al, Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes, JAMA 2005 294 3108-31 16. 

Altman R, Luciardi HL, Muntaner J, etal, Efficacy assessment of meloxicam, a preferential cyclooxygenase-2 inhibitor, in acute coronary syndromes without ST-segment elevation the Nonsteroidal Anti-Inflammatory Drugs in Unstable Angina Treatment-2 (NUT-2) pilot study, Circulation 2002 106 191-195. 

Boersma E, Akkerhuis KM, Theroux P et al, Platelet glycoprotein llb/llla receptor inhibition in non-ST-elevation acute coronary syndromes early benefit during medical treatment only, with additional protection during percutaneous coronary intervention. Circulation 1999 100 2045-2048. 

James S, Armstrong R Califf R, et al. Safety of abciximab combined with dalteparin in treatment of acute coronary syndromes, Eur Heart J 2002 23 1 538-1 545,... 

Ferguson JJ, Antman EM, Bates ER, etal. Combining enoxaparin and glycoprotein llb/llla antagonists for the treatment of acute coronary syndromes final results of the National Investigators Collaborating on Enoxaparin-3 (NICE-3) study. Am Heart J 2003 146 628-634. 

GUSTO II b Investigators. A comparison of recombinant hirudin with heparin for the treatment of acute coronary syndromes. N Engl J Med 1996 335 775-782. 

Cuisset T Frere C, Quilici J, et al, High post-treatment platelet reactivity identified low-responders to dual antiplatelet therapy at increased risk of recurrent cardiovascular events after stenting for acute coronary syndrome, J Thromb Haemost 2006 4 542-549. 

Abbreviations ACS. acute coronary syndrome AECG. ambulatory electrocardiogram FLORIDA, fluvastatin on risk diminishment after acute myocardial infarction Ml. myocardial infarction MIRACL, myocardial ischemia reduction with aggressive cholesterol lowering nfMI. nonfatal myocardial infarction PACT, pravastatin in acute coronary treatment PROVE-IT TIMI 22. pravastatin or atoivastatin evaluation and infection therapy—thrombolysis in myocardial infarction 22 UAP, unstable anginapectoris. 

Okazaki S, Yakoyama T, Miyauchi K, et al. Early statin treatment in patients with acute coronary syndrome demonstration of the beneficial effect on atherosclerotic lesions by serial volumetric intravascular ultrasound analysis during half a year after coronary event the ESTABLISH Study, Circulation 2004 I 10 1061-1068. 

In the CURE study, 12,562 patients with acute coronary syndromes without ST-segment elevation have received ASA and clopidogrel 300 mg bolus, followed by 75 mg daily, versus ASA and placebo (50). The clopidogrel group had early reduction [within 24 hours of treatment—9.3% vs. I 1.4%, RR reduction 20% (p < 0.001) in the primary endpoint death from cardiovascular cause, nonfatal Ml, or stroke], which was sustained at one year, and was observed in all patients with acute coronary syndromes regardless of their level of risk. CURE patients who underwent PCI and were randomized to clopidogrel had a 31% RR reduction in death and Ml compared with placebo-treated PCI patients (51). 

There are several new factor Xa inhibitors currently under development. One is apixaban 40 (BMS-562247), which is in Phase III clinical trials and, if approved, will be marketed by joint venture of Bristol-Myers Squibb and Pfizer for prevention of venous thromboembolism. The other factor Xa inhibitor being developed is otamixaban 41, which is being investigated by Sanofi-Aventis in Phase II clinical trials (at the time of writing) as a treatment for acute coronary syndrome. 

Honderick T, Williams D, Seaberg D, Wears R. A prospective, randomized, controlled trial of benzodiazepines and nitroglycerine or nitroglycerine alone in the treatment of cocaine-associated acute coronary syndromes. Am J Emerg Med 2003 21 39 12. 

Baumann BM, Perrone J, Hornig SE, Shofer FS, Hollander JE. Randomized, double-blind, placebo-con-trolled trial of diazepam, nitroglycerine, or both for treatment of patients with potential cocaine-associated acute coronary syndromes. Acad Emerg Med 2000 7 878-86. 

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