Treatment Options And Post Discharge Care In ACS

Dr Rajesh Pandey

Acute Coronary Syndrome

Acute Coronary Syndrome (ACS) is an operational term used to refer to any constellation of clinical symptoms that are compatible with acute myocardial ischemia, including acute myocardial infarction (ST-segment elevation and depression, Q-wave and non Q-wave) and unstable angina. Because of increasing awareness about coronary artery disease, more patients with symptoms are reporting to hospitals and coronary admissions are increasing day by day.

Pathophysiology Of ACS

NSTEMI and UA may be caused by a variety of mechanisms, the most common of which is rupture of an unstable plaque. Plaque rupture activates both the platelet and coagulation cascades, causing clot formation. These clots may then result in a partial or complete blockage of the coronary artery and prevent the delivery of oxygenated blood to the heart. Recent advances in pharmacotherapy and in-hospital procedures have significantly prolonged survival and increased the chances of recovery to an active lifestyle. These treatments must be tailored according to patient risk to derive optimal benefit and avoid unnecessary risk.

Treatment of ACS

The goals of long-term therapy for patients with an ACS include preventing recurrent cardiovascular events (outcome benefit) and improving quality of life through symptom reduction (symptom benefit). These goals are achieved using pharmacologic therapy as well as interventional procedures, when indicated. Pharmacologic management of an ACS focuses on maintaining patency of coronary arteries, plaque stabilisation, increasing myocardial oxygen supply and reducing myocardial oxygen demand.

The level of patient risk, as determined at the patient’s acute presentation, will determine aggressiveness of therapy. Management of symptoms and prevention of complications necessitates a combination of medications, which are listed in the table below. Some of these medications may require titration to a target dose.

Revascularisation strategies include percutaneous coronary interventions (PCI) or coronary artery bypass grafting (CABG), both of which are used to stabilize patients with an ACS. In the case of PCI with coronary stent implantation, adjunctive therapy with a combination of antiplatelet agents (ie ASA and clopidogrel) is effective in reducing the risk of post-procedure thrombosis and long-term complications.

Drug	Outcome benefit	Symptom benefit
ASA (Aspirin®)
Clopidogrel
Angiotensin-converting enzyme inhibitor
Lipid-lowering agent (statins, fibrates, niacin)
Beta-blocker
Calcium channel blocker
Nitroglycerin

Combination Antiplatelet Therapy

Recent data have demonstrated the benefit of combining a second antiplatelet agent (like clopidogrel) with ASA for improved survival and reduction of risk of a repeat cardiac event. Monitoring of the signs and symptoms of bleeding is required in patients receiving combination antiplatelet therapy.

While continued combination antiplatelet therapy for a patient who is to undergo surgery poses an increased risk of bleeding, the risk of a recurrence of ACS without therapy must be determined. If it is decided to discontinue antiplatelet therapy, stop clopidogrel five to seven days prior to surgery to allow for the reversal of the antiplatelet effect. ASA may or may not be continued up until the time of surgery.

The number of patients being discharged from the hospital with ACS is increasing, approximately 9.3 million every year in the United States. Therefore, post discharge advice has become an important component, which helps in reducing subsequent risk significantly.

The writer is Head, Critical Care, Fortis Hospital, Noida