Treatment

Acute treatment

The acute (initial) treatment of ACS includes a combination of anti-ischaemic and antithrombotic agents, with coronary reperfusion (blood flow restoration) achieved using fibrinolysis and/or revascularization (PCI or CABG).1-3

During an ACS event, platelets become activated and thrombin is generated, leading to potentially life threatening coronary artery occlusion (blockage).^4,5 Antiplatelet and anticoagulant agents are routinely used during the acute phase of ACS treatment, for example:1-3

• Antiplatelets – ASA, P2Y₁₂ inhibitors (e.g. clopidogrel, ticagrelor, prasugrel)
• Anticoagulants – UFH, LMWH, bivalirudin, fondaparinux

The risk of recurrent events after initial ACS

Before the introduction of routine antiplatelet therapy, recurrence rates and mortality in patients with ACS were high. However, improvements in patient management (such as earlier initiation of therapy, increased use of PCI) and the routine use of antiplatelet therapy, together with a greater understanding of lifestyle factors that contribute to the pathogenesis of CAD, have resulted in considerable reductions in recurrence rates and mortality. From 1961 to 2009 there was an approximately 50% reduction in the number of deaths from CAD, with even greater benefits seen in elderly patients.

Coronary heart disease events are significantly more likely to be fatal in patients with a history of MI than in those without, with a 2.5-fold increase reported in an observational study.6 Furthermore, the rate of sudden death in patients who have experienced an MI is 4–6 times higher than in the general population.7

Assessing recurrence risk

Risk stratification schemes can be used to translate patient characteristics into the probability of experiencing a recurrent ACS event. The Global Registry of Acute Coronary Events (GRACE) risk score is a tool for assessing the mid-term risk of mortality after an ACS event. The GRACE risk score is based on data from the global GRACE registry and is used to predict mortality from hospital discharge to 6 months after an ACS event.8 Another tool based on data from the GRACE registry is used upon admission to estimate the risk of in-hospital mortality.9

Factors included in the GRACE score for prediction of mortality from hospital discharge to 6 months are:8

• Older age
• History of MI
• History of heart failure
• Increased pulse rate at presentation
• Lower systolic blood pressure at presentation
• Elevated initial serum creatinine level
• Elevated initial serum cardiac biomarker levels
• ST-segment depression on presenting ECG
• No PCI performed

Link to online GRACE score calculator:

Next section: Secondary Prevention of ACS