This document discusses the management of coronary artery disease and acute coronary syndromes. It begins by describing atherosclerotic plaque buildup and rupture which can lead to acute coronary syndromes like unstable angina and myocardial infarction. It then outlines guidelines for treating ST-elevation myocardial infarction with therapies like thrombolysis and primary percutaneous coronary intervention. For unstable angina and non-ST-elevation myocardial infarction, the document recommends antiplatelet and anticoagulant therapies as well as looking for high-risk features with the TIMI risk score to determine whether early invasive treatment is needed. The TIMI risk score is shown to predict short-term mortality for both ST-elevation and non-ST-elevation acute coronary syndromes

1. Management of Coronary
Artery Disease:
Saravanan Kuppuswamy MD
Division of Cardiology
Department of Internal Medicine
University of Missouri Hospital

3. Atherosclerotic Plaque

4. ACS=acute coronary syndrome.
UA=unstable angina.
Bhatt DL. J Invasive Cardiol. 2003;15:3B-9B.
Acute Plaque Rupture
(UA/NSTEMI/STEMI)
Presence of Multiple
Coronary Plaques
Persistent Hyperreactive
Platelets
Vascular
Inflammation
Clinical
Subclinical
ACS: The Tip of the
Atherothrombotic “Iceberg”
NSTEMI=non-ST-segment elevation myocardial infarction.
STEMI=ST-segment elevation myocardial infarction.

6. STRIVETM

7. STEMI
Clinical finding
EKG
Serum markers
Risk assessment
Non-cardiac
chest pain
Stable
angina
UA NSTEMI
Negative Positive
ST-T wave
changes
ST
elevation
Low
probability
Medium-high
risk
Thrombolysis
Primary PCI
Aspirin + GP IIb/IIIa inhibitor
clopidogrel + heparin/
LMWH + anti-ischemic Rx
Early invasive Rx
Discharge
Negative
Diagnostic
rule out MI/ACS
pathway
STEMI
Negative
Atypical
pain
Low
risk
Aspirin, heparin/low-molecular-
weight heparin (LMWH) +
clopidogrel
Anti-ischemic Rx
Early conservative therapy
Ongoing
pain
DM=diabetes mellitus.
Cannon, Braunwald. Heart Disease. 2001.
Rest pain, Post-MI,
DM, Prior Aspirin
Exertional
pain
The Spectrum of ACS

8. Acute Coronary Syndromes:
Management of STEMI

12. Acute Coronary Syndromes:
Management of UA/NSTEMI

13. RR:
Death/MI
ASA Alone
68/655=10.4%
Heparin + ASA
55/698=7.9%
B
B
B
B
B
B
B
0.1 1 10
Summary Relative Risk
0.67 (0.44-0.1.02)
Theroux
RISC
Cohen 1990
ATACS
Holdright
Gurfinkel
Comparison of Heparin + ASA vs ASA Alone
ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic
Therapy in Acute Company Syndromes; RR, relative risk; MI, myocardial infarction.
Oler A, et al. JAMA. 1996;276:811-815. (with permission)

15. TIMI, thrombosis in myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation
myocardial infarction; CAD, coronary artery disease.
Antman EM, et al. JAMA. 2000;284:835-842.
TIMI Risk Score for UA/NSTEMI:
7 Independent Predictors
– Aged ≥65 years
– ≥3 CAD risk factors
– Prior CAD (stenosis >50%)
– Aspirin in last 7 days
– >2 anginal events in
≤24 hours
– ST deviation
– Elevated cardiac markers
(CK-MB or troponin)

16. TIMI risk score predicts 30 day mortality after a myocardial infarction
The TIMI risk score has a continuous association with 30-day mortality in patients with an ST elevation
(STE) myocardial infarction who are eligible for fibrinolytic therapy.
Morrow, DA, Antman, EM, Charlesworth, A, et al Circulation 2000; 102:2031.

17. TIMI risk score predicts 14 day outcome for NSTEMI and UA
The TIMI risk score has a continuous association with 14-day mortality, recurrent MI and target vessel
revascularization in patients with an NSTEMI and unstable angina (UA)
Antman, EM, Cohen, et al, JAMA 2000; 284:835.