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Acute cardiovascular care
Antithrombotic therapy in medically managed patients with non-ST-segment elevation acute coronary syndromes
  1. Paul A Gurbel,
  2. Udaya S Tantry
  1. Inova Centre for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, Virginia, USA
  1. Correspondence to Professor Paul A Gurbel, Inova Centre for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA, 22042, USA; Paul.gurbel{at}inova.org

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Learning objectives

Upon completion of this module, the reader will be able to:

  • Explain the mechanism of action and role of aspirin, clopidogrel, ticagrelor, vorapaxar, unfractionated heparin, low-molecular-weight heparins and fondaparinux in the medical management of patients with non-ST-segment elevation acute coronary syndromes.

  • Explain the side effects of aspirin, clopidogrel, ticagrelor, unfractionated heparin, low-molecular-weight heparins fondaparinux and rivaroxaban in the medical management of patients with non-ST-segment elevation acute coronary syndromes.

  • Recall the 2011 European Society of Cardiology guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.

Introduction

Non-ST-segment elevation acute coronary syndromes (NSTE-ACS) comprise unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). Among patients admitted for myocardial infarction (MI), nearly two times more were hospitalised for NSTEMI as compared with ST-segment elevation myocardial infarction (STEMI) in a recent community-based registry.1 In the French Registry of Acute Coronary Syndrome (FAST) MI registry, only 20% of patients presenting with NSTEMI were managed conservatively, and 75% of these were aged ≥75 years. Patients with NSTEMI also had significantly more cardiovascular (CV) complications than those with STEMI.2 Moreover, medically managed patients with NSTE-ACS are at increased risk for recurrent events as compared with patients who undergo revascularisation as shown in clinical trials and national registries.3–5

Current NSTE-ACS guidelines recommend an assessment of ischaemic and bleeding risk using validated risk assessment methods to decide on pharmacological and invasive management.6 Ischaemic events continue to occur over time after NSTE-ACS, possibly because patients with NSTE-ACS are older and have more comorbidities than patients with STEMI. Therefore, NSTE-ACS treatment strategies must equally address the acute phase as well as long-term management. Some of the major goals of conservative strategy (CS) in NSTE-ACS are angina relief, improvement in myocardial perfusion, prevention of thrombus propagation, stabilisation of vulnerable plaque and reduction of long-term recurrent …

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