Welcome to the Acute Coronary Syndrome Condition Center
MARCH 24, 2013
Jeannette Y. Wick, RPh, MBA, FASCP
Acute coronary syndrome patients often have complex medication regimens, which means that pharmacists play an important role in condition management and patient counseling.
Welcome to the inaugural post in Pharmacy Times’ Acute Coronary Syndrome (ACS) Condition Center. Acute coronary syndrome is an umbrella term for emergency situations in which cardiac blood supply stops suddenly, and the heart muscle receives no oxygen. Approximately 1.36 million Americans are hospitalized for ACS each year; 60% have a myocardial infarction (MI), and the rest suffer from unstable angina—an indicator that things are not right or about to go terribly wrong. ACS is the leading cause of death in the United States and among the most prevalent non-communicable diseases in the world.
ACS refers to any group of symptoms attributed to obstruction of the coronary arteries. Obstruction usually results from coronary arthrosclerosis or thrombosis that decreases cardiac blood flow. ACS’s most common symptom—the 1 that alarms patients and sends them or a loved one directly to the phone to dial 911—is chest pain. The pain typically radiates to the left arm, jaw, back, or stomach. The sweating (and often nauseated and breathless) patient describes the pain as crushing or pressure-like in character. ACS pain occurs abruptly, often at rest or with minimal exertion. This pain is unlike stable angina, which comes on with exertion and resolves at rest. In patients who have stable angina, an ACS event causes crescendo angina, which occurs at unexpectedly low levels of exertion. ACS also presents in atypical patterns, especially in women and patients who have diabetes.
Once the ACS patient arrives at a health care facility, clinicians generally use the most reliable predictive tool: an electrocardiogram (ECG). ACS is usually associated with one of 3 changes detectable with an ECG: ST-elevation myocardial infarction (STEMI, accounting for about 30% of cases), non-ST-elevation myocardial infarction (NSTEMI, 25%), or unstable angina (UA, 38%). (New-onset angina is considered UA, since it suggests a new problem in a coronary artery.) UA and NSTEMI have similar pathophysiologic origins and clinical presentations, but NSTEMI is more severe. (Myocardial damage has already occurred, and myocardial biomarkers will be seen in the bloodstream within hours).
Assessment is usually quick but thorough, and directed at risk stratification that will be used to guide treatment. Emergency personnel scramble to take chest X-rays, send blood to the lab, and order cardiac telemetry. Once they determine the type of ACS the patient has, they can create a care plan with 3 goals: stabilizing the patient, relieving ischemic pain, and starting antithrombotic therapy.
Researchers and cardiac interest associations have created evidence-based guidelines for ACS management. Clinicians usually treat high-risk patients with UA or NSTEMI quickly with cardiac catheterization and revascularization of viable myocardium. Research has proven that outcomes are best if revascularization is followed with aggressive cardioprotective medications to improve quality of life and increase survival. Patients with any form of ACS leave the hospital and head to the pharmacy with fistfuls of prescriptions. Every ACS patient will need nitrites for symptomatic relief as well as beta-blockers, unless they are contraindicated. In addition, patients may need anti-ischemic, antiplatelet, anticoagulant, antihypertensives, and lipid-lowering drugs. Clearly, pharmacists play an important role in ACS management and patient counseling.
The way we manage ACS today is far different from how we managed it just a few decades ago. Our diagnostic tools are better, as are our invasive strategies and drug options. Treatment strategies are developing and changing at dizzying speeds, and researchers have large-scale randomized controlled trials underway around the world to find better ways to save patients’ lives. The goal of this Acute Coronary Syndrome Condition Center is to keep pharmacists informed about drugs and therapeutic strategies that deliver best outcomes.
Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.