0521779407-C03 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:54
412 Coronary Syndromes, Acute
Conservative strategy should be mainly reserved for low-risk
UA patients (no recurrent ischemia, EF > 40, negative stress
test, no prior coronary revascularization).
Add imaging (nuclear or echo) to stress in presence of:
Baseline ST abnormality, LVH, digoxin
IVCD (LBBB, RBBB or NSIVCD)
Paced rhythm
Pre-excitation
Exercise is preferred, but use pharmacological stress with
imaging if pt cannot exercise adequately (adenosine or per-
santine nuclear; dobutamine echo)
Prompt coronary angiography for any ACS patient who fails to
stabilize
Prompt coronary angiography for ACS patients with any prior
CABG or PCI within past 6 months
➣Revascularization, CABG or PCI
CABG favored: Significant left main or multivessel disease with
proximal LAD involvement, particularly in diabetics
PCI or CABG not recommended if stenosis <50% or if dis-
ease not affecting proximal LAD and pt has not been treated
with medical therapy or has no evidence of ischemia on non-
invasive testing
BARI trial – 1829 pts with 2 or 3 vessel disease, 64% with UA, 7
year follow up. Only significant benefit for CABG over PCI was
in subgroup of diabetics who received IMA graft. Numerous
trials are ongoing to assess CABG vs multivessel PCI with DES.follow-up
■Acute phase of disease (highest risk) usually over by 2 months
■At D/C, all patients should receive nitroglycerin tabs (or spray) with
instructions
■Aspirin
■Clopidogrel
■Thorough instructions for any new or adjusted medications
■Multidisciplinary approach with (dietician, rehabilitation) can
improve compliance
■Instruct patient to call physician for change in anginal threshold,
frequency or severity
■Follow up appointment needed in 1–2 weeks, up to 6 if low risk
■Aggressive attention to modifiable traditional risk factors
➣D/C tobacco