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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Focus On The Management Of Acute Coronary Syndrome: What's Now And What's To Come


GOAL
To provide interventional cardiologists and cardiologists with up-to-date information on the treatment and management of patients with acute coronary syndrome (ACS).

TARGET AUDIENCE
This activity is designed for interventional cardiologists and cardiologists involved in the management of ACS. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, the participant should be able to:

  • Promote quality improvement in the care of patients with ACS among various healthcare disciplines.
  • Discuss diagnosis and acute care protocols in the hospital setting.
  • Apply knowledge based on recent clinical studies to improve patient outcome following percutaneous coronary intervention.
  • Identify current and future treatment strategies for ACS.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 2 hours.
Release date: June 15, 2006.
Expiration date: June 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from GlaxoSmithKline.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the
disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

Roger S. Blumenthal, MD
Associate Professor
Department of Medicine
Division of Cardiology
Johns Hopkins University School of Medicine
The Johns Hopkins Ciccarone Preventive Cardiology Center
Baltimore, Maryland
Dr Blumenthal reports receiving grants/research support from Kos Pharmaceuticals Inc, Merck & Co., Inc, Novartis Pharmaceuticals Corporation, Pfizer, Inc, and Schering-Plough; and receiving honoraria from Merck & Co., Inc, and Pfizer, Inc.

PARTICIPATING FACULTY

Hossein Ardehali, MD, PhD
Assistant Professor of Medicine
Molecular Pharmacology and Biological  Chemistry
Feinberg Cardiovascular Institute
Northwestern University Medical Center
Chicago, Illinois
Dr Ardehali reports having no financial or advisory relationships with corporate organizations related to this activity.

M. Dominique Ashen, PhD, CRNP
Program Coordinator
Department of Medicine
Division of Cardiology
Johns Hopkins University School of  Medicine
Nurse Practitioner
Johns Hopkins Ciccarone Preventive Cardiology Center
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Ashen reports having no financial or advisory relationships with corporate organizations related to this activity.

Gary Gerstenblith, MD
Professor
Department of Medicine
Division of Cardiology
Johns Hopkins University School of Medicine
Cardiology
The Johns Hopkins Hospital
East Baltimore Campus
Baltimore, Maryland
Dr Gerstenblith reports having no financial or advisory relationships with corporate organizations related to this activity.

Kurt C. Kleinschmidt, MD, FACEP
Associate Medical Director, Emergency Department
Parkland Memorial Hospital
Associate Professor of Surgery
Division of Emergency Medicine
University of Texas Southwestern Medical Center
Dallas, Texas
Dr Kleinschmidt reports receiving honoraria from Sanofi-Aventis and The Medicines Company.

Edith A. Nutescu, PharmD
Clinical Associate Professor
Director, Antithrombosis Center
College of Pharmacy
The University of Illinois at Chicago
Chicago, Illinois
Dr Nutescu reports having no financial or advisory relationships with corporate organizations related to this activity.

Notice: The audience is advised that the articles in this CME activity contain no reference(s) to unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Focus On The Management Of Acute Coronary Syndrome: Whatõs Now And What's To Come
Roger S. Blumenthal, MD

Heart disease is the number 1 cause of death in the United States.1 Many patients with coronary atherosclerosis will eventually present to the hospital with an acute coronary syndrome (ACS). Patients with ACS are at significant risk of death and subsequent cardiovascular (CV) events. However, immediate assessment of clinical risk upon presentation followed by appropriate treatment reduces the risk of a poor outcome.

The prevalence of risk factors for cardiovascular disease (CVD) is high in developed and developing countries. This high prevalence of risk factors for heart disease ensures that many patients will eventually develop an ACS. In the United States, the prevalence of risk factors is influenced by cultural differences, among many other factors, and is inversely proportional to economic and education levels. Therefore, many patients who are at the greatest risk for CV events are also those who face the greatest barriers to appropriate care.

ACS represents a range of clinical presentations, all of which are life-threatening consequences of coronary artery disease. Upon presentation, patients with symptoms of ACS are stratified by the results of an initial

12-lead electrocardiogram (ECG) as having ST-segment elevation myocardial infarction or nonÐST-segment elevation myocardial infarction (NSTEMI). Unstable angina (UA) is a condition that is closely related to NSTEMI and may show similar results on the initial ECG. UA is the relatively high-risk middle ground between stable angina and myocardial infarction, both of which qualify as an ACS.2

The treatment goals for patients with NSTEMI/UA are the relief of ischemia and prevention of subsequent CV events. Evidence-based treatment strategies for these patients include: pharmacologic interventions, such as anti-ischemic agents, antiplatelet agents, and antithrombotic agents; and invasive interventions, such as percutaneous coronary intervention and coronary artery bypass graft (CABG) surgery. Invasive interventions are generally reserved for patients who are at high risk or for those who do not respond to pharmacologic intervention. Low-risk patients may benefit from assessments that determine their need for angiography or revascularization. Patient preference for treatment approach will likely affect the choice of intervention in this group.2

In this issue of Johns Hopkins Advanced Studies in Medicine, Kurt C. Kleinschmidt, MD, FACEP, explains the epidemiology and pathophysiology of ACS. He discusses the current prevalence estimates of heart disease among Americans, in addition to the impact of heart disease on healthcare costs, morbidity, and mortality rates. Dr Kleinschmidt also reviews the current estimates for the prevalence of CVD risk factors among Americans and the impact these factors may have on the future incidence of ACS. Because inflammation is implicated in all stages of heart disease, Dr Kleinschmidt discusses the proposed role of inflammation in atherosclerotic plaque formation, plaque progression, and thrombus formation. In addition, he reviews the studies that have assessed the use of guideline-recommended therapies in patients with ACS.

In her article, Edith A. Nutescu, PharmD, discusses the necessary assessments for diagnosing ACS and determining patient risk level. Her review of clinical evaluation strategies covers American College of Cardiology/American Heart Association (ACC/AHA) defined characteristics for patients at high, moderate, or low risk for death or CV events upon presentation, including diagnostic ECG morphology and diagnostic serum cardiac markers. Dr Nutescu also explains the TIMI risk score and ACC/AHA recommended assessments for early risk stratification. Lastly, she discusses immediate patient management strategies for patients at various levels of risk.

M. Dominique Ashen, PhD, CRNP, identifies current and emerging treatment strategies for patients with ACS in her article. She reviews ACC/AHA guideline-recommended pharmacologic interventions and invasive interventions, including anti-ischemic agents, antiplatelet agents, anticoagulants, percutaneous coronary intervention, and CABG surgery. In her discussion of emerging treatment strategies, she explains the clinical implications of recent studies in patients with ACS. Dr Ashen also reviews the results of pharmacologic interventions in primary prevention and secondary prevention, in addition to pharmacologic treatments in conjunction with invasive intervention. Dr Ashen summarizes her discussion of emerging treatment strategies by analyzing the potential clinical impact of recent trial results.

Also included in this monograph is a clinician interview with Hossein Ardehali, MD, PhD, which provides insight into ACC/AHA guidelines. Dr Ardehali explains the guidelines for timing of angiography, the implications of data from the REPAIR-AMI clinical trial, utility of serum markers of myocardial damage, the impact of lipid profiles on progression of CVD, and the role of imaging techniques in patients with ACS. He also assesses the use of pharmacologic agents, such as antiplatelet therapy, angiotensin-converting enzyme inhibitors, clopidogrel, and low-molecular-weight heparins.

A case study provided by Dr Ardehali reviews the clinical presentation and treatment course for a 66-year-old male patient with no prior history of symptomatic CV disease. The patient had a number of risk factors including hypertension, hyperlipidemia, family history, and smoking. He presented to the hospital with recurrent episodes of pain and shortness of breath, which had been increasing in duration and intensity. This case history illustrates the impact of a congregation of CV risk factors on the emergence of ACS and highlights the need to aggressively manage these risks to prevent major complications from ACS.

A second case study provided by Gary Gerstenblith, MD, reviews the clinical presentation and treatment course for a 62-year-old male patient with a history of angina who presented to the hospital with severe pain at rest associated with dyspnea. The patient had multiple risk factors, prior and repeat CABG, and was taking multiple medications for his conditions. This case demonstrates that new or changed ischemic chest pain can signal a manifestation of ACS.

This issue of Johns Hopkins Advanced Studies in Medicine will emphasize the importance of early detection and early treatment strategies for those at risk for ACS. By providing education about appropriate recognition, risk stratification, and prompt acute treatment intervention, it is hoped that there will be improved clinical survival and long-term functional benefits for patients with ACS.

REFERENCES

1. Thom T, Haase N, Rosamond W, et al. Heart disease and stroke statistics — 2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics
 Subcommittee. Circulation. 2006;113(6):85-151.
2. Braunwald E, Antman E, Beasley J, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Available at: http://www.acc.org/clinical/ guidelines/unstable/unstable.pdf. Accessed March 25, 2006.

*Associate Professor, Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, The Johns Hopkins Ciccarone Preventive Cardiology Center, Baltimore, Maryland.
Address correspondence to: Roger S. Blumenthal, MD, Associate Professor, Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, The Johns Hopkins Ciccarone Preventive Cardiology Center, Blalock 524C, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: rblument@jhmi.edu.

The content in this monograph was developed with the
assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.