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


Can We Do Better? Strategies for Acute Coronary Syndrome with Percutaneous Coronary Intervention


GOAL
To provide primary care physicians with up-to-date information on the treatment and management of patients with acute coronary syndrome.

TARGET AUDIENCE
This activity is designed for primary care physicians involved in treating patients with acute coronary syndrome. No prerequisites required.

LEARNING OBJECTIVES
At the conclusion of this activity, the participant should be able to:

  • Discuss current antiplatelet treatments for patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).
  • Differentiate antiplatelet treatment strategies and their effect on the risk of late-stent thrombosis in ACS.
  • Evaluate the clinical implications of data from recently completed trials of thienopyridines in patients with, or at risk of, ACS and currently undergoing PCI.

The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity.

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)™. 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.

After reading this monograph, participants may receive credit by completing the CME test, evaluation, and receiving a score of 70% or higher.

Release date: December 15, 2007. Expiration date: December 15, 2009.

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 Johns Hopkins University School of Medicine 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 Daiichi Sankyo, Inc. and Eli Lilly and Company.

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 provider 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

Jon R. Resar, MD
Associate Professor of Medicine
Director, Adult Cardiac Catheterization Laboratory
Director, Interventional Cardiology
The Johns Hopkins Hospital
Baltimore, Maryland
Dr Resar reports having no significant financial or advisory relationships with corporate organizations related to this activity.

PARTICIPATING FACULTY

Eric R. Bates, MD, FACC, FAHA
Professor of Internal Medicine
University of Michigan Medical Center
Cardiovascular Center
Ann Arbor, Michigan
Dr Bates reports receiving grants/research support from Eli Lilly/Daiichi Sankyo; serving as a consultant for Eli Lilly/Daiichi Sankyo and Sanofi-Aventis; and receiving honoraria from Eli Lilly and Company, Sanofi-Aventis, and Schering-Plough.

Christopher P. Cannon, MD
Associate Professor of Medicine
Harvard Medical School
Brigham and Women’s Hospital
Boston, Massachusetts
Dr Cannon reports receiving research/grants support from Accumetrics, AstraZeneca, GlaxoSmithKline, Merck & Co, Inc, Merck/Schering-Plough Partnership, Sanofi-Aventis/Bristol-Myers Squibb Partnership, and Schering-Plough.

A. Michael Lincoff, MD
Vice Chairman for Research, Department of Cardiovascular Medicine
Director, Cleveland Clinic Coordinating Center for Clinical Research (C5Research)
Professor of Medicine
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
The Cleveland Clinic Foundation
Cleveland, Ohio
Dr Lincoff reports receiving grants/research support from Pfizer Inc and Sanofi-Aventis.

Notice: All faculty have indicated that they have not referenced 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.

Can We Do Better? Strategies for ACS with Percutaneous Coronary Intervention
Jon R. Resar, MD*

Coronary heart disease (CHD) affects approximately 15 million American adults1 and is commonly encountered in daily practice. However, many patients are unaware of their underlying disease and risk for clinical events, including acute coronary syndrome (ACS), a clinical event that has the potential to result in substantial complications and early mortality. The primary care community is ultimately responsible for managing the common risk factors for CHD, including hypertension, dyslipidemia, smoking, diabetes, and overweight/obesity,2 and for educating patients on the importance of early care when symptoms consistent with ACS arise. The timing of care cannot be overemphasized and can dictate the type of intervention, either conservative or invasive, that the patient receives for ACS. Early diagnosis of ST-segment elevation myocardial infarction (STEMI) or unstable angina (UA)/non–ST-segment elevation myocardial infarction (NSTEMI) is also critical to stratify a patient’s risk and determine the most appropriate treatment.

Regardless of whether a patient is managed with a conservative strategy of medical fibrinolysis with pharmacologic agents or with an invasive strategy consisting of a percutaneous coronary intervention (PCI) procedure, supportive pharmacologic therapy is required. Medical fibrinolysis typically involves a combination of antiplatelet agents, antithrombotic therapy, as well as a glycoprotein IIb/IIIa inhibitor in high-risk patients.3 Patients undergoing PCI also require pharmacologic antiplatelet management with aspirin and a thienopyridine (usually clopidogrel) before the procedure, as well as periprocedural management with antithrombotic therapy.3,4 Periprocedural use of a glycoprotein IIb/IIIa inhibitor is also common.

Once a patient has been treated for ACS with medical fibrinolysis or PCI, long-term follow-up care and pharmacologic management is necessary to reduce the risk of future events, especially in those who underwent PCI with the placement of a stent. Primary care physicians (PCP) are often responsible for managing long-term antiplatelet therapy in patients recovering from ACS, and should follow evidence-based guidelines in administering these treatments. Aspirin therapy should continue after an ACS event, initially at a higher daily dose of 162 to 325 mg, and indefinitely at a low daily dosage of 75 to 162 mg. The guidelines recommend that thienopyridine therapy be administered for at least 1 month, and for up to 1 year, in patients recovering from ACS. Follow-up antiplatelet management is particularly critical in PCI patients who received a bare-metal or drug-eluting stent during the procedure.2-4 Referral to a cardiac rehabilitation center is also important in many patients recovering from ACS to provide counseling on regular physical activity, dietary changes, smoking cessation, and other important lifestyle modifications that reduce the residual risk of ACS.2

Despite close attention to appropriate follow-up care, physicians and patients should understand that the risk of a future ACS event continues after discharge for the initial episode. Physicians should also be aware that antiplatelet resistance is possible in some patients and may contribute to the ongoing risk of subsequent events.5-7 New pharmacologic options, including the introduction of new thienopyridine therapies and the emergence of data supporting the use of high-dose statins in patients diagnosed with ACS, may further reduce the residual risk of ACS recurrence.

In this issue of Johns Hopkins Advanced Studies in Medicine, leading cardiologists address the appropriate use of PCI or medical fibrinolytic therapy in patients presenting with ACS. After completing this educational opportunity, PCPs should have a better understanding of the therapeutic regimens that are used in conjunction with both conservative and invasive strategies in ACS, including antiplatelet options, anticoagulants, and other supportive therapies that are recommended in evidence-based guidelines.

Christopher P. Cannon, MD, presents a review of ACS and explains in detail the conservative and invasive therapeutic pathways that are available to patients presenting with STEMI or UA/NSTEMI ACS. He also provides an overview of important therapeutic issues in the treatment of ACS, including the possibility of antiplatelet resistance in some patients and the reluctance of the medical community as a whole to follow established evidence-based treatment guidelines. The review concludes with a brief discussion of continuing opportunities to improve outcomes in ACS, including the emergence of data from trials that support aggressive lipid-lowering statin therapy in ACS and new antiplatelet options that may offer an alternative to currently available therapies.

A. Michael Lincoff, MD, and Eric R. Bates, MD, FACC, FAHA, continue the discussion with a clinician interview that addresses the importance of early recognition and risk stratification in ACS. They discuss the use of specific ACS risk stratification tools and offer advice on early pharmacologic intervention and appropriate follow-up care in patients presenting with ACS in the primary care setting. Standard ACS treatment algorithms also are described, in addition to coordination patterns between PCI specialty centers and hospitals without catheterization facilities.

Each faculty member also presents a relevant case study to illustrate appropriate management strategies in patients with suspected ACS presenting with varying degrees of risk based on symptoms, diagnostic findings, and underlying comorbidities. Each case stresses the importance of supportive pharmacologic care in the management of ACS with either PCI or a conservative medical strategy.
Throughout this monograph, the faculty members stress the importance of early appropriate care in ACS. Consequently, the primary care community plays an important role in recognizing patients at risk and counseling these individuals to be alert to the early warning signs of ACS. Furthermore, through a better understanding of the role of long-term post-ACS pharmacologic management, PCPs will recognize the best strategies to reduce the risk of future events in patients who experience ACS.

REFERENCES
1.    Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics—2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.
2.    Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50:e1-e157.
3.    Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82-e292.
4.    Smith SC Jr, Feldman TE, Hirshfeld JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention). Circulation. 2006;113:e166-e286.
5.    Wiviott SD, Antman EM. Clopidogrel resistance: a new chapter in a fast-moving story. Circulation. 2004;109:3064-3067.
6.    Wiviott SD. Clopidogrel response variability, resistance, or both? Am J Cardiol. 2006;98:S18-S24.
7.    Michos ED, Ardehali R, Blumenthal RS, et al. Aspirin and clopidogrel resistance. Mayo Clin Proc. 2006;81:518-526.

*Associate Professor of Medicine, Director, Adult Cardiac Catheterization Laboratory, Director, Interventional Cardiology, The Johns Hopkins Hospital, Baltimore, Maryland.
Address correspondence to: Jon R. Resar, MD, Associate Professor of Medicine, Director, Adult Cardiac Catheterization Laboratory, Director, Interventional Cardiology, The Johns Hopkins Hospital, 524 Blalock—Cardiology, 600 North Wolfe Street, Baltimore, MD 21287. E-mail: jresar@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his 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.