Managing acute coronary syndrome: evidence-based approaches.

Area of Science:

• Cardiology
• Clinical Quality Improvement
• Pharmacotherapy

Background:

• Current American College of Cardiology/American Heart Association (ACC/AHA) guidelines for acute coronary syndrome (ACS) management require ongoing evaluation.
• National quality improvement initiatives and clinical trials provide crucial data to refine ACS treatment protocols.

Observation:

• The CRUSADE registry indicates suboptimal use of glycoprotein (GP) IIb/IIIa inhibitors and clopidogrel in non-ST-segment elevation ACS, with opportunities for improved angiotensin-converting-enzyme (ACE) inhibitor prescribing at discharge.
• The ACUITY study explored bivalirudin's efficacy and safety, alone or with GP IIb/IIIa inhibitors, in high-risk non-ST-segment elevation ACS patients undergoing intervention.
• Recent studies demonstrate clopidogrel's benefit in ST-segment elevation myocardial infarction (MI), including its use with fibrinolytic therapy.

Findings:

• Adherence to ACC/AHA guidelines for non-ST-segment elevation ACS is improving but requires further enhancement.
• Inappropriate GP IIb/IIIa inhibitor dosing in renal insufficiency increases bleeding risk, particularly in vulnerable populations.
• Bivalirudin offers a potential alternative to standard therapy in non-ST-segment elevation ACS, with bivalirudin alone showing a lower bleeding risk, though methodologic concerns warrant further investigation.
• Clopidogrel provides significant early and late benefits in ST-segment elevation MI, reducing mortality and morbidity without increasing bleeding risk when used with fibrinolysis.

Implications:

• Optimizing the use of GP IIb/IIIa inhibitors, clopidogrel, and ACE inhibitors is crucial for improving non-ST-segment elevation ACS outcomes.
• Further research and careful interpretation of ACUITY results are needed to define bivalirudin's role in ACS management.
• Pharmacists and clinicians must integrate the latest evidence on clopidogrel and other therapies into clinical practice to align with evolving ACS guidelines and improve patient outcomes.