1. Management of Coronary
Artery Disease:
Saravanan Kuppuswamy MD
Division of Cardiology
Department of Internal Medicine
University of Missouri Hospital

3. Atherosclerotic Plaque

4. ACS=acute coronary syndrome.
UA=unstable angina.
Bhatt DL. J Invasive Cardiol. 2003;15:3B-9B.
Acute Plaque Rupture
(UA/NSTEMI/STEMI)
Presence of Multiple
Coronary Plaques
Persistent Hyperreactive
Platelets
Vascular
Inflammation
Clinical
Subclinical
ACS: The Tip of the
Atherothrombotic “Iceberg”
NSTEMI=non-ST-segment elevation myocardial infarction.
STEMI=ST-segment elevation myocardial infarction.

6. STRIVETM

7. STEMI
Clinical finding
EKG
Serum markers
Risk assessment
Non-cardiac
chest pain
Stable
angina
UA NSTEMI
Negative Positive
ST-T wave
changes
ST
elevation
Low
probability
Medium-high
risk
Thrombolysis
Primary PCI
Aspirin + GP IIb/IIIa inhibitor
clopidogrel + heparin/
LMWH + anti-ischemic Rx
Early invasive Rx
Discharge
Negative
Diagnostic
rule out MI/ACS
pathway
STEMI
Negative
Atypical
pain
Low
risk
Aspirin, heparin/low-molecular-
weight heparin (LMWH) +
clopidogrel
Anti-ischemic Rx
Early conservative therapy
Ongoing
pain
DM=diabetes mellitus.
Cannon, Braunwald. Heart Disease. 2001.
Rest pain, Post-MI,
DM, Prior Aspirin
Exertional
pain
The Spectrum of ACS

8. Acute Coronary Syndromes:
Management of STEMI

12. Acute Coronary Syndromes:
Management of UA/NSTEMI

13. RR:
Death/MI
ASA Alone
68/655=10.4%
Heparin + ASA
55/698=7.9%
B
B
B
B
B
B
B
0.1 1 10
Summary Relative Risk
0.67 (0.44-0.1.02)
Theroux
RISC
Cohen 1990
ATACS
Holdright
Gurfinkel
Comparison of Heparin + ASA vs ASA Alone
ASA, acetylsalicylic acid; RISC, Research on InStability in Coronary artery disease; ATACS, Antithrombotic
Therapy in Acute Company Syndromes; RR, relative risk; MI, myocardial infarction.
Oler A, et al. JAMA. 1996;276:811-815. (with permission)

15. TIMI, thrombosis in myocardial infarction; UA, unstable angina; NSTEMI, non–ST-segment elevation
myocardial infarction; CAD, coronary artery disease.
Antman EM, et al. JAMA. 2000;284:835-842.
TIMI Risk Score for UA/NSTEMI:
7 Independent Predictors
– Aged ≥65 years
– ≥3 CAD risk factors
– Prior CAD (stenosis >50%)
– Aspirin in last 7 days
– >2 anginal events in
≤24 hours
– ST deviation
– Elevated cardiac markers
(CK-MB or troponin)

16. TIMI risk score predicts 30 day mortality after a myocardial infarction
The TIMI risk score has a continuous association with 30-day mortality in patients with an ST elevation
(STE) myocardial infarction who are eligible for fibrinolytic therapy.
Morrow, DA, Antman, EM, Charlesworth, A, et al Circulation 2000; 102:2031.

17. TIMI risk score predicts 14 day outcome for NSTEMI and UA
The TIMI risk score has a continuous association with 14-day mortality, recurrent MI and target vessel
revascularization in patients with an NSTEMI and unstable angina (UA)
Antman, EM, Cohen, et al, JAMA 2000; 284:835.