Acute Coronary Syndromes – part I

Acute Myocardial Infarction (AMI) / Acute Coronary syndromes (ACS)

Epidemiology

  • Over 32,000 deaths per year in Australia: largest single cause.
  • 50% reduction age-adjusted mortality (by risk-factor modification) since 1960, still falling now, but those with chronic CAD are increasing commensurately.
  • Still 60-70% die prehospital (this proportion unchanged) – thus overall 28-day mortality has improved little, compared with reduced in-hospital mortality.
  • Emerging risk factors for ACS include C-reactive protein (reduced by statin therapy), raised homocysteine, amyloid A, interleukin-6, mercury, sleep-disordered breathing, coffee (only in slow-caffeine metabolisers!) and obesity (using waist-to-hip ratio not simply BMI).

Cornelis MC et al. Coffee, CTP1A2 genotype, and the risk of myocardial infarction. JAMA 2006;295:1135-41. [Reference]

Yusuf S, Hawken S et al. Obesity and the risk of myocardial infarction in 27,000 participants from 52 countries: a case controlled study. Lancet 2005;366:1640-9. [Reference]

Boersma E, Mercado N et al. Acute myocardial infarction. Lancet 2003; 361:847-58. (Meta-analysis of 20 047 papers Jan 1990 – Jan 2003). [Reference]

Albert CM, Ma J et al. Prospective study of C-reactive protein, homocysteine and plasma lipid levels as predictors of sudden cardiac death. Circulation 2002; 105:2595-99. [Reference]

  • Consumption of alcohol of any type 3-4 times a week is protective.

Mukamal K, Conigrave K et al. Roles of drinking pattern and type of alcohol consumed in coronary heart disease in men. NEJM 2003; 348:109-18. [Reference]

  • ‘Polypill’ suggested with aspirin 75mg, statin, half-dose thiazide +beta blocker +ACEI, folic acid 0.8mg could reduce heart attack and stroke in those over 55 years and in all with known cardiovascular disease by >80%.

Wald N, Law M. A strategy to reduce cardiovascular disease by more than 80%. BMJ 2003; 326:1419-23. [Reference] (Editorial Rodgers A: BMJ 2003; 326:1407-8) [Reference]. Benefits refuted; cost per life year gain US$ 2,600. (Mayor S. BMJ 2004;329:589.) [Reference]

  • Multivariate tool developed to predict higher- and lower-risk in ACS patients based on age, HF, PVD, SBP, Killip class, serum creatinine, cardiac enzymes, cardiac arrest, ST segment deviation.

Fox K, Dabbous O, Goldberg R et al. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006;333:1091-4. [Reference] Risk calculator available electronically from Outcomes Website. Alternatives include TIMI or PURSUIT risk scores.

  • Guidelines on secondary prevention, National Heart Foundation/Cardiac Care Soc Aus NZ.

Reducing Risk in Heart Disease 2007. A summary guide [PDF guide]

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