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With >1.5 million hospitalizations for acute coronary syndrome (ACS) each year in the United States, the management of patients with suspected ACS is a very common clinical challenge with a correspondingly substantial impact on public health and health care resources. The expanding number of effective antithrombotic agents available to the clinician has increased the number of alternatives that may be used in the care of these patients and at the same time has increased the complexity of decision making. Also, new insights into the association of bleeding with major cardiovascular complications have underscored the importance of weighing the potential reduction in recurrent ischemic complications with possible increases in the risk of bleeding events. Therefore, the appropriate selection of antithrombotic therapy no longer can be based on a “one-size-fitsall” approach. Rather, present guidelines place increased emphasis on individualizing therapy based on a concurrent assessment of the patient’s risk of cardiovascular death and recurrent ischemic events as well as the risk of important bleeding.
In this issue of Thrombosis Clinic, these issues are reviewed in detail, bringing in the most recent data from clinical trials and integrating updates to professional guidelines. Cedric W. Lefebvre, MD, and James Hoekstra, MD, provide a practical guide to the use of risk stratification in the emergency department linked to guidelinesbased recommendations for the management of non–ST-segment elevation ACS. Pallav Garg, MBBS, MSc, FRACP, and Deepak L. Bhatt, MD, MPH, FACC, FAHA, FSCAI, FESC, review data from recent clinical trials with a focus on challenging subgroups of patients, including elderly patients, those with renal dysfunction, and patients with diabetes mellitus. In addition, Sarah A. Spinler, PharmD, FCCP, BCPS (AQ Cardiology), discusses the association of bleeding with adverse outcomes in patients with ACS and approaches to reducing the risk of bleeding. Together, these articles provide a state-of-theart update on the key data and professional guidelines that can direct the selection and tailoring of therapy for patients presenting with ACS. |