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2014 ; 114
(12
): 1944-58
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Nonantithrombotic medical options in acute coronary syndromes: old agents and new
lines on the horizon
#MMPMID24902977
Soukoulis V
; Boden WE
; Smith SC Jr
; O'Gara PT
Circ Res
2014[Jun]; 114
(12
): 1944-58
PMID24902977
show ga
Acute coronary syndromes (ACS) constitute a spectrum of clinical presentations
ranging from unstable angina and non-ST-segment elevation myocardial infarction
to ST-segment myocardial infarction. Myocardial ischemia in this context occurs
as a result of an abrupt decrease in coronary blood flow and resultant imbalance
in the myocardial oxygen supply-demand relationship. Coronary blood flow is
further compromised by other mechanisms that increase coronary vascular
resistance or reduce coronary driving pressure. The goals of treatment are to
decrease myocardial oxygen demand, increase coronary blood flow and oxygen
supply, and limit myocardial injury. Treatments are generally divided into
disease-modifying agents or interventions that improve hard clinical outcomes and
other strategies that can reduce ischemia. In addition to traditional drugs such
as ?-blockers and inhibitors of the renin-angiotensin-aldosterone system, newer
agents have expanded the number of molecular pathways targeted for treatment of
ACS. Ranolazine, trimetazidine, nicorandil, and ivabradine are medications that
have been shown to reduce myocardial ischemia through diverse mechanisms and have
been tested in limited fashion in patients with ACS. Attenuating the no-reflow
phenomenon and reducing the injury compounded by acute reperfusion after a period
of coronary occlusion are active areas of research. Additionally, interventions
aimed at ischemic pre- and postconditioning may be useful means by which to limit
myocardial infarct size. Trials are also underway to examine altered metabolic
and oxygen-related pathways in ACS. This review will discuss traditional and
newer anti-ischemic therapies for patients with ACS, exclusive of
revascularization, antithrombotic agents, and the use of high-intensity statins.
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