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(Circulation. 1999;100:1586-1589.)
© 1999 American Heart Association, Inc.

Editorial

Pursuing Progress in Acute Coronary Syndromes

Paul W. Armstrong, MD

From the Department of Medicine, University of Alberta, Edmonton, Canada.

Correspondence to Paul W. Armstrong, MD, Department of Medicine, University of Alberta, Edmonton, Alberta, T6G 2H7, Canada. (Circulation. 1999;100:1586-1589.)

Key Words: Editorials • anticoagulation • heparin • unstable angina • acute coronary syndromes

 
"The difficulty in life is the choice."

George Moore

The sheer scope of the burden of acute ischemic heart disease, initially evident in Western civilization but now increasingly a global problem, places a high priority on understanding its pathophysiology and identifying individuals at increased risk of morbid and mortal events. So too is there strong impetus for the timely development and introduction of cost-effective therapeutic solutions coupled with concurrent strategies for both primary and secondary prevention.

Patients presenting with ischemic chest pain and transient electrocardiographic abnormalities as part of an acute coronary syndrome have an unfavourable prognosis.¹ Their risk is augmented if there are abnormalities in cardiac markers or enzymes and if older age, diabetes, prior myocardial infarction, left ventricular dysfunction, or other unfavourable baseline characteristics are present. Recurrent ischemia, whether clinically evident or silent, further increases the probability of mortality and subsequent myocardial damage.^{1 2} A bewildering array of therapeutic options has emerged to combat this common and important problem. Accompanying these diverse options over the past 5 years has been an explosion in our knowledge of the pathophysiology of acute coronary syndromes.³ Plaque fissuring promoted by inflammation and possibly infection, as well as a coronary thrombotic process mediated through the coagulation cascade and activated platelets, all of which unfold on a unique genetic template, make it unlikely that a single pharmacological agent will achieve the results we desire for our patients (Figure).

View larger version (56K): [in this window] [in a new window]   Figure 1. Acute coronary syndromes: future therapeutic opportunities.

Low Molecular Weight Heparins
The venerability of our traditional therapy with . . . [Full Text of this Article]