Acute Coronary Syndromes PDF

Preface

This book was the first of its kind and the first to be called Acute Coronary Syndromes when it was published in 1998. Since the first edition of this book was published, our understanding of the biologic basis of acute coronary syndromes has been greatly enhanced. While the process of arterial inflammation was acknowledged as important at that time, recent work has provided considerable insight on the specific genes and proteins that drive atherosclerotic plaque disruption. Beyond the biologic basis of the clinical syndrome, there continues to be intensive, rigorous clinical investigation in the field to provide the evidence for improving care. One of the most significant developments since the last edition was published has been the full validation of the use of early coronary revascularization as the preferred strategy to manage patients with acute coronary syndromes.

While progress is being made, there are sobering aspects of the campaign to prevent and improve management of acute coronary syndromes. While the population is graying at an accelerated rate, the incidence of the disease is compounded by the ‘‘diabesity'' epidemic. Nearly 70% of Americans are obese or overweight, and now evidence has mounted that this profound public health epidemic has reached global proportions. Furthermore, the population is at the nadir of physical activity, which not only contributes to the obesity problem but independently adds risk of developing acute coronary syndromes. Accordingly, the incidence and prevalence of this condition is on the rise despite our better biologic understanding and improvements in therapy.

In this third edition, seven new chapters have been added to fulfill the objective of providing the most comprehensive and up-to-date panoramic view of the field. Now that specific genes have been identified, a chapter dedicated to the genomics of acute myocardial infarction is incorporated. One of the most important advances in recent years has been the use of protein biomarker measurements, such as the impressive body of data for brain natiuretic peptide and its pro-peptide. A chapter that hones in on this is included in the new edition and emphasis is placed throughout the book on the other useful biomarkers that include Troponin, C-reactive protein, and myeloperoxidase. A sweep across the data for the new arterial inflammatory markers is the subject of a new, dedicated chapter.

Now that we have seen validation for early percutaneous coronary intervention, the need for specialized centers of excellence, akin to trauma centers, has been raised. A new chapter that presents the case for these regional centers of excellence is an important component of this edition. At the time of coronary revascularization, there is a significant limitation of providing normal coronary blood flow. This is typically due to arterial inflammation and embolization of microparticulate atheromatous debris or thrombus, and the microcirculation or ‘‘watershed zone'' is the problematic zone. A chapter that features concerns about improving microcirculatory perfusion in the coronary bed is a new dimension of the book. The other major trend in recent years that deserves highlighting is the appreciation that diabetes, and the metabolic syndrome, is a cardiovascular entity. Patients with diabetes or the metabolic syndrome have excessive risk of developing acute coronary syndromes, and particular high adverse outcomes once this condition arises. Thus, it is pivotal for the practitioner to recognize the importance of diabetes, and a new chapter delves into this pressing issue.

A particularly frustrating aspect of acute myocardial infarction management is that considerable damage to the myocardium has already occurred at the time of the patient's initial presentation. The topic of cardiogenic shock and Killip Class III, which carry a dreadful diagnosis, is now fully covered in a new chapter, as well as the most exciting new therapy, which has a chance to regenerate myocardium and involves the use of pluripotent stem cells. A chapter has been added to feature the biology of and review the initial data on stem cell therapy for acute myocardial infarction.

Many of the leading investigators of the field have contributed to this project and I remain deeply indebted for their willingness to cull their insights and expertise into this new edition. In the 32 chapters, 45 authors from around the world have come together to refine the only dedicated book that exists in this field. As the Editor, I am deeply thankful to all of the authors for their timely submission of high quality manuscripts that assured the fine makeup of this monograph, and to all of the production team at Marcel Dekker for their supportive effort. In particular, I would like to acknowledge the Managing Editor, Ms. Donna Wasiewicz-Bressan at the Cleveland Clinic Foundation. We hope that this book will serve as a useful resource for all clinicians, including cardiologists, internists, nurses, and paraprofessional staff, who are engaged in caring for patients with acute coronary syndromes. If the book promotes better understanding and care of these patients, we have again achieved our primary objective.