Nastaran Ostad, BScPharm, PharmD Candidate, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON.
Glen J. Pearson, BSc, BScPharm, PharmD, FCSHP, Associate Professor of Medicine, Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB.

Dual antiplatelet therapy (DAT) with acetylsalicylic acid and a thienopyridine agent (clopidogrel) as secondary prevention for patients with atherosclerotic coronary artery disease has been proven effective in those with unstable angina or acute coronary syndromes and following a percutaneous coronary intervention. At present, detailed guidelines provide specific guidance to clinicians regarding which patients to treat, the specific safe and effective combination regimen to use, and the appropriate duration of DAT. This evidence applies to the prevention of cardiovascular events in older adults; however, special considerations should be undertaken when using DAT in older adults due to their overall increased propensity for bleeding complications and potential concomitant medication use for comorbid conditions. This article provides an overview of the evidence for DAT, with a focus on treating older adults.
Key words: cardiovascular protection, clopidogrel, acetylsalicylic acid, acute coronary syndromes, coronary stenting.

Anna J.M. van de Sande, BSc, Medical Student, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Visiting Medical Student, Canadian VIGOUR Center, University of Alberta, Edmonton, AB.
Paul W. Armstrong, MD, Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.
Padma Kaul, PhD, Assistant Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.

The burden of cardiovascular disease increases significantly with age. One of the most complex decisions facing clinicians is whether or not to perform coronary revascularization in an older patient. Our review of recent evidence on revascularization therapies for aging patients with non-ST-elevation acute coronary syndromes found an inverse relationship between age and the use of evidence-based medications as well as revascularization procedures. Older patients undergoing revascularization had a higher likelihood of adverse outcomes compared with younger patients undergoing revascularization. However, older patients who underwent revascularization had significantly better outcomes than their counterparts who did not undergo revascularization, suggesting that they deserve the same consideration as younger patients in the use of coronary interventions.
Key words: acute coronary syndromes, percutaneous coronary intervention, coronary artery bypass graft surgery, evidence-based medications, outcomes.

Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY.

Patients with unstable angina pectoris/non-ST-segment elevation myocardial infarction should be treated with nitrates, beta-blockers, Aspirin plus clopidogrel and angiotensin-converting enzyme inhibitors, as well as with diet plus statins if the serum low-density lipoprotein cholesterol is = 100mg/dL. Intravenous unfractionated heparin or preferably low-molecular-weight heparin should be given to high-risk or intermediate-risk patients. A platelet glycoprotein IIb/IIIa inhibitor should be administered if percutaneous coronary intervention is planned. Eptifibatide or tirofiban should be given to patients with continuous myocardial ischemia, an elevated troponin T or I level, or other high-risk features, and in whom an invasive strategy is not planned. High-risk patients should have early invasive management.
Key words: acute coronary syndromes, unstable angina pectoris, non-ST-segment elevation myocardial infarction, percutaneous coronary intervention.

Cynthia M. Westerhout, MSc^1,2 and Eric Boersma, PhD¹
From the ¹Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands and the ²University of Alberta, Edmonton, AB.

Introduction
The chain of events leading to acute coronary syndromes (ACS), including unstable angina (UA) and non-ST-segment elevation (NSTE) or ST-segment elevation myocardial infarction (STEMI), is triggered by the disruption of an atherosclerotic plaque, which leads to the formation of a platelet-rich thrombus within a coronary artery.^1,2 The inhibition of platelet aggregation is fundamental to the treatment of these patients; however, standard antiplatelet agents such as aspirin do not completely obstruct this activity. Advances in understanding the pathophysiology of ACS have to the recognition of the activation of the glycoprotein IIb/IIIa (Gp IIb/IIIa) receptors on platelets as the final common pathway leading to platelet aggregation. With this target in mind, pharmacological treatment of ACS has been propelled into a new era with agents that completely inhibit platelet aggregation.

Diagnosis and Management of Acute Coronary Syndromes

Nariman Malik, BSc, MD
Medical Writer,
Geriatrics & Aging

Coronary heart disease (CHD) is one of the leading causes of death in individuals over the age of 65¹ and, through a variety of syndromes, is responsible for symptomatic and asymptomatic functional abnormalities. The prevalence of cardiovascular disease increases with age and is a major cause of death and disability in the elderly population.² CHD is the most prevalent cardiac illness in this population: it accounts for 85% of all deaths due to heart disease in persons over the age of 65.³ By age 70, 15% of men and 9% of women have coronary artery disease (CAD) and are at an increased risk of suffering an acute coronary syndrome (ACS).⁴ By age 80, the severity of lesions becomes nearly equal for men and women.⁴ An estimated 40% of all individuals over the age of 80 have symptomatic cardiac disease.²

Despite advances in cardiology, CHD is still the leading cause of death in older individuals, especially those aged over 75.¹ Nevertheless, there is wide variation in the severity of coronary illness and in the functional status of elderly patients.