Acute coronary syndromes (ACS), which include unstable angina and myocardial infarction with or without ST-segment elevation, are life-threatening disorders that remain a source of high morbidity and mortality despite advances in treatment. The economic impact of ACS is also very high, costing Americans more than $150 billion, according to American Heart Association estimates. Approximately 20% of the patients are rehospitalized within 1 year, and nearly 60% of the costs related to ACS are the result of rehospitalization. However, the evidence-based therapeutic management of ACS remains suboptimal.
Several strategies have been strongly suggested for reducing ACS-related morbidity, mortality, and costs, such as early revascularization with percutaneous coronary intervention (PCI) and stenting as well as thrombolytic and anticoagulant therapies. The safety and efficacy of drug-eluting stents (DESs) versus bare-metal stents (BMSs) have been a topic of much recent debate. It is believed that the most prominent complication of BMSs is restenosis while that of DESs is late thrombosis, but several contradictory reports have been published, both in support of and against these observations. The high mortality rates signify the need for heightened emphasis on preventing the first episode of stent thrombosis and adequately treating patients with the high-risk profile for minimizing recurrence after the first episode. The benefits of dual antiplatelet therapy in ACS patients following PCI have been established by clinical trials but the concerns regarding the risk of major bleeding have been raised. Part of the reason for the debate is the differences in the interpretation of results of clinical trials and discrepancy between rates of bleeding and overall mortality. This educational supplement will examine these and related issues from a managed care perspective to enable well-informed therapeutic decisions and patient-centered, individualized antiplatelet therapy management.