Prothrombotic and antithrombotic pathways in acute coronary syndromes.
The acute coronary syndromes arise from procoagulant changes in complex plaques, which trigger both platelet activation and coagulation pathways. These 2 pathways intersect at a number of points that form positive-feedback loops to sustain and accelerate thrombus formation. In normal hemostasis and with a healthy endothelium, intravascular thrombosis is prevented, and vascular patency is protected by the fibrinolytic system and a number of antithrombotic factors, such as antithrombin, thrombomodulin, and tissue factor pathway inhibitor. However, atherosclerosis is characterized by a hypercoagulable state, and the fibrinolytic balance is skewed toward occlusive thrombus formation at critical sites on vulnerable plaques. This review focuses on cellular and humoral mechanisms and the antithrombotic strategies that are important during the acute phase of an ischemic coronary syndrome, both in patients managed conservatively and in patients scheduled for an interventional procedure. These strategies include fibrinolytic therapy, antiplatelet therapies (aspirin, clopidogrel, glycoprotein IIb/IIIa receptor inhibitors), and low-molecular-weight heparin.
Selwyn
Andrew P
AP
Cardiovascular Division and the Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA. aselwyn@partners.org
D000208:Acute Disease; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000494:pharmacology; D001777:Blood Coagulation / Q000502:physiology; D003327:Coronary Disease / Q000150:complications / Q000503:physiopathology*; D006495:Heparin, Low-Molecular-Weight / Q000494:pharmacology; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000494:pharmacology; D015539:Platelet Activation / Q000502:physiology; D010975:Platelet Aggregation Inhibitors / Q000494:pharmacology; D013577:Syndrome; D013917:Thrombin / Q000037:antagonists & inhibitors / Q000502:physiology; D013925:Thromboplastin / Q000502:physiology; D013927:Thrombosis / Q000150:complications / Q000188:drug therapy / Q000503:physiopathology*
D000806:Angiotensin-Converting Enzyme Inhibitors; D006495:Heparin, Low-Molecular-Weight; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D013925:Thromboplastin; D013917:Thrombin