Acute Coronary Syndrome

I remember one time, when we were living in the mountains of Northern California; I stopped by to check on my Mom and Dad.  It had been snowing pretty good for a few days and even though they lived in the center of town and we talked on the phone every day, it was still nice to stop by and make sure the snow wasn’t causing too much trouble.  As I got out of my truck I could see that Dad was shoveling the snow off the driveway back to his garage.  Dad was about 78 or 79 years old at the time; however, he had always been in relatively good health and walked voraciously. 

I noticed that as I came up, he took a rest and reached in his pocket and pulled out this little bottle of pills and put one under his tongue.  I asked him about it and he said that his doctor had told him that whenever he begins to feel his chest pain to go ahead and dissolve one of these nitroglycerin tablets under his tongue and it will help the pain.  I asked him if it works very well and his response was that most of the time it helps, and sometimes he needs to take a second pill a few minutes later.  This concerned me a little so I asked him how often he needed to use these little pills.  He then told me that on any given day he will use about 6 or 7 tablets.

Six or Seven Tablets!  As a pharmacist I was exasperated by the thought that a doctor had told my dad to go ahead and use these as often as he needed.  What exactly is going on that is causing this pain, and is it this particular doctors thought that we will just wait for my 79 year old Dad to have a heart attack or a stroke?  We did a follow-up phone call and a visit to the doctor in the next couple of days and the doctor adjusted Dad’s maintenance medication so that the chest pain was much less frequent. 

The doctor went on to explain again that it was not his intention for my Dad to use these little nitroglycerin tablets as a maintenance therapy.  Yes, if the chest pain comes on go ahead and use them to help treat the chest pain; however, if he needs to use  2 or 3 tablets in a row, or needs to treat the chest pain on a daily basis, please call the office so that we can take another look at what is going on.  Within the next 12 months Dad had a cardiac bypass surgery which relieved the chest pain completely and he lived another 7 or 8 years, free of chest pain.

I can’t express how important it is to be aware of the barriers to effective communication when counseling patients about their medications; however, that is the topic for another blog that we will see in the near future!

What dad had been experiencing was Acute Coronary Syndrome (ACS).  ACS is a syndrome brought on by decreased blood flow to the heart.  This can be described as the crushing pain one feels during a heart attack, or the light chest pain one may feel while at rest or performing light physical activity.  Please, if you experience chest pain at rest or during light exercise, see your doctor as soon as possible and discuss this with them.

Atherosclerosis is the most common cause of ACS.  Atherosclerosis involves the buildup of plaque along the wall of the artery which hinders blood flow and circulation.  Please take a moment to read my blog that describes the process of atherosclerosis.  Quite often, a patient is not diagnosed with ACS until they appear at the emergency room with chest pain.

In management of a patient with ACS, the focus is on three main therapies.  First, the patient needs to be stabilized, second, the chest pain needs to be relieved, and third, anti thrombotic therapy needs to be provided to prevent a clot.  My focus for this discussion is on the third step of therapy management, the prevention of a clot.

Currently we have three categories of anti coagulation medications available.

The first category is the type that blocks the production vitamin K which in turn inhibits the production of clotting factor.  Warfarin is in this category and is considered a vitamin K antagonist.

The second category is the medications that interfere with thrombin and inhibit the clotting cascade at one point or another.  Some examples of medications in this category include (but not limited to) ribaroxaban, apixoban, dabigatran, and enoxaparin.

The third category of medications act on the platelets, which are a type of blood cell that help damaged arteries by forming a plug to prevent bleeding.  The anti-platelet medications work to inhibit platelet aggregation in patients who are at risk for developing blood clots in their arteries.  Clopidogrel, prasugrel, dipyridamole and aspirin are considered members of this category.

Both clopidogrel and prasugrel are indicated for the treatment of Acute Coronary Syndrome while dipyridamole and aspirin are indicated for prevention of a thrombotic stroke event.  To learn more about these medications, visit and LISTEN to the Consumer Medication Information for each specific med.
  • Aspirin/Dipyridamole (Aggrenox-TM)
  • Clopidogrel (Plavix-TM)
  • Prasugrel (Effient-TM)
  • Ticagrelor (Brilinta-TM) 

  • Apixaban (Eliquis-TM)
  • Dabigatran (Pradaxa-TM)
  • Rivaroxaban (Xarelto-TM)

                Vitamin K Antagonist
  • Warfarin (Coumadin-TM)

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