Abstract
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.
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