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The year in cardiology 2014: acute coronary syndromes.

This review provides an overview of key findings published in 2014 on the pathophysiology, early diagnosis, prognosis, and acute and long-term treatment of acute coronary syndromes (ACS). A perspective on future research is provided at the end. We did not report on the progress made with mechanical interventions as this topic will be covered in another review. As so many studies have been published on ACS and because of the restrictions imposed by the journal, the selected papers unavoidably reflect the interests and personal opinion of the authors to a certain extent. As in many other studies ACS covers all types of non-ST-segment elevation and ST-segment elevation myocardial infarction (NSTEMI and STEMI). Little data have been provided on unstable angina patients in recent years. The increasing use of high-sensitivity troponins (hsTn) makes the diagnosis of unstable angina very unusual if not impossible.

Plaque rupture, plaque erosion, and functional alterations of coronary circulation are responsible for ACS. Niccoli et al .1 found that these different mechanisms, identified by optical coherence tomography, were associated with different patterns of biomarker levels. Indeed, patients with plaque rupture displayed a marked elevation of C-reactive protein suggesting a systemic active inflammatory process that progressively leads to cap thinning and rupture. Patients with erosion, on the other hand, exhibited higher myeloperoxidase levels, which might trigger thrombus formation at the site of an eroded plaque expressing hyaluronan. Finally, cystatin-C levels were higher in patients who did not exhibited fissure or erosion of the culprit plaque, thus suggesting functional mechanisms operating in epicardial coronary arteries or in the microcirculation. Biomarkers able to identify the mechanism of instability operating in the individual patient might …