What is the treatment for Acute Coronary Syndrome (ACS)?

From the Guidelines

The treatment of acute coronary syndrome (ACS) should prioritize anticoagulation with unfractionated heparin (UFH) in addition to antiplatelet therapy, as recommended by the most recent guidelines 1. The management of ACS involves a combination of medications and procedures to prevent further clot formation, reduce myocardial oxygen demand, and restore blood flow to the affected coronary arteries.

• Initially, aspirin (162-325mg loading dose, then 81mg daily) and a P2Y12 inhibitor such as clopidogrel (300-600mg loading, then 75mg daily), ticagrelor (180mg loading, then 90mg twice daily), or prasugrel (60mg loading, then 10mg daily) should be administered.
• Anticoagulation with UFH is the standard of care for NSTE-ACS patients due to its favourable risk-benefit profile, with a recommended initial loading dose of 60 IU/kg (maximum 4000 IU) and initial infusion of 12 IU/kg per hour (maximum 1000 IU/h) adjusted per activated partial thromboplastin time to maintain therapeutic anticoagulation according to the specific hospital protocol 1.
• Pain management with nitroglycerin (0.4mg sublingual every 5 minutes as needed) and morphine (2-4mg IV) helps relieve chest discomfort.
• Beta-blockers like metoprolol (25-50mg orally) reduce myocardial oxygen demand, while high-dose statins such as atorvastatin (80mg daily) provide plaque stabilization.
• For non-ST elevation ACS, an early invasive strategy with cardiac catheterization within 24-72 hours is recommended for high-risk patients, with UFH as the preferred anticoagulant during invasive management 1.
• Following the acute phase, long-term management includes dual antiplatelet therapy for 6-12 months, statins, beta-blockers, and ACE inhibitors or ARBs, particularly for patients with reduced ejection fraction or diabetes. Key considerations in the management of ACS include:
• The use of anticoagulation in addition to antiplatelet therapy to prevent further clot formation 1.
• The selection of an early invasive strategy for high-risk patients with non-ST elevation ACS 1.
• The importance of individualizing treatment based on patient risk and clinical presentation 1.

From the FDA Drug Label

Clopidogrel tablets are indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS (unstable angina [UA]/non–ST-elevation myocardial infarction [NSTEMI]), including patients who are to be managed medically and those who are to be managed with coronary revascularization In patients who need an antiplatelet effect within hours, initiate clopidogrel tablets with a single 300 mg oral loading dose and then continue at 75 mg once daily.

The treatment of acute coronary syndrome with clopidogrel involves a loading dose of 300 mg orally, followed by a maintenance dose of 75 mg once daily. This should be administered in conjunction with aspirin. The goal of this treatment is to reduce the rate of myocardial infarction and stroke in patients with non-ST-segment elevation ACS or acute ST-elevation myocardial infarction who are to be managed medically 2.

• Key points:
  • Loading dose: 300 mg orally
  • Maintenance dose: 75 mg once daily
  • Administered in conjunction with aspirin
  • Reduces rate of myocardial infarction and stroke in patients with ACS
• Important considerations:
  • Patients who are CYP2C19 poor metabolizers may have reduced antiplatelet activity
  • Concomitant use of omeprazole or esomeprazole should be avoided due to reduced antiplatelet activity of clopidogrel 2

From the Research

Treatment Overview

• The treatment of acute coronary syndrome (ACS) involves a combination of medical therapy and revascularization techniques 3, 4.
• Medical therapy includes antiplatelet and anticoagulant agents, such as aspirin, clopidogrel, and unfractionated heparin, to reduce the risk of thrombus formation and myocardial ischemia 5, 6.

Revascularization Techniques

• For patients with ST-segment elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) within 120 minutes of presentation is recommended to reduce mortality 3, 4.
• If PCI is not possible within 120 minutes, fibrinolytic therapy with alteplase, reteplase, or tenecteplase should be administered, followed by transfer to a facility with the goal of PCI within the next 24 hours 3.
• For patients with non-ST-segment elevation ACS (NSTE-ACS), prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death 3, 4.

Medical Therapy

• Aspirin is recommended for all patients with suspected ACS unless contraindicated, and addition of a second antiplatelet agent (dual antiplatelet therapy) is also recommended for most patients 4, 6.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended, and proton pump inhibitors should be used to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher risk of gastrointestinal bleeding 4.
• Other medical therapies, such as statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine, should be used to relieve chest pain and modify the metabolic milieu that predisposes to plaque formation and rupture 4, 7.

Anticoagulation Therapy

• The choice of anticoagulant agent depends on the patient's clinical presentation and the planned revascularization strategy, with options including unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 5, 6.
• New oral anticoagulants, such as rivaroxaban, have been shown to be effective in reducing cardiovascular mortality in patients with ACS, but their use is still being established in clinical practice 6.