What is the initial management for a patient with suspected Acute Coronary Syndrome (ACS) versus aortic dissection?

From the Guidelines

The initial management of suspected Acute Coronary Syndrome (ACS) and aortic dissection differs significantly, with the key distinction being that antithrombotic therapy beneficial in ACS can be fatal in aortic dissection. For suspected ACS, immediately administer aspirin 325mg chewed, supplemental oxygen if saturation is below 94%, sublingual nitroglycerin 0.4mg every 5 minutes for up to 3 doses for chest pain, and IV morphine 2-4mg if pain persists. Additional medications include P2Y12 inhibitors (clopidogrel 600mg loading dose, ticagrelor 180mg, or prasugrel 60mg) and anticoagulation with unfractionated heparin or enoxaparin 1. For suspected aortic dissection, the priority is blood pressure control with IV beta-blockers (labetalol as a first choice due to its alpha- and beta-blocking properties) to target heart rate below 60 bpm, followed by vasodilators like nitrates or dihydropyridine CCBs (e.g. nicardipine) to maintain systolic BP between 100-120 mmHg, as recommended by the 2024 ESC guidelines 1. Avoid antiplatelets and anticoagulants in aortic dissection. Both conditions require immediate ECG, cardiac biomarkers, and appropriate imaging—coronary angiography for ACS and CT angiography for suspected dissection. Pain control is essential in both scenarios, but the fundamental approach differs based on pathophysiology: ACS requires reperfusion strategies while aortic dissection management focuses on reducing shear forces on the aortic wall by controlling heart rate and blood pressure. Key considerations in aortic dissection include early placement of an arterial line to monitor BP invasively and admission to an intensive care unit, as well as the potential need for surgical intervention, particularly for Type A dissections, as highlighted in the 2014 ESC guidelines 1. The management approach should be tailored to the individual patient's risk factors, comorbidities, and clinical presentation, with a focus on minimizing morbidity, mortality, and improving quality of life. Some key points to consider in the management of ACS and aortic dissection include:

• The importance of prompt diagnosis and treatment to reduce morbidity and mortality
• The need for careful consideration of the patient's individual risk factors and comorbidities in determining the optimal management approach
• The role of imaging studies, such as coronary angiography and CT angiography, in guiding management decisions
• The importance of pain control and hemodynamic stability in both ACS and aortic dissection.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Management for Suspected ACS vs Aortic Dissection

The initial management for a patient with suspected Acute Coronary Syndrome (ACS) versus aortic dissection involves several key steps:

• For patients with suspected ACS, immediate electrocardiography (within 10 minutes of presentation) is crucial to distinguish between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 2.
• Aspirin is recommended for all patients with suspected ACS unless contraindicated, along with the addition of a second antiplatelet and parenteral anticoagulation 3.
• For patients with STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality, while fibrinolytic therapy is reserved for patients without access to immediate PCI 2, 3.
• In contrast, aortic dissection is an extremely severe condition with a high risk of mortality, and its diagnosis can be challenging due to symptoms that may mimic ACS 4, 5.
• Emergency imaging techniques, such as transthoracic echocardiography, can help guide the correct diagnosis of aortic dissection, and surgery represents the primary treatment for these patients 4.
• The importance of early detection and differentiation between ACS and aortic dissection is highlighted by cases where aortic dissection masquerades as ACS, emphasizing the need for careful diagnosis and consideration of bedside echocardiography before proceeding with primary PCI 5.

Diagnostic Considerations

• The diagnosis and differential diagnosis of acute coronary syndrome are based on clinical history, physical examination, electrocardiogram, echocardiogram, coronarogram, and new serum markers of the patients 6.
• Risk stratification algorithms are necessary to integrate patients into a realistic management strategy, categorizing them as high, intermediate, or low risk 6.
• High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI, and prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death in high-risk patients with NSTE-ACS 2.