From the Guidelines
The recommended management regimen for Acute Coronary Syndrome (ACS) involves immediate dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as ticagrelor or clopidogrel, for at least 12 months as the default strategy in patients who are not at high bleeding risk. According to the most recent guidelines 1, dual antiplatelet therapy is indicated for patients with ACS who have undergone PCI and require antiplatelet therapy. The choice of P2Y12 inhibitor includes ticagrelor (180mg loading dose, then 90mg twice daily) or clopidogrel (600mg loading dose, then 75mg daily) 1.
Key Considerations
- Aspirin is recommended for all patients without contraindications at an initial oral loading dose of 150–300 mg (or 75–250 mg i.v.), and at a maintenance dose of 75–100 mg daily long-term 1.
- A P2Y12 inhibitor is recommended in addition to aspirin, maintained over 12 months unless there are contraindications such as an excessive risk of bleeding 1.
- For patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended 1.
- In patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI 1.
- In patients who require long-term anticoagulation, aspirin discontinuation is recommended 1 to 4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel) 1.
Additional Management Strategies
- Pain should be managed with sublingual nitrates and intravenous opioids if needed.
- Oxygen therapy should be administered only if oxygen saturation falls below 94%.
- For ST-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) should be performed within 120 minutes of first medical contact, with fibrinolysis considered if PCI cannot be delivered within this timeframe.
- For non-ST elevation ACS, risk stratification using the GRACE score determines the timing of coronary angiography, with high-risk patients requiring intervention within 24 hours.
- Additional medications include beta-blockers, ACE inhibitors, and high-intensity statins.
- Anticoagulation during the acute phase typically involves low molecular weight heparin or fondaparinux.
From the Research
Management Regimen for Acute Coronary Syndrome (ACS)
The National Institute for Health and Care Excellence (NICE) guidelines recommend the following management regimen for Acute Coronary Syndrome (ACS):
- Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated 2
- Addition of a second antiplatelet (ie, dual antiplatelet therapy) (eg, clopidogrel, ticagrelor, or prasugrel) also is recommended for most patients 2, 3, 4, 5
- Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 2, 3
- Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 2
- Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin and morphine (to relieve chest pain), and oxygen 2, 6
Treatment Approach Based on Type of ACS
The treatment approach may vary based on the type of ACS:
- For patients with an ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 2
- Fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 2
- For non-ST-segment elevation ACS, PCI is recommended; fibrinolytic therapy typically is not recommended 2
- If patients require coronary artery bypass graft to reestablish coronary artery flow, it ideally is delayed 3 to 7 days after admission unless the patient has cardiogenic shock, life-threatening arrhythmias, three-vessel disease (with 70% occlusion each), greater than 50% left main coronary artery occlusion, unsuccessful or complicated PCI, or mechanical complications (eg, valve rupture) 2