Management of Acute Coronary Syndrome
Dual antiplatelet therapy with aspirin plus ticagrelor or prasugrel (preferred over clopidogrel) is the cornerstone of ACS management, combined with early invasive strategy and high-intensity statin therapy. 1
Immediate Antiplatelet Therapy
Start dual antiplatelet therapy immediately upon ACS diagnosis:
- Aspirin (loading dose) for all patients unless contraindicated
- P2Y12 inhibitor selection based on PCI timing:
Continue dual antiplatelet therapy for at least 12 months as the default strategy in patients without high bleeding risk 1
Anticoagulation
Add parenteral anticoagulation with one of the following 2:
- Unfractionated heparin
- Low-molecular-weight heparin
- Bivalirudin
- Fondaparinux
Invasive Strategy Timing
The timing of coronary angiography depends on presentation:
STEMI patients:
- Perform PCI with stent placement as soon as possible 2
- If PCI will be delayed >120 minutes, use fibrinolytic therapy first 2
- Use drug-eluting stents over bare-metal stents 3
- Radial access is the standard approach 3
NSTE-ACS patients - perform early invasive strategy within 24 hours if any of these high-risk features 3:
- NSTEMI diagnosis confirmed
- Dynamic or new contiguous ST/T-segment changes suggesting ongoing ischemia
- Transient ST-segment elevation
- GRACE risk score >140
Emergency coronary angiography is required for cardiogenic shock complicating ACS 3
Revascularization Strategy
- Culprit lesion PCI immediately in appropriate patients
- Complete revascularization in hemodynamically stable patients with multivessel disease is reasonable 4
- Culprit-lesion-only initial PCI in cardiogenic shock 4
- Emergency CABG if coronary anatomy not amenable to PCI in shock patients 3
Bleeding Risk Mitigation
Three specific strategies to reduce bleeding while maintaining efficacy 1:
- Proton pump inhibitor for patients at risk for GI bleeding
- Transition to ticagrelor monotherapy 1 month after PCI in patients who tolerated dual antiplatelet therapy
- Discontinue aspirin 1-4 weeks after PCI in patients requiring long-term anticoagulation (continue P2Y12 inhibitor, preferably clopidogrel)
Cardiogenic Shock Management
- Microaxial flow pump use is reasonable in selected patients with cardiogenic shock to reduce death, though complications (bleeding, limb ischemia, renal failure) are higher 1
- Careful attention to vascular access and weaning is critical
- Routine IABP use is NOT recommended in shock without mechanical complications 3
- Do NOT perform routine immediate revascularization of non-culprit lesions in NSTE-ACS with multivessel disease presenting with shock 3
Additional Acute Management
- High-intensity statin therapy initiated immediately 4
- Beta blockers
- ACE inhibitors
- Nitroglycerin and morphine for chest pain relief
- Oxygen as needed
- Red blood cell transfusion to maintain hemoglobin of 10 g/dL may be reasonable in patients with acute or chronic anemia who are not actively bleeding 1
Post-Discharge Secondary Prevention
Critical components after discharge 1:
- Fasting lipid panel 4-8 weeks after initiating or adjusting lipid-lowering therapy
- Add ezetimibe early when needed with high-intensity statin 4
- Cardiac rehabilitation referral (home-based programs acceptable for those unable to attend in person)
- PCSK9 inhibitors and low-dose colchicine are selective strategies 4
- SGLT2 inhibitors and GLP-1RAs for specific comorbid indications 4
Special Populations
Diabetes: Screen all patients; monitor glucose frequently; avoid hypoglycemia 3
CKD: Apply same diagnostic and therapeutic strategies with dose adjustments; use low- or iso-osmolar contrast at lowest volume 3
Older patients: Apply same diagnostic and interventional strategies as younger patients, but adapt antithrombotic dosing to renal function 3