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

From the Guidelines

The treatment of Acute Coronary Syndrome (ACS) requires immediate intervention with a combination of medications and procedures, prioritizing reducing myocardial oxygen demand, preventing further thrombosis, and restoring coronary blood flow to minimize myocardial damage and improve outcomes. Initially, aspirin (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, as recommended by the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. Anticoagulation with heparin or low molecular weight heparin is essential, with options including enoxaparin, bivalirudin, fondaparinux, or unfractionated heparin, as outlined in the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1.

Medications and Procedures

• Aspirin: 325mg loading dose, then 81mg daily
• P2Y12 inhibitor: clopidogrel (300-600mg loading, then 75mg daily), ticagrelor (180mg loading, then 90mg twice daily), or prasugrel (60mg loading, then 10mg daily)
• Anticoagulation: heparin or low molecular weight heparin, such as enoxaparin, bivalirudin, fondaparinux, or unfractionated heparin
• Pain management: nitroglycerin (0.4mg sublingual or IV infusion) and morphine if needed
• Beta-blockers: metoprolol (25-50mg) if no contraindications
• High-intensity statins: atorvastatin (40-80mg) or rosuvastatin (20-40mg)
• Oxygen therapy: indicated for patients with oxygen saturation below 90%

Definitive Treatment

• ST-elevation myocardial infarction (STEMI): immediate reperfusion via primary percutaneous coronary intervention (PCI) within 90 minutes or fibrinolysis if PCI is unavailable within 120 minutes
• Non-ST elevation ACS: early invasive strategy with cardiac catheterization within 24-72 hours recommended for high-risk patients

The 2020 ESC guidelines provide the most recent and highest quality evidence for the management of ACS, and should be prioritized in clinical decision-making 1. The 2014 AHA/ACC guideline and the 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care provide additional support for the recommended treatment approach 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 Clopidogrel tablets should be administered in conjunction with aspirin. 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 for Acute Coronary Syndrome (ACS) is:

• Clopidogrel 300 mg oral loading dose, followed by 75 mg once daily
• Aspirin should be administered in conjunction with clopidogrel
• The treatment should be individualized based on the patient's condition and medical history 2 2 2

From the Research

Treatment Overview

The treatment for Acute Coronary Syndrome (ACS) involves a combination of medical therapies and interventions.

• Aspirin is recommended for all patients with suspected ACS unless contraindicated 3.
• Dual antiplatelet therapy, which includes aspirin and another antiplatelet agent such as clopidogrel, ticagrelor, or prasugrel, is also recommended for most patients 3, 4.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 3, 5.
• Other medical therapies include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine to relieve chest pain, as well as oxygen 3.

Interventional Therapies

• For patients with ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 3, 4.
• If PCI will be delayed for more than 120 minutes, fibrinolytic therapy should be used first 3.
• For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is typically not recommended 3, 6.
• Coronary artery bypass grafting may be necessary to reestablish coronary artery flow in some patients, ideally delayed 3 to 7 days after admission unless certain conditions are present 3.

Antithrombotic Therapy

• Antithrombotic therapy, which combines antiplatelet and anticoagulant therapy, is a crucial component of ACS management 5, 7.
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, such as prasugrel or ticagrelor, is the gold standard 5.
• Unfractionated heparin, low-molecular-weight heparin, and fondaparinux are commonly used anticoagulants, with bivalirudin being a direct parenteral factor IIa inhibitor 5, 7.