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 ST-elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PCI) within 90 minutes or fibrinolysis if PCI is unavailable within 120 minutes, as recommended by the 2020 ESC guidelines 1. The initial management of ACS involves administering aspirin (325mg loading dose, then 81mg daily) and a P2Y12 inhibitor such as clopidogrel, ticagrelor, or prasugrel, along with anticoagulation using heparin or low molecular weight heparin, as suggested by the 2014 AHA/ACC guideline 1. Key considerations in the treatment of ACS include:

• Pain management with nitroglycerin and morphine to relieve chest discomfort
• Beta-blockers, such as metoprolol, to reduce heart rate and blood pressure
• High-dose statins, like atorvastatin, to stabilize plaques
• Oxygen therapy if saturation is below 90%
• Early invasive strategy with coronary angiography for high-risk patients with non-ST elevation ACS Following the acute phase, long-term management includes dual antiplatelet therapy for 6-12 months, statins, beta-blockers, ACE inhibitors (especially with reduced ejection fraction), lifestyle modifications, and cardiac rehabilitation, as outlined in the 2010 American Heart Association guidelines 1. It is essential to recognize that the symptoms of ACS can be atypical, especially in the elderly, women, and diabetic patients, and that early recognition and treatment can significantly improve outcomes, as emphasized by the 2010 American Heart Association guidelines 1. The most critical aspect of ACS treatment is timely reperfusion, which can be achieved through primary PCI or fibrinolysis, as recommended by the 2020 ESC guidelines 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.

The treatment for Acute Coronary Syndrome (ACS) is clopidogrel in conjunction with aspirin.

• The recommended dosage is a single 300 mg oral loading dose, followed by 75 mg once daily.
• Clopidogrel is indicated to reduce the rate of myocardial infarction (MI) and stroke in patients with non–ST-segment elevation ACS and acute ST-elevation myocardial infarction (STEMI) 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

• Antiplatelet and anticoagulant therapy are essential components of ACS treatment 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 an alternative option 5, 7.