What are the guidelines for Acute Coronary Syndrome (ACS) management?

From the Guidelines

The management of Acute Coronary Syndrome (ACS) should prioritize an early invasive strategy with coronary angiography, ideally within 24 hours, for high-risk patients, as recommended by the most recent guidelines 1. The goal of ACS management is to restore blood flow to the heart muscle, prevent further clot formation, reduce myocardial oxygen demand, and limit infarct size, ultimately improving survival and reducing complications.

Key Interventions

• Dual antiplatelet therapy with aspirin (162-325mg loading dose, then 81mg daily) and a P2Y12 inhibitor such as ticagrelor (180mg loading dose, then 90mg twice daily) or clopidogrel (600mg loading dose, then 75mg daily) should be initiated promptly 2.
• Anticoagulation with heparin or low molecular weight heparin should be started immediately.
• Pain management with nitroglycerin (0.4mg sublingual every 5 minutes as needed) and morphine (2-4mg IV) is recommended for ongoing chest pain.
• High-dose statin therapy (atorvastatin 80mg or rosuvastatin 40mg daily) should be started regardless of baseline cholesterol levels.
• Oxygen should be administered only if saturation is below 90%.
• Beta-blockers (metoprolol 25-50mg orally every 6 hours) should be given within 24 hours if there are no contraindications.
• ACE inhibitors or ARBs should be started within 24 hours for patients with anterior MI, heart failure, or reduced ejection fraction.

Revascularization Strategy

• For high-risk patients and those with recurrent ischemia, an immediate or early invasive approach (within 24 hours) with potential revascularization is recommended 1.
• A delayed invasive strategy (before discharge) after initial stabilization may be considered for lower risk patients.
• Primary PCI is the preferred treatment for ST elevation myocardial infarction, and is also recommended for patients in shock or who are hemodynamically unstable.

From the FDA Drug Label

Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.

The guidelines for Acute Coronary Syndrome (ACS) management with prasugrel include:

• Initiating treatment with a single 60 mg oral loading dose, followed by 10 mg orally once daily
• Administering aspirin (75 mg to 325 mg) daily
• Considering the timing of the loading dose, which may be administered at the time of diagnosis or at the time of PCI
• Being cautious in patients with low weight (<60 kg) and considering a lower maintenance dose of 5 mg
• Avoiding use in patients with active pathological bleeding, history of TIA or stroke, or those who are likely to undergo urgent CABG 3
• Initiating prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily 4

From the Research

Guidelines for Acute Coronary Syndrome (ACS) Management

The management of Acute Coronary Syndrome (ACS) involves a combination of medical therapies and interventions. The following are the guidelines for ACS management:

• Aspirin is recommended for all patients with suspected ACS unless contraindicated 5
• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor (e.g., clopidogrel, prasugrel, or ticagrelor) is recommended for most patients 5, 6, 7
• Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux 5
• Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 5
• Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 5

Interventional Management

The following are the guidelines for interventional management of ACS:

• For patients with ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 5
• Fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 5
• For non-ST-segment elevation ACS, PCI is recommended; fibrinolytic therapy typically is not recommended 5
• Coronary artery bypass grafting (CABG) may be necessary to reestablish coronary artery flow, ideally delayed 3 to 7 days after admission unless certain conditions are met 5

Individualized Approach

It is essential to take an individualized approach to treatment, considering long-term safety and efficacy when managing patients with a history of ACS after hospital discharge 8