Management of CAD with ACS and Normal LVEF Planned for Coronary Angiography
For patients with CAD and ACS with normal LVEF planned for coronary angiography, an early invasive strategy (<24 hours) with appropriate antithrombotic therapy is recommended, followed by revascularization based on coronary anatomy findings. 1
Initial Management and Risk Stratification
- An early invasive strategy (<24 hours) is recommended for patients with ACS who have high-risk criteria including rise or fall in cardiac troponin compatible with MI, dynamic ST- or T-wave changes, or GRACE score >140 1
- For very high-risk patients (hemodynamic instability, refractory angina, life-threatening arrhythmias, mechanical complications of MI, or acute heart failure), an immediate invasive strategy (<2 hours) is recommended 1
- Normal LVEF (>50%) is associated with better prognosis compared to reduced LVEF, but does not change the recommendation for early coronary angiography in ACS 2, 3
Antithrombotic Therapy Before and During Coronary Angiography
- Dual antiplatelet therapy (DAPT) with aspirin (150-300 mg loading dose, then 75-100 mg daily) plus a P2Y12 inhibitor is recommended 1
- A potent P2Y12 inhibitor (prasugrel or ticagrelor) is preferred over clopidogrel unless contraindicated 1
- Important: Do not administer prasugrel until coronary anatomy is known in NSTEMI/UA patients, as it is contraindicated if urgent CABG is needed 4
- Peri-interventional anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended in addition to antiplatelet therapy 1
- For patients on fondaparinux, a single bolus of UFH (85 IU/kg, or 60 IU with GPIIb/IIIa inhibitors) is indicated 1
- Crossover between UFH and LMWH is not recommended 1
Revascularization Strategy Based on Coronary Anatomy
Left Main Disease
- For significant left main coronary stenosis, CABG is generally recommended over PCI to improve survival and reduce risk of repeat revascularization 1
- For left main disease with low complexity (SYNTAX score ≤22), PCI is an acceptable alternative to CABG 1
Multivessel Disease
- For patients with three-vessel disease and normal LVEF, CABG is recommended to improve long-term survival 1
- For three-vessel disease of low-to-intermediate complexity where PCI can provide similar completeness of revascularization to CABG, PCI is an acceptable alternative 1
- For diabetic patients with multivessel disease, CABG is preferred over PCI 1
Single or Double Vessel Disease
- For single or double vessel disease involving the proximal LAD, either CABG or PCI is recommended 1
- For single or double vessel disease not involving the proximal LAD, PCI is recommended 1
Post-Revascularization Management
- DAPT with a P2Y12 inhibitor plus aspirin is recommended for 12 months after ACS with stent implantation, unless there are contraindications such as excessive bleeding risk 1
- Secondary prevention measures including medical therapy and lifestyle changes should be started and reinforced after revascularization 1
- Participation in a cardiac rehabilitation program is recommended to improve outcomes 1
- For patients with normal LVEF, standard secondary prevention includes:
Common Pitfalls and Caveats
- Administering prasugrel before knowing coronary anatomy increases bleeding risk if urgent CABG is needed 4
- Failure to use a potent P2Y12 inhibitor (prasugrel or ticagrelor) in ACS patients without contraindications may lead to worse outcomes 1
- For patients weighing <60 kg on prasugrel, consider lowering maintenance dose to 5 mg due to increased bleeding risk 4
- Proton pump inhibitors should be considered in patients at high risk of gastrointestinal bleeding receiving DAPT 1
- Ensure proper timing of coronary angiography based on risk stratification - very high-risk patients need immediate intervention (<2h) while high-risk patients should receive intervention within 24h 1