Initial Management of Acute Coronary Syndrome (ACS)
The initial management of ACS requires immediate 12-lead ECG within 10 minutes of presentation, blood sampling for high-sensitivity cardiac troponin, administration of aspirin and anticoagulation, and risk stratification to determine the timing of invasive strategy. 1, 2
Immediate Assessment and Diagnosis
- Obtain a 12-lead ECG within 10 minutes of first medical contact to differentiate between STEMI and NSTE-ACS 1, 2
- Continuously monitor cardiac rhythm for detection of life-threatening arrhythmias 1, 2
- Collect blood samples for high-sensitivity cardiac troponin at presentation (0h) and after 1-3 hours for rapid diagnosis 1, 2
- Perform echocardiography to evaluate regional and global left ventricular function and rule out differential diagnoses 1, 2
- Assess vital signs regularly with particular attention to hemodynamic stability and signs of heart failure 1, 2
- Evaluate chest pain characteristics, duration, and persistence along with symptom-oriented physical examination 1
- Assess probability of CAD based on chest pain characteristics, age, gender, cardiovascular risk factors, and known CAD 1
Initial Pharmacological Management
- Administer aspirin 150-300mg loading dose immediately to all patients without contraindications 2, 3
- Initiate a P2Y12 inhibitor in addition to aspirin for 12 months unless contraindicated 1, 4
- Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for moderate to high-risk patients 1
- Prasugrel (60 mg loading dose, 10 mg daily) is recommended for patients proceeding to PCI 1
- Clopidogrel (300-600 mg loading dose, 75 mg daily) is recommended when ticagrelor or prasugrel cannot be used 1, 4
- Administer parenteral anticoagulation with low molecular weight heparin or unfractionated heparin 2, 3
- Administer sublingual or intravenous nitrates for ongoing chest pain 1, 2
- Initiate beta-blockers in the absence of contraindications (hypotension, bradycardia, acute heart failure) 2
- Consider calcium channel blockers for patients with contraindications to beta-blockers 2
- Initiate high-intensity statin therapy as early as possible 2
Risk Stratification and Timing of Invasive Strategy
Implement an immediate invasive strategy (<2h) for patients with very high-risk criteria: 1, 2
- Hemodynamic instability or cardiogenic shock
- Recurrent or ongoing chest pain refractory to medical treatment
- Life-threatening arrhythmias or cardiac arrest
- Mechanical complications of MI
- Acute heart failure with refractory angina or ST deviation
- Recurrent dynamic ST- or T-wave changes, particularly with intermittent ST elevation
Implement an early invasive strategy (<24h) for patients with high-risk criteria: 1, 2, 5
- Rise or fall in cardiac troponin compatible with MI
- Dynamic ST- or T-wave changes (symptomatic or silent)
- GRACE score >140
Implement an invasive strategy (<72h) for patients with intermediate-risk criteria: 1, 2
- Diabetes mellitus
- Renal insufficiency (eGFR <60 mL/min/1.73 m²)
- LVEF <40% or congestive heart failure
- Early post-infarction angina
- Recent PCI
- Prior CABG
- GRACE risk score >109 and <140
STEMI-Specific Management
- For STEMI patients, rapid reperfusion with primary PCI within 120 minutes is essential to reduce mortality 5
- If PCI within 120 minutes is not possible, administer fibrinolytic therapy followed by transfer to a PCI-capable facility 5, 3
Common Pitfalls to Avoid
- Delaying ECG beyond 10 minutes of presentation can lead to missed diagnosis and delayed treatment 2
- Waiting for troponin results before initiating antiplatelet therapy in high-risk patients can delay critical treatment 2
- Failing to recognize atypical presentations of ACS, particularly in women, elderly, and diabetic patients 2
- Overlooking the need for defibrillator patches in cases of ongoing ischemia until urgent revascularization 1
- Neglecting to assess renal function when dosing antithrombotic medications 1