What is the management approach for acute coronary syndrome?

Management of Acute Coronary Syndrome

The management of acute coronary syndrome requires immediate risk stratification followed by appropriate antiplatelet therapy, anticoagulation, and timely invasive strategy based on risk assessment, with dual antiplatelet therapy including a P2Y12 inhibitor (preferably ticagrelor or prasugrel) in addition to aspirin as the cornerstone of treatment. 1

Initial Assessment and Diagnosis

• Perform immediate ECG (within 10 minutes of first medical contact) to detect ST-segment deviations or other abnormalities 1
• Obtain cardiac biomarkers, preferably high-sensitivity cardiac troponin, with a rapid rule-out and rule-in protocol at 0h and 1h (additional testing after 3-6h if inconclusive) 1
• Perform echocardiography to evaluate regional and global left ventricular function and rule out differential diagnoses 1
• Monitor for arrhythmias with multi-lead ECG monitoring 1

Risk Stratification and Timing of Invasive Strategy

Very High-Risk Criteria (Immediate Invasive Strategy <2h)

• 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 1

High-Risk Criteria (Early Invasive Strategy <24h)

• Rise or fall in cardiac troponin compatible with MI
• Dynamic ST- or T-wave changes (symptomatic or silent)
• GRACE score >140 1

Intermediate-Risk Criteria (Invasive Strategy <72h)

• Diabetes mellitus
• Renal insufficiency (eGFR <60 mL/min/1.73 m²)
• LVEF <40% or congestive heart failure
• Early post-infarction angina
• Recent PCI or prior CABG
• GRACE risk score >109 and <140 1

Pharmacological Management

Antiplatelet Therapy

• Aspirin: Initial dose of 150-300 mg non-enteric formulation followed by 75-100 mg/day 1
• P2Y12 inhibitor (in addition to aspirin for 12 months unless contraindicated):
  • Ticagrelor (180 mg loading dose, 90 mg twice daily) - recommended for all patients at moderate to high risk of ischemic events regardless of initial treatment strategy 1
  • Prasugrel (60 mg loading dose, 10 mg daily dose) - recommended in patients proceeding to PCI without contraindications 1
  • Clopidogrel (300-600 mg loading dose, 75 mg daily dose) - recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation 1, 2

Anticoagulation

• Fondaparinux: 2.5 mg daily subcutaneously (preferred option) 1
• Enoxaparin: 1 mg/kg twice daily subcutaneously 1
• Unfractionated heparin: IV bolus 60-70 IU/kg (maximum 5000 IU) followed by infusion of 12-15 IU/kg/h (maximum 1000 IU/h) titrated to aPTT 1.5-2.5× control 1, 3
• Bivalirudin: Indicated only in patients with planned invasive strategy 1

Other Medications

• Beta-blockers: Administer if tachycardic or hypertensive without signs of heart failure 1
• Nitrates: For symptom relief in persistent or recurrent chest pain 1
• Statins: Start high-intensity statin therapy as early as possible 1
• ACE inhibitors: Recommended in patients with systolic LV dysfunction, heart failure, hypertension, or diabetes 1
• GP IIb/IIIa inhibitors: Consider in high-risk patients while waiting for angiography 1

Revascularization Strategies

Percutaneous Coronary Intervention (PCI)

• Radial approach is preferred over femoral approach to reduce bleeding, vascular complications, and death 1
• Intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions 1
• Complete revascularization strategy is recommended in patients with multivessel disease 1

Coronary Artery Bypass Grafting (CABG)

• Consider for patients with multivessel disease based on complexity of coronary artery disease and comorbidities 1
• If early surgery poses extremely high risk, consider initial PCI of the culprit lesion only 1

Special Considerations

Cardiogenic Shock

• Emergency revascularization of the culprit vessel is indicated 1
• Routine PCI of non-infarct-related arteries at the time of PCI is not recommended 1
• Consider mechanical circulatory support in selected patients 1

Bleeding Risk Management

• In patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended 1
• For patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI 1
• In patients requiring long-term anticoagulation, consider aspirin discontinuation 1-4 weeks after PCI with continued use of a P2Y12 inhibitor (preferably clopidogrel) 1

Long-term Management and Secondary Prevention

• Continue beta-blockers, especially in patients with reduced LV function 1
• Maintain high-intensity statin therapy long-term 1
• Aggressive risk factor modification including smoking cessation 1
• Refer to cardiac rehabilitation 1
• Consider ACE inhibitors for secondary prevention, particularly in patients with LV dysfunction 1

Common Pitfalls to Avoid

• Delaying ECG beyond 10 minutes of first medical contact 1
• Administering prasugrel in patients with unknown coronary anatomy 1
• Underestimating the importance of dual antiplatelet therapy for 12 months 1
• Failing to recognize very high-risk features requiring immediate invasive strategy 1
• Neglecting to start high-intensity statin therapy early 1