What is the management of Acute Coronary Syndrome (ACS)?

Management of Acute Coronary Syndrome (ACS)

The management of Acute Coronary Syndrome requires immediate risk stratification followed by appropriate antiplatelet therapy, anticoagulation, and timely invasive strategy based on risk category, with dual antiplatelet therapy and high-intensity statins continued long-term for secondary prevention. 1, 2

Initial Assessment and Diagnosis

• Obtain a 12-lead ECG within 10 minutes of presentation to differentiate between ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation ACS (NSTE-ACS) 2
• Collect blood samples for high-sensitivity cardiac troponin measurement at presentation (0h) and after 1-3 hours to rapidly rule-in or rule-out myocardial infarction 1, 2
• Perform echocardiography to evaluate regional and global left ventricular function and rule out differential diagnoses 1, 2
• Monitor cardiac rhythm continuously for detection of arrhythmias 1, 2
• Assess vital signs with particular attention to hemodynamic stability and signs of heart failure 1, 2

Initial Pharmacological Management

• Administer aspirin 150-300mg loading dose immediately to all patients without contraindications 1, 2
• Initiate a P2Y12 inhibitor in addition to aspirin for 12 months unless contraindicated 1:
  • Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all patients at moderate to high risk of ischemic events 1
  • Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended in patients proceeding to PCI 1, 3
  • Clopidogrel (300-600 mg loading dose, 75 mg daily dose) for patients who cannot receive ticagrelor or prasugrel 1
• Administer parenteral anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin 1, 2
• Administer sublingual or intravenous nitrates for ongoing chest pain 1, 2
• Initiate beta-blockers in the absence of contraindications (hypotension, bradycardia, acute heart failure) 1
• Consider calcium channel blockers for patients with contraindications to beta-blockers 1

Risk Stratification and Invasive Strategy

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

• Hemodynamic instability or cardiogenic shock 1
• Recurrent or ongoing chest pain refractory to medical treatment 1
• Life-threatening arrhythmias or cardiac arrest 1
• Mechanical complications of MI 1
• Acute heart failure with refractory angina or ST deviation 1
• 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 1
• Dynamic ST- or T-wave changes (symptomatic or silent) 1
• GRACE score >140 1

Intermediate-Risk Criteria (Invasive Strategy <72h)

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

Specific Management Based on ACS Type

STEMI Management

• Immediate reperfusion therapy is required 2, 4
• Primary PCI within 120 minutes of first medical contact is preferred 4
• If PCI cannot be performed within 120 minutes, administer fibrinolytic therapy followed by transfer to a PCI-capable facility 4

NSTE-ACS Management (Unstable Angina and NSTEMI)

• For high-risk patients, administer GP IIb/IIIa receptor inhibitors while preparing for angiography 1
• Coronary angiography should be performed during the initial hospitalization 1
• In patients with suitable lesions, proceed with PCI or CABG as appropriate 1
• For patients not suitable for revascularization, optimize medical therapy 1

Long-Term Management and Secondary Prevention

• Continue dual antiplatelet therapy for 12 months 1
• Initiate high-intensity statin therapy as early as possible 1
• Continue beta-blockers long-term, especially after myocardial infarction 1
• Consider ACE inhibitors, particularly in patients with left ventricular dysfunction 1
• Aggressive risk factor modification including smoking cessation 1
• Cardiac rehabilitation should be recommended 5

Special Considerations and Pitfalls

• Prasugrel is contraindicated in patients with prior stroke/TIA and generally not recommended for patients ≥75 years of age 3
• Consider lower maintenance dose (5 mg) of prasugrel in patients weighing <60 kg 3
• Do not administer prasugrel until coronary anatomy is known in NSTE-ACS patients 3
• Discontinue prasugrel at least 7 days prior to CABG when possible 3
• Atypical presentations are common in women, elderly, and diabetic patients - maintain high index of suspicion 2, 5
• Delaying ECG beyond 10 minutes of presentation can lead to missed diagnosis and delayed treatment 2