From the Guidelines
Management of Acute Coronary Syndrome (ACS) requires immediate intervention with a comprehensive approach, prioritizing dual antiplatelet therapy, anticoagulation, high-intensity statin therapy, beta-blockers, and sublingual nitroglycerin for chest pain, as outlined in the 2021 ESC guidelines 1. For suspected ACS, administer aspirin 325mg chewed immediately, followed by dual antiplatelet therapy with aspirin 81mg daily plus a P2Y12 inhibitor (ticagrelor 180mg loading dose then 90mg twice daily, or clopidogrel 600mg loading dose then 75mg daily). Start anticoagulation with unfractionated heparin (60 units/kg bolus, maximum 4000 units, followed by 12 units/kg/hour infusion) or enoxaparin (1mg/kg subcutaneously twice daily). Administer high-intensity statin therapy (atorvastatin 80mg or rosuvastatin 40mg daily), beta-blockers (metoprolol 25-50mg every 6 hours as tolerated), and sublingual nitroglycerin 0.4mg every 5 minutes for chest pain. For STEMI patients, immediate reperfusion is crucial, with primary PCI preferred if available within 90 minutes of first medical contact, or fibrinolytic therapy if PCI is delayed beyond 120 minutes, as supported by previous guidelines 1. For NSTEMI/UA patients, an early invasive strategy is recommended for high-risk features, with a focus on risk stratification and individualized treatment plans. Continuous cardiac monitoring, oxygen therapy for saturations below 90%, and pain management are essential components of ACS management. This approach targets the underlying pathophysiology of coronary thrombosis while preventing further ischemic damage and complications, ultimately reducing morbidity, mortality, and improving quality of life.
Key considerations in ACS management include:
- Early recognition and diagnosis of ACS, using electrocardiogram (ECG) and biochemical markers such as cardiac troponin T or cardiac troponin I
- Risk stratification to guide treatment decisions, including the use of early invasive strategies for high-risk patients
- Individualized treatment plans, taking into account patient-specific factors such as comorbidities and contraindications to certain therapies
- Close monitoring and adjustment of treatment as needed to optimize outcomes and minimize complications. The most recent and highest quality study, the 2021 ESC guidelines 1, provides the foundation for these recommendations, with additional support from previous guidelines and studies 1.
From the Research
Management of Acute Coronary Syndrome (ACS)
The management of ACS involves a combination of medical therapies and interventions.
- Aspirin is recommended for all patients with suspected ACS unless contraindicated 2.
- Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel), is recommended for most patients 3, 2.
- Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux 4, 2.
- Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 2.
Antiplatelet Therapy
- DAPT reduces cardiovascular event rates after ACS 3.
- The choice of P2Y12 inhibitor depends on the patient's risk of bleeding and ischemia 3.
- Prasugrel and ticagrelor are more potent than clopidogrel, but may increase the risk of bleeding 3, 5.
- Clinicians should avoid prescribing prasugrel to patients with a history of stroke or transient ischemic attack, and to patients older than 75 years or who weigh less than 60 kg 3.
Interventional Management
- Percutaneous coronary intervention (PCI) with stent placement is recommended for patients with ST-segment elevation myocardial infarction (STEMI) as soon as possible 2.
- Fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes 2.
- For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is typically not recommended 2.
- Coronary artery bypass grafting (CABG) may be necessary for some patients, ideally delayed 3 to 7 days after admission unless certain conditions are met 2.