What is the treatment for coronary artery syndrome?

Treatment of Coronary Artery Syndrome

All patients with acute coronary syndrome require immediate dual antiplatelet therapy (aspirin 75-150 mg plus clopidogrel), anticoagulation with LMWH or unfractionated heparin, beta-blockers, and nitrates for ongoing chest pain, with treatment pathway determined by whether ST-segment elevation is present on ECG. 1

Immediate Assessment and Risk Stratification

The critical first step is obtaining a 12-lead ECG within 10 minutes of presentation to differentiate treatment pathways: 1, 2, 3

• ST-segment elevation (STEMI): Signifies complete coronary occlusion requiring immediate reperfusion 1
• Non-ST-segment elevation ACS: Includes ST-depression, T-wave changes, or normal ECG requiring troponin measurement 1, 2

Measure cardiac troponin T or I immediately and repeat at 6-12 hours to distinguish myocardial infarction from unstable angina. 1

Acute Management for STEMI

Primary percutaneous coronary intervention (PCI) within 120 minutes of presentation reduces mortality from 9% to 7% and is the preferred reperfusion strategy. 2

If PCI cannot be achieved within 120 minutes: 2

• Administer fibrinolytic therapy (alteplase, reteplase, or tenecteplase at full dose for patients <75 years)
• Use half-dose for patients ≥75 years
• Transfer for PCI within 24 hours after fibrinolysis

Acute Management for Non-ST-Elevation ACS

All patients require immediate medical therapy while awaiting risk stratification: 1

Antiplatelet Therapy

• Aspirin 75-150 mg daily (loading dose if not on maintenance) 1
• Clopidogrel 75 mg daily (600 mg loading dose) 1
• Continue dual antiplatelet therapy for 6 months post-PCI 1

Anticoagulation

• LMWH or unfractionated heparin initiated immediately 1
• Continue until angiography is performed 1

Anti-Ischemic Therapy

• Beta-blockers for heart rate control and symptom relief 1
• Oral or intravenous nitrates for persistent/recurrent chest pain 1
• Never use nitrates in hypertrophic cardiomyopathy or with phosphodiesterase inhibitors 1

High-Risk Criteria Requiring Early Invasive Strategy

Patients meeting any of these criteria require coronary angiography as soon as possible (within 24-48 hours), which reduces mortality from 6.5% to 4.9%: 1, 2

• Recurrent ischemia (chest pain or dynamic ST-segment changes, particularly ST-depression or transient ST-elevation) 1
• Elevated troponin levels 1
• Hemodynamic instability (hypotension, pulmonary rales) 1
• Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation) 1
• Diabetes mellitus 1
• Early post-infarction unstable angina 1

Invasive Management Protocol

• Start GPIIb/IIIa receptor inhibitor before angiography 1
• Continue for 12 hours (abciximab) or 24 hours (tirofiban, eptifibatide) after PCI 1
• Perform coronary angiography with FFR/iFR guidance when appropriate 1

Long-Term Medical Management (Chronic Phase)

Event Prevention - Mandatory for All Patients

Antiplatelet Therapy:

• Aspirin 75-100 mg daily lifelong after initial DAPT period 1
• Clopidogrel 75 mg daily is an effective alternative in aspirin-intolerant patients 1

Lipid Management:

• Statins are mandatory in all patients 1
• Add ezetimibe if LDL goals not achieved with maximum tolerated statin 1
• Add PCSK9 inhibitor for very high-risk patients not at goal on statin plus ezetimibe 1

ACE Inhibitors/ARBs:

• Recommended particularly with hypertension, diabetes, heart failure, or LV dysfunction 1

Symptom Management

First-line therapy: 1

• Beta-blockers and/or calcium channel blockers for heart rate control and angina relief
• Short-acting nitrates for immediate relief of effort angina

Second-line options when first-line inadequate: 1

• Long-acting nitrates
• Consider alternative calcium channel blocker if beta-blocker contraindicated

Gastrointestinal Protection

• Proton pump inhibitors recommended for patients on aspirin or DAPT at high gastrointestinal bleeding risk 1

Essential Lifestyle Interventions

Exercise-based cardiac rehabilitation is mandatory and significantly reduces cardiovascular mortality: 1

• Aerobic physical activity 150-300 minutes/week moderate intensity or 75-150 minutes/week vigorous intensity 1
• Multidisciplinary program involving cardiologists, nurses, dieticians, physiotherapists, psychologists 1

Additional interventions: 1

• Annual influenza vaccination, especially in elderly patients
• Psychological interventions for depression symptoms
• Cognitive behavioral interventions for lifestyle modification

Critical Monitoring and Follow-Up

• Review patient response to medical therapies at 2-4 weeks after drug initiation 1
• Patient education about disease, risk factors, and treatment strategy is essential 1
• Periodic cardiovascular assessment to reassess risk status, lifestyle adherence, and comorbidities 1

Common Pitfalls to Avoid

Do not delay reperfusion therapy in STEMI - every minute counts, with PCI preferred over fibrinolysis when achievable within 120 minutes. 2

Do not use prasugrel or ticagrelor as part of triple antithrombotic therapy with aspirin and oral anticoagulation. 1

Do not combine ivabradine with non-dihydropyridine calcium channel blockers due to drug interactions. 1

Do not perform coronary angiography solely for risk stratification without clinical indication for revascularization. 1