What is the appropriate management for a patient with acute coronary syndrome and HFpEF?

Management of Acute Coronary Syndrome with HFpEF

This patient requires an early invasive strategy with coronary angiography within 24 hours given his elevated troponins, lateral wall ischemia, and new RBBB, combined with dual antiplatelet therapy (aspirin plus ticagrelor), anticoagulation, high-intensity statin therapy, and beta-blocker therapy.

Immediate Risk Stratification and Timing of Intervention

This patient meets high-risk criteria for NSTE-ACS requiring early invasive management:

• Rising troponin levels (62.92 → 68.55) compatible with myocardial infarction 1
• Dynamic ECG changes with lateral wall ischemia and new RBBB 1
• Strong family history of premature coronary disease (father and uncle with MI in their 30s-50s) increases risk stratification 2

An early invasive strategy (<24 hours) is mandated based on ESC guidelines for patients with troponin elevation and dynamic ECG changes 1, 2. While the patient's chest pain has improved, this does not indicate plaque stabilization—ruptured plaques can show sustained potential for rapid progression despite clinical stability 1.

Antiplatelet Therapy

Immediate Dual Antiplatelet Therapy

Aspirin:

• Loading dose: 150-300 mg non-enteric formulation immediately 2
• Maintenance: 75-100 mg daily (specifically 81 mg when combined with ticagrelor) 2, 3

P2Y12 Inhibitor - Ticagrelor is the preferred agent:

• Ticagrelor 180 mg loading dose, then 90 mg twice daily is recommended for all patients at moderate-to-high risk with elevated troponins, regardless of initial treatment strategy 1, 2
• Ticagrelor is superior to clopidogrel with mortality benefit in contemporary guidelines 3
• Continue for 12 months unless contraindications such as excessive bleeding risk 1, 2

Alternative if ticagrelor contraindicated:

• Prasugrel (60 mg loading, 10 mg daily) if proceeding to PCI and no contraindications 1, 2
• Clopidogrel (300-600 mg loading, 75 mg daily) only if ticagrelor and prasugrel cannot be used 1, 4

Critical pitfall: The most common error is discharging ACS patients on aspirin monotherapy—dual antiplatelet therapy is mandatory 3. Do not use aspirin doses >81 mg when combining with ticagrelor, as higher doses increase bleeding without improving efficacy 3, 5.

Anticoagulation Therapy

Fondaparinux is the preferred anticoagulant:

• Fondaparinux 2.5 mg subcutaneously daily 2

Alternatives:

• Enoxaparin 1 mg/kg subcutaneously twice daily 2
• Unfractionated heparin (IV bolus 60-70 IU/kg, then infusion 12-15 IU/kg/h) 2
• Bivalirudin only if planned invasive strategy 2

Additional Pharmacological Management

High-Intensity Statin Therapy:

• Start immediately with high-intensity statin (e.g., atorvastatin 80 mg or rosuvastatin 40 mg daily) 1, 2
• Target LDL-C reduction ≥50% from baseline and achieve LDL-C <55 mg/dL 2

Beta-Blocker Therapy:

• Administer beta-blocker given his heart rate of 58 bpm is acceptable, though sinus bradycardia at rate 31 on ECG requires careful monitoring 2
• With HFpEF (LVEF 50-55%), beta-blockers are beneficial for symptom control and secondary prevention 2, 3
• Titrate to target heart rate 50-60 bpm as tolerated 3

ACE Inhibitor:

• Not immediately mandated with LVEF 50-55% unless he has hypertension (which he does—BP 134/83) 1, 2, 3
• Consider initiating ACE inhibitor given his hypertension history 2

Nitrates:

• For symptom relief if chest pain recurs 2

Gastroprotection:

• Proton pump inhibitor recommended given dual antiplatelet therapy and anticoagulation to prevent gastrointestinal bleeding 2, 6
• Avoid omeprazole or esomeprazole with clopidogrel (if used) as they reduce antiplatelet activity 4

Invasive Strategy and Revascularization

Coronary Angiography Timing:

• Perform within 24 hours based on high-risk criteria 1, 2

Revascularization Approach:

• Radial approach preferred over femoral to reduce bleeding, vascular complications, and mortality 2
• Intracoronary imaging to guide PCI in complex lesions 2
• Complete revascularization strategy if multivessel disease identified 2
• Consider CABG for multivessel disease based on complexity and comorbidities 2

Important consideration: If clopidogrel is used (not ticagrelor), stop it approximately 5 days before CABG if surgery is planned 1. However, ticagrelor is preferred and should be the initial choice 1.

Special Considerations for HFpEF

• His HFpEF (LVEF 50-55%) does not contraindicate standard ACS management 1
• Beta-blockers remain beneficial despite preserved ejection fraction 2, 3
• Avoid volume overload during management 2
• Monitor closely for acute heart failure decompensation, which would escalate to immediate invasive strategy (<2 hours) if accompanied by refractory angina or ST deviation 1

Monitoring and Follow-up

• Serial troponins to assess for ongoing myocardial injury 2
• Continuous cardiac monitoring for arrhythmias given new RBBB 2
• Echocardiography to evaluate regional wall motion abnormalities and confirm LV function 1, 2
• Cardiac rehabilitation referral after discharge 2

Key Clinical Pitfalls to Avoid

• Do not delay angiography beyond 24 hours in this high-risk patient—initial clinical stability does not indicate plaque stabilization 1
• Do not discharge on aspirin monotherapy—this is the most critical error 3
• Do not use high-dose aspirin (>81 mg) with ticagrelor—increases bleeding without efficacy benefit 3, 5
• Do not assume beta-blockers are contraindicated with sinus bradycardia rate 31 on single ECG—his vital signs show HR 58, which is acceptable 2, 3
• Do not withhold ticagrelor pending angiography—it should be started immediately for all moderate-to-high risk patients 1, 2