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

From the Guidelines

Management of acute coronary syndrome (ACS) requires immediate intervention with a dual approach of pharmacological therapy and potential revascularization, with the goal of reducing morbidity, mortality, and improving quality of life. The initial management includes administering aspirin (325 mg loading dose, then 81 mg daily), a P2Y12 inhibitor such as clopidogrel (300-600 mg loading dose, then 75 mg daily), ticagrelor (180 mg loading dose, then 90 mg twice daily), or prasugrel (60 mg loading dose, then 10 mg daily), and anticoagulation with unfractionated heparin or low molecular weight heparin 1.

Key Components of Management

• Pain management with nitroglycerin (0.4 mg sublingual or IV infusion at 5-200 mcg/min) helps relieve chest pain and improve myocardial oxygen supply.
• Beta-blockers like metoprolol (5 mg IV every 5 minutes for 3 doses, then 25-100 mg orally twice daily) reduce heart rate and contractility, decreasing oxygen demand.
• High-dose statins such as atorvastatin 80 mg daily should be initiated promptly.
• Oxygen therapy is recommended for patients with oxygen saturation below 90%.

Revascularization Strategies

• For ST-elevation myocardial infarction (STEMI), primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact is preferred, or fibrinolytic therapy if PCI is not available within 120 minutes 1.
• For non-ST elevation ACS, an early invasive strategy with coronary angiography within 24-72 hours is recommended for high-risk patients 1.

Long-term Management

• Dual antiplatelet therapy for 6-12 months, statins, beta-blockers, ACE inhibitors or ARBs, lifestyle modifications, and cardiac rehabilitation are essential for preventing recurrent events and improving quality of life 1.

This comprehensive approach targets both immediate stabilization and prevention of recurrent events by addressing thrombosis, ischemia, and underlying atherosclerotic disease, ultimately reducing morbidity, mortality, and improving quality of life for patients with ACS.

From the FDA Drug Label

Prasugrel tablets are indicated to reduce the rate of thrombotic CV events (including stent thrombosis) in patients with acute coronary syndrome (ACS) who are to be managed with percutaneous coronary intervention (PCI) as follows: Patients with unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) Patients with ST-elevation myocardial infarction (STEMI) when managed with primary or delayed PCI.

The management of acute coronary syndrome with prasugrel involves administering a 60 mg oral loading dose, followed by 10 mg orally once daily. Patients should also take aspirin (75 mg to 325 mg) daily. The loading dose can be administered at the time of diagnosis for STEMI patients presenting within 12 hours of symptom onset, or at the time of PCI for UA/NSTEMI patients and STEMI patients presenting more than 12 hours after symptom onset.

• Key considerations:
  • Prasugrel is generally not recommended in patients ≥75 years of age, except in high-risk situations.
  • The medication is contraindicated in patients with active pathological bleeding or a history of transient ischemic attack (TIA) or stroke.
  • Patients weighing <60 kg may require a lower maintenance dose of 5 mg due to increased exposure to the active metabolite and risk of bleeding.
  • Prasugrel should be discontinued at least 7 days prior to any surgery, if possible.
  • Discontinuing prasugrel, particularly in the first few weeks after acute coronary syndrome, increases the risk of subsequent cardiovascular (CV) events 2, 2, 2.

From the Research

Management of Acute Coronary Syndrome

The management of acute coronary syndrome (ACS) involves a combination of pharmacological and interventional therapies.

• Aspirin is recommended for all patients with suspected ACS unless contraindicated, and dual antiplatelet therapy with a second agent such as clopidogrel, prasugrel, or ticagrelor is also recommended for most patients 3.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 3, 4.
• Other medical therapies that may be used include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine for chest pain relief, as well as oxygen therapy 3, 5.

Interventional Therapies

• For patients with ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) with stent placement is recommended as soon as possible, with fibrinolytic therapy used if PCI is delayed for more than 120 minutes 3.
• For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is not typically used 3.
• Coronary artery bypass grafting (CABG) may be necessary for some patients, ideally delayed 3-7 days after admission unless certain high-risk conditions are present 3.

Antiplatelet and Anticoagulation Therapy

• Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is recommended for patients with ACS, with the choice of P2Y12 inhibitor depending on individual patient factors 4, 6, 7.
• Anticoagulation therapy with bivalirudin, unfractionated heparin, enoxaparin, or fondaparinux may be used, with the choice of agent depending on individual patient factors and the specific clinical scenario 4, 6.
• New oral anticoagulants such as rivaroxaban may also be used in certain patients with ACS, particularly those with a history of atrial fibrillation or other indications for anticoagulation 6.