What is the initial treatment for Acute Coronary Syndrome (ACS)?

From the Guidelines

The initial treatment for acute coronary syndrome (ACS) should begin immediately with aspirin 325 mg chewed (or 162-325 mg orally), followed by a maintenance dose of 81-325 mg daily, as recommended by the most recent guidelines 1.

Initial Treatment

The treatment should also include oxygen administration if oxygen saturation is below 90% or the patient is in respiratory distress.

• Pain management with nitroglycerin (0.4 mg sublingual every 5 minutes for up to 3 doses) is recommended unless systolic blood pressure is below 90 mmHg or the patient has used phosphodiesterase inhibitors within 24-48 hours.
• Morphine (2-4 mg IV with incremental doses) can be given for persistent pain.

Additional Medications

Additional medications include:

• P2Y12 inhibitors such as ticagrelor (180 mg loading dose, then 90 mg twice daily) or clopidogrel (600 mg loading dose, then 75 mg daily) 1.
• Anticoagulation with unfractionated heparin or low molecular weight heparin.
• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily).

Beta-Blockers and Risk Stratification

• Beta-blockers (metoprolol 25-50 mg orally every 6-12 hours) should be started within 24 hours if there are no contraindications.
• Patients should undergo immediate risk stratification to determine if urgent cardiac catheterization is needed, particularly for ST-elevation myocardial infarction where primary percutaneous coronary intervention within 90 minutes is the goal 1. The most recent guidelines from the European Heart Journal 1 provide the best approach for managing ACS, focusing on reducing morbidity, mortality, and improving quality of life.

From the FDA Drug Label

Initiate prasugrel tablets treatment as a single 60 mg oral loading dose and then continue at 10 mg orally once daily. In the clinical trial that established the efficacy and safety of prasugrel tablets, the loading dose of prasugrel tablets was not administered until coronary anatomy was established in UA/NSTEMI patients and in STEMI patients presenting more than 12 hours after symptom onset In STEMI patients presenting within 12 hours of symptom onset, the loading dose of prasugrel tablets was administered at the time of diagnosis, although most received prasugrel tablets at the time of PCI

The initial treatment for Acute Coronary Syndrome (ACS) with prasugrel is a single 60 mg oral loading dose, followed by 10 mg orally once daily. The timing of the loading dose depends on the type of ACS and the time of symptom onset.

• For UA/NSTEMI patients, the loading dose is administered after coronary anatomy is established.
• For STEMI patients presenting within 12 hours of symptom onset, the loading dose is administered at the time of diagnosis, usually at the time of PCI.
• For STEMI patients presenting more than 12 hours after symptom onset, the loading dose is administered after coronary anatomy is established. It is also recommended that patients take aspirin (75 mg to 325 mg) daily. 2

From the Research

Initial Treatment for Acute Coronary Syndrome

The initial treatment for acute coronary syndrome (ACS) involves a combination of medical therapies and interventions.

• Aspirin is recommended for all patients with suspected ACS unless contraindicated 3.
• Dual antiplatelet therapy, which includes aspirin and a second antiplatelet agent such as clopidogrel, ticagrelor, or prasugrel, is also recommended for most patients 3, 4.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 3, 4.
• Other medical therapies that should be considered include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 3.

Interventional Therapies

• For patients with ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible 3.
• If PCI will be delayed for more than 120 minutes, fibrinolytic therapy should be used first 3.
• For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is typically not recommended 3.
• Coronary artery bypass grafting may be necessary in some cases, ideally delayed 3 to 7 days after admission unless certain conditions are present, such as cardiogenic shock or life-threatening arrhythmias 3.

Antiplatelet and Anticoagulation Agents

• The choice of antiplatelet and anticoagulation agents depends on the individual patient's risk factors and medical history 4, 5.
• New P2Y12 receptor inhibitors, such as prasugrel and ticagrelor, have clear benefits compared with clopidogrel for dual antiplatelet therapy 5.
• Novel oral anticoagulants, such as rivaroxaban, have been shown to be at least as effective as vitamin K antagonists in atrial fibrillation and led to fewer bleeding complications 5.