From the Guidelines
The therapy for Acute Coronary Syndrome (ACS) involves an invasive strategy with coronary angiography and revascularization, or an initial conservative strategy with medical therapy and possible later invasive evaluation, depending on patient risk and symptoms 1.
Treatment Pathways
- Invasive Strategy: Patients undergo coronary angiography within 4 to 24 hours of admission, with anti-ischemic, antiplatelet, and anticoagulant therapy started before angiography 1.
- Initial Conservative Strategy: Invasive evaluation is reserved for patients who fail medical therapy or have objective evidence of ischemia, with medical therapy including ASA, clopidogrel, and anticoagulants 1.
Medical Therapy
- Antiplatelet therapy: ASA and P2Y12 receptor inhibitors (e.g., clopidogrel) are essential for modifying the disease process and preventing recurrent MI 1.
- Anticoagulant therapy: UFH, enoxaparin, or fondaparinux are used to prevent thrombosis, with the choice and duration of therapy depending on patient risk and renal function 1.
Risk Assessment
- TIMI and GRACE risk scores are valuable tools for estimating patient risk and guiding therapy, with higher-risk patients benefiting from more aggressive treatment, including early coronary revascularization 1.
Special Considerations
- Patients with refractory ischemic symptoms or hemodynamic instability require urgent catheterization and revascularization, with GP IIb/IIIa inhibitors or P2Y12 receptor inhibitors started at the physician's discretion 1.
From the Research
Therapy for Acute Coronary Syndrome (ACS)
The therapy for Acute Coronary Syndrome (ACS) involves a multidisciplinary approach, including anti-platelet therapy, anticoagulant therapy, and reperfusion therapy.
- Dual antiplatelet therapy comprising aspirin plus a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor) is recommended for patients with non-ST-segment elevation ACS (NSTE-ACS) and those with ST-segment elevation myocardial infarction (STEMI) both during and after reperfusion 2.
- Anticoagulation in conjunction with antiplatelet therapy is central to the management of ACS, and is associated with a reduction in recurrent ischemic events and death 3.
- In patients with STEMI, an immediate reperfusion therapy is indicated, with primary percutaneous coronary intervention (PCI) being the gold standard 4.
- For patients with NSTE-ACS, coronary angiography should be performed within 72 hours in patients with risk factors, and treatment options include PCI, aorto-coronary bypass surgery, or sole medical therapy 4.
- The choice of antithrombotic agent(s), route of administration, drug-drug interactions, therapeutic drug monitoring, and factors that affect drug efficacy and safety should be carefully considered to minimize the risk of sub- or supra-therapeutic dosing and associated adverse events 5.
- A patient-tailored approach is necessary to reduce the risk and manage bleeding complications in ACS patients treated with dual antiplatelet therapy (DAPT) 6.