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.
Key Principles
- Optimal anti-ischemic and antithrombotic medical therapy should be administered to all patients with ACS, including aspirin, clopidogrel, and anticoagulant therapy such as unfractionated heparin or enoxaparin 1.
- The invasive strategy involves coronary angiography within 4 to 24 hours of admission, and is recommended for patients with high-risk features, such as refractory angina or hemodynamic instability 1.
- The initial conservative strategy involves medical therapy and possible later invasive evaluation, and is recommended for patients with low-risk features, such as stable angina or no evidence of ischemia 1.
Treatment Pathways
- Urgent coronary angiography and revascularization is recommended for patients with ongoing ischemic symptoms or hemodynamic or rhythm instability 1.
- Early invasive strategy is recommended for patients with high-risk features, such as elevated troponin levels or ST-segment depression 1.
- Selective invasive management is recommended for patients with intermediate-risk features, such as stable angina or no evidence of ischemia 1.
Medical Therapy
- Aspirin should be administered to all patients with ACS, unless contraindicated 1.
- Clopidogrel should be administered to all patients with ACS, unless contraindicated 1.
- Anticoagulant therapy should be administered to all patients with ACS, unless contraindicated, and should be managed according to patient risk and symptoms 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.