What is the first line treatment in Acute Coronary Syndrome (ACS)?

From the Guidelines

The first line treatment for acute coronary syndrome (ACS) should include immediate administration of aspirin, antiplatelet therapy with a P2Y12 inhibitor such as ticagrelor or prasugrel, anticoagulation, and pain management with nitroglycerin. The treatment approach may vary depending on whether the patient has ST-elevation myocardial infarction (STEMI) or non-ST elevation ACS (NSTE-ACS) [ 1 ]. For patients with STEMI, immediate reperfusion therapy with primary percutaneous coronary intervention (PCI) within 90 minutes of first medical contact or fibrinolytic therapy within 30 minutes if PCI is not available is crucial [ 1 ]. In contrast, for patients with NSTE-ACS, an early invasive strategy with cardiac catheterization within 24-72 hours is recommended for high-risk patients [ 1 ]. Key components of the treatment include:

• Aspirin (loading dose followed by a maintenance dose of 75-100 mg once daily) [ 1 ]
• Antiplatelet therapy with a P2Y12 inhibitor such as ticagrelor or prasugrel, with clopidogrel being an alternative only when the others are contraindicated or not available [ 1 ]
• Anticoagulation with unfractionated heparin or low molecular weight heparin
• Pain management with nitroglycerin (0.4 mg sublingual every 5 minutes as needed)
• Oxygen administration if saturation is below 90%
• Beta-blockers (such as metoprolol) should be given within the first 24 hours if there are no contraindications
• High-intensity statins (such as atorvastatin 80 mg or rosuvastatin 40 mg daily) should be initiated promptly [ 1 ]. This comprehensive approach targets multiple pathophysiological mechanisms to improve outcomes in patients with ACS.

From the Research

First Line Treatment in Acute Coronary Syndrome

The first line treatment in acute coronary syndrome (ACS) involves a combination of medical therapies and interventions.

• Aspirin is recommended for all patients with suspected ACS unless contraindicated 2.
• Dual antiplatelet therapy, which includes the addition of a second antiplatelet such as clopidogrel, ticagrelor, or prasugrel, is also recommended for most patients 2, 3.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 2, 3.

Medical Therapies

Other medical therapies that should be considered include:

• Statins to reduce cholesterol levels 2, 4.
• Angiotensin-converting enzyme inhibitors to reduce blood pressure and decrease the heart's workload 2.
• Beta blockers to reduce the heart's workload and prevent arrhythmias 2, 4.
• Nitroglycerin and morphine to relieve chest pain 2.
• Oxygen therapy to increase oxygen supply to the heart muscle 2.
• Proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher risk of gastrointestinal bleeding 2.

Interventional Therapies

Interventional therapies, such as percutaneous coronary intervention (PCI) with stent placement, should be performed as soon as possible in patients with ST-segment elevation myocardial infarction (STEMI) 2, 5.

• If PCI will be delayed for more than 120 minutes, fibrinolytic therapy should be used first 2, 5.
• For non-ST-segment elevation ACS, PCI is recommended, but fibrinolytic therapy is typically not recommended 2, 5.
• Coronary artery bypass grafting (CABG) may be necessary in some patients, ideally delayed 3 to 7 days after admission unless certain conditions are present, such as cardiogenic shock or life-threatening arrhythmias 2.