What is the management of Acute Coronary Syndrome (ACS) with concomitant hypertension in the emergency room?

From the Guidelines

In the emergency room setting for patients with acute coronary syndrome (ACS) and high blood pressure, blood pressure should be controlled but not aggressively lowered, with first-line medications including intravenous nitroglycerin and beta-blockers such as metoprolol, as recommended by the most recent guidelines 1.

Key Considerations

• The primary goal is to balance blood pressure control with the need to maintain coronary perfusion, as aggressive lowering can worsen myocardial ischemia.
• Target blood pressure should be approximately 130-140/80-90 mmHg, avoiding drops greater than 25% in the first 24 hours.
• For patients with severe hypertension (>180/110 mmHg), additional options include labetalol or nicardipine.
• ACE inhibitors should be started within 24 hours for patients with anterior MI, heart failure, or ejection fraction <40%, but are generally not first-line for immediate blood pressure control in the ER.
• Calcium channel blockers like amlodipine may be used in patients with contraindications to beta-blockers, but verapamil and diltiazem should be avoided in heart failure or reduced ejection fraction.

Management Approach

• Initial evaluation and management should take place promptly, with a focus on rapid assessment and initiation of therapy, as recommended by the American College of Cardiology/American Heart Association guidelines 1.
• The use of emergency coronary angiography and primary percutaneous coronary intervention (PCI) may be considered in patients with cardiogenic shock or other high-risk features, as recommended by the European Society of Cardiology guidelines 1.
• The management of acute heart failure should follow current guideline recommendations, with a focus on emergency echocardiography and the use of evidence-based therapies, as recommended by the European Society of Cardiology guidelines 1.

Evidence-Based Recommendations

• The 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation recommend the use of emergency coronary angiography and primary PCI in patients with cardiogenic shock or other high-risk features 1.
• The 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction recommend the use of intravenous nitroglycerin and beta-blockers as first-line therapies for patients with ACS and high blood pressure 1.
• The 2007 scientific statement from the American Heart Association Council for High Blood Pressure Research and the Councils on Clinical Cardiology and Epidemiology and Prevention recommend the use of intravenous nitroglycerin, furosemide, and a short-acting or intravenous ACE inhibitor in patients with acute severe hypertension and "flash" pulmonary edema 1.

From the Research

Management of ACS in the Emergency Room

• Aspirin is recommended for all patients with suspected acute coronary syndrome (ACS) unless contraindicated, as stated in the study 2.
• Addition of a second antiplatelet, such as clopidogrel, ticagrelor, or prasugrel, is also recommended for most patients 2.
• Parenteral anticoagulation with unfractionated heparin, low-molecular-weight heparin, bivalirudin, or fondaparinux is recommended 2.
• Nitroglycerin is used to relieve angina and beta blockers are recommended if not contraindicated 3.

High Blood Pressure Medication in ACS Patients

• A history of hypertension is highly prevalent among patients presenting with myocardial infarction (MI) and some studies have associated it with a worse prognosis 4.
• Good long-term blood pressure control, ideally initiated prior to discharge, should be pursued in order to improve secondary prevention 4.
• Low levels of admission and in-hospital blood pressure may indicate an increased risk for subsequent events 4.

Prehospital Administration of Medication

• Prehospital administration of aspirin and nitroglycerin by non-physician healthcare professionals is beneficial for patients with suspected ACS, although the certainty of evidence is very low 5.
• Prehospital aspirin administration is associated with significantly lower 30-day and 1-year mortality compared with aspirin administration after arrival at hospital 5.
• Prehospital nitroglycerin administration is also associated with significantly lower 30-day and 1-year mortality compared with no prehospital administration 5.