What is the latest American Heart Association (AHA) recommendation for treating a patient with Acute Coronary Syndrome (ACS)?

Latest AHA Recommendations for Acute Coronary Syndrome Management

All patients with ACS should receive dual antiplatelet therapy (DAPT) consisting of aspirin plus a P2Y12 inhibitor for at least 12 months, with ticagrelor or prasugrel strongly preferred over clopidogrel for patients undergoing PCI. 1

Immediate Antiplatelet Therapy

Aspirin Administration

• Administer aspirin 162-325 mg orally (chewed, non-enteric coated) immediately upon ACS diagnosis to reduce death and major adverse cardiovascular events 1
• Continue with daily maintenance dose of 75-100 mg (non-enteric coated) 1
• If oral administration impossible, use rectal or intravenous routes 1

P2Y12 Inhibitor Selection

For patients undergoing PCI:

• First-line: Ticagrelor 180 mg loading dose, then 90 mg twice daily 1, 2, 3
• Alternative first-line: Prasugrel 60 mg loading dose, then 10 mg daily (if body weight ≥60 kg and age <75 years) 1, 2
• Avoid prasugrel in patients with prior stroke/TIA due to increased cerebrovascular event risk 3
• Reserve clopidogrel (300-600 mg loading, then 75 mg daily) only for patients who cannot receive ticagrelor or prasugrel due to contraindications or need for oral anticoagulation 1, 2

For NSTE-ACS patients with invasive strategy delayed >24 hours:

• Upstream treatment with clopidogrel or ticagrelor may be considered 1, 3

For patients already on clopidogrel:

• Switch to ticagrelor early after hospital admission with 180 mg loading dose, regardless of clopidogrel timing 2

Revascularization Strategy

Procedural Approach

• Radial artery access is preferred over femoral access to reduce bleeding, vascular complications, and death 1, 3
• Intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions 1, 3

Extent of Revascularization

• Complete revascularization is recommended for both STEMI and NSTE-ACS patients 1, 3
• For STEMI with multivessel disease, PCI of non-culprit stenoses can be performed in single procedure or staged, with preference toward single-procedure multivessel PCI 1, 3
• In cardiogenic shock, emergency revascularization of culprit vessel only is indicated—do not perform routine PCI of non-infarct-related arteries during the same procedure 1, 3

Anticoagulation

All ACS patients require parenteral anticoagulation regardless of management strategy (options: enoxaparin, bivalirudin, fondaparinux, or unfractionated heparin) 2, 3

Adjunctive Pharmacotherapy

Symptom Management

• Sublingual nitroglycerin 0.3-0.4 mg every 5 minutes (maximum 3 doses) for persistent anginal pain 1
• Avoid nitrates if systolic BP <90 mmHg, >30 mmHg drop from baseline, or suspected right ventricular infarction 1
• Avoid nitrates within 12 hours of avanafil, 24 hours of sildenafil/vardenafil, or 48 hours of tadalafil 1
• Morphine 2-4 mg IV or fentanyl 25-50 μg IV only for pain resistant to maximally tolerated anti-ischemic medications (note: may delay oral P2Y12 inhibitor absorption) 1

Glycoprotein IIb/IIIa Inhibitors

• Do not administer routinely due to lack of ischemic benefit and increased bleeding risk 1
• Reasonable only as adjunctive/bailout therapy during PCI with large thrombus burden, no-reflow, or slow flow 1

Mandatory Bleeding Risk Mitigation

Three critical interventions to reduce bleeding:

1. Prescribe proton pump inhibitor (PPI) to all patients on DAPT (Class I recommendation)—PPIs are superior to H2 receptor antagonists 2, 3
2. Use radial access for PCI when performed by experienced radial operator 2, 3
3. Maintain aspirin dose at 75-100 mg daily when combined with P2Y12 inhibitor (full-dose aspirin 300-325 mg increases bleeding without ischemic benefit) 1, 2

Duration of DAPT

• Default duration: 12 months for all ACS patients not at high bleeding risk, regardless of ACS type, stent type, or completeness of revascularization 1, 2, 3
• For high bleeding risk patients: shortened duration of 6 months may be reasonable 2
• After tolerating DAPT with ticagrelor ≥1 month post-PCI, transition to ticagrelor monotherapy is recommended 1, 3

Special Populations

Patients Requiring Long-Term Anticoagulation

• Discontinue aspirin 1-4 weeks after PCI and continue P2Y12 inhibitor (preferably clopidogrel, not ticagrelor or prasugrel) 1, 2, 3, 4
• Limit triple therapy (OAC + aspirin + clopidogrel) to maximum 1 month, then transition to dual therapy (OAC + P2Y12 inhibitor) 4
• Use lowest effective NOAC dose for stroke prevention when combined with antiplatelet therapy 4

Post-CABG Patients

• Resume P2Y12 inhibitor therapy after CABG to complete 12 months of DAPT 2

Cardiogenic Shock

• Microaxial flow pump use is reasonable in selected patients to reduce mortality, but requires careful attention to vascular access and weaning due to increased bleeding, limb ischemia, and renal failure complications 1, 3

Anemia

• Red blood cell transfusion to maintain hemoglobin of 10 g/dL may be reasonable in patients with ACS and acute or chronic anemia who are not actively bleeding 1, 3

Secondary Prevention After Discharge

• Fasting lipid panel 4-8 weeks after initiating or adjusting lipid-lowering therapy 1, 3
• Referral to cardiac rehabilitation is recommended, with home-based programs as option for patients unable to attend in person 1, 3

Critical Pitfalls to Avoid

1. Never use clopidogrel as first-line therapy when ticagrelor or prasugrel are available and not contraindicated—this represents suboptimal care 2
2. Never discontinue DAPT prematurely, especially within first month after stent placement—dramatically increases risk of stent thrombosis, MI, and death 2
3. Never fail to prescribe PPI with DAPT—this simple intervention significantly reduces GI bleeding 2, 3
4. Never use ticagrelor or prasugrel in combination with oral anticoagulation—significantly increases bleeding risk without clear ischemic benefit; use clopidogrel instead 4
5. Never give prasugrel to patients with prior stroke/TIA, age >75 years, or weight <60 kg without dose adjustment 1, 3