Acute Coronary Syndrome Management

Diagnosis and Initial Assessment

Obtain 12-lead ECG within 10 minutes of arrival at emergency facility, and perform serial ECGs at 15-30 minute intervals during the first hour in symptomatic patients with initial nondiagnostic ECG, as recommended by the American Heart Association 1, 2
Measure cardiac troponin (preferably high-sensitivity) as soon as possible, and repeat in 1-2 hours for high-sensitivity assays or 3-6 hours for conventional assays if initial troponin is nondiagnostic, to diagnose Acute Coronary Syndrome (ACS) 2
Use the TIMI Risk Score to predict all-cause mortality, new/recurrent MI, or severe recurrent ischemia requiring revascularization, and the GRACE Risk Score to predict death or MI in STEMI or intermediate-risk NSTE-ACS 1, 2
Early ECG acquisition should be performed within 10 minutes of first medical contact to diagnose STEMI and NSTEMI, characterized by new ST-elevation ≥1 mm in ≥2 contiguous leads and ST-depression ≥0.5 mm in ≥2 contiguous leads, respectively, as recommended by the American College of Cardiology 2

The American Heart Association recommends aspirin (Class I) for immediate and daily oral administration, and a P2Y12 inhibitor (Class I) such as clopidogrel, ticagrelor, or prasugrel in addition to aspirin, for patients with ACS 1, 3
Administer nitrates (Class IC) sublingually followed by intravenous administration, and β-blockers (Class IB) intravenously, and consider morphine (Class IC) for symptoms not relieved with nitroglycerin or acute pulmonary congestion/agitation, as recommended by the American College of Cardiology 3
Continue antiplatelet therapy for up to 12 months if medically treated, and at least 12 months if treated with coronary stenting, with a preference for ticagrelor or prasugrel over clopidogrel for ACS patients undergoing PCI, as recommended by the American College of Cardiology 1, 2

An urgent/immediate invasive strategy (Class I, LOE A) is recommended for patients with refractory angina, hemodynamic instability, or electrical instability, and an early invasive strategy (Class I, LOE B) is recommended for initially stabilized patients with elevated risk for clinical events, as recommended by the American Heart Association 1
Consider an early invasive strategy (Class IIa, LOE B) over delayed invasive strategy for high-risk patients, and an ischemia-guided strategy (Class IIb) may be considered for low-risk patients with negative biomarkers, as recommended by the American College of Cardiology 1, 4
Intracoronary imaging is recommended to guide PCI in patients with ACS with complex coronary lesions, as recommended by the American College of Cardiology 2

Echocardiography is indicated for patients with cardiogenic shock, hemodynamic instability, or suspected mechanical complications, and radionuclide imaging can provide additional evidence for ACS in patients with nondiagnostic ECGs and normal cardiac biomarkers, as recommended by the American College of Cardiology 2, 3
Obtain supplemental ECG leads (V7-V9) in patients with initial nondiagnostic ECG at intermediate/high risk for ACS (Class IIa, LOE B), as recommended by the American Heart Association 1

Admit patients with ongoing angina, hemodynamic instability, uncontrolled arrhythmias, or cardiogenic shock to the Cardiac Intensive Care Unit (CICU), and stable patients without recurrent ischemia or significant arrhythmias can be admitted to intermediate care or telemetry unit, as recommended by the American College of Cardiology 2
Cardiac rehabilitation is recommended for all ACS patients, and should include assessment of self-care capacity, barriers to medication adherence, and referral to cardiac rehabilitation with consideration of home-based or hybrid options, as recommended by the American College of Cardiology 2

Fibrinolytic therapy is contraindicated in NSTE-ACS and may be harmful, and glucocorticoids and NSAIDs may increase the risk of recurrent MI, as recommended by the American Heart Association 2, 4
Careful assessment of contraindications to invasive approaches including bleeding risk, thrombocytopenia, kidney disease, and patient preferences is recommended, as recommended by the American College of Cardiology 2

The American College of Cardiology recommends aggressive lipid management with high-intensity statins regardless of baseline LDL-C, and multiple add-on lipid-lowering therapies (ezetimibe, PCSK9 inhibitors, bempedoic acid), as recommended by the American College of Cardiology 2
Medication reconciliation, including prescription for sublingual nitroglycerin, and bleeding risk reduction strategies, such as proton pump inhibitor for GI bleeding risk and ticagrelor monotherapy ≥1 month after PCI, are also recommended, as recommended by the American College of Cardiology 2