Management of Coronary Artery Disease with Acute Coronary Syndrome and Normal Left Ventricular Ejection Fraction

Initial Management and Risk Stratification

The European Society of Cardiology recommends an early invasive strategy (<24 hours) with appropriate antithrombotic therapy for patients with CAD and ACS with normal LVEF planned for coronary angiography, followed by revascularization based on coronary anatomy findings 1
For patients with ACS who have high-risk criteria, including rise or fall in cardiac biomarkers compatible with myocardial infarction, dynamic ST- or T-wave changes, or GRACE score >140, an early invasive strategy (<24 hours) is recommended 1
For very high-risk patients, including those with hemodynamic instability, refractory angina, life-threatening arrhythmias, mechanical complications of myocardial infarction, or acute heart failure, an immediate invasive strategy (<2 hours) is recommended 1

Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor is recommended for patients with CAD and ACS 2
A potent P2Y12 inhibitor, such as prasugrel or ticagrelor, is preferred over clopidogrel unless contraindicated 2
Peri-interventional anticoagulation with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) is recommended in addition to antiplatelet therapy 2
For patients on fondaparinux, a single bolus of UFH is indicated 2

For significant left main coronary stenosis, coronary artery bypass grafting (CABG) is generally recommended over percutaneous coronary intervention (PCI) to improve survival and reduce risk of repeat revascularization 3
For left main disease with low complexity, PCI is an acceptable alternative to CABG 3
For patients with three-vessel disease and normal LVEF, CABG is recommended to improve long-term survival 3, 4
For diabetic patients with multivessel disease, CABG is preferred over PCI 4
For single or double vessel disease involving the proximal left anterior descending artery, either CABG or PCI is recommended 3, 4
For single or double vessel disease not involving the proximal left anterior descending artery, PCI is recommended 3

DAPT with a P2Y12 inhibitor plus aspirin is recommended for 12 months after ACS with stent implantation, unless there are contraindications such as excessive bleeding risk 2
Secondary prevention measures, including medical therapy and lifestyle changes, should be started and reinforced after revascularization 2
Participation in a cardiac rehabilitation program is recommended to improve outcomes 2
Standard secondary prevention includes antiplatelet therapy, statins to achieve low-density lipoprotein cholesterol targets, beta-blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers 2, 5
Proton pump inhibitors should be considered in patients at high risk of gastrointestinal bleeding receiving DAPT 5