Management of Acute Coronary Syndrome

Initial Assessment and Diagnosis

• The European Society of Cardiology recommends obtaining a 12-lead ECG to distinguish ST-segment elevation myocardial infarction (STEMI) from non-ST-segment elevation ACS (NSTE-ACS), as STEMI requires immediate reperfusion while NSTE-ACS follows a risk-stratified approach 1, 2
• Administer aspirin 150-300 mg loading dose immediately to all patients without contraindications, as recommended by the European Heart Journal 1, 2
• Start continuous cardiac monitoring for arrhythmia detection and multi-lead ischemia monitoring, as suggested by the European Heart Journal 3, 4
• Assess vital signs with particular attention to hemodynamic instability and signs of heart failure, as recommended by the European Heart Journal 3, 4

Initial Pharmacological Management

• The European Society of Cardiology recommends dual antiplatelet therapy (DAPT) for 12 months unless contraindicated, with ticagrelor as the preferred P2Y12 inhibitor for all patients at moderate to high risk of ischemic events 1, 5, 6
• Initiate parenteral anticoagulation with low molecular weight heparin (LMWH) or unfractionated heparin immediately, as recommended by the European Heart Journal 3, 7, 2
• Administer sublingual or intravenous nitrates for ongoing chest pain, as suggested by the European Heart Journal 3, 7, 4, 2
• Initiate beta-blockers in the absence of contraindications, as recommended by the European Heart Journal 3, 7, 4, 2

Risk Stratification and Invasive Strategy

• The European Society of Cardiology recommends an immediate invasive strategy (<2 hours) for very-high-risk criteria, including hemodynamic instability or cardiogenic shock 1, 5, 6, 8
• Perform primary PCI within 120 minutes of presentation for patients with persistent ST-segment elevation, as recommended by the European Heart Journal 8
• Consider an early invasive strategy (<24 hours) for high-risk criteria, including rise or fall in cardiac troponin compatible with MI, as suggested by the European Heart Journal 1, 5, 6

Revascularization Strategy

• The European Society of Cardiology recommends radial access as the standard approach for percutaneous coronary intervention (PCI), unless there are overriding procedural considerations 8
• Use drug-eluting stents (DES) over bare-metal stents for any PCI, as recommended by the European Heart Journal 8
• Base revascularization strategy on patient's clinical status, comorbidities, and disease severity, as suggested by the European Heart Journal 8

Special Populations

• Apply the same diagnostic and interventional strategies to elderly patients (≥75 years) as to younger patients, with adjustments for antithrombotic agent dosage based on renal function and specific contraindications, as recommended by the European Heart Journal 8
• Use low- or iso-osmolar contrast media at the lowest possible volume in invasive strategies for patients with chronic kidney disease, as suggested by the European Heart Journal 8
• Screen all patients with NSTE-ACS for diabetes and monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycemia, as recommended by the European Heart Journal 8