Acute Coronary Syndrome Management

Initial Approach and Risk Stratification

The European Society of Cardiology recommends that the initial management of acute coronary syndrome (ACS) should be risk-stratified, with an early invasive strategy recommended for high-risk patients, while PCI is the preferred revascularization method for most ACS patients, with CABG reserved for complex coronary anatomy or left main disease 1, 2
All patients with suspected ACS should undergo immediate risk stratification based on clinical presentation, ECG findings, and cardiac biomarkers to determine the appropriate management strategy 3, 4
The TIMI risk score, which includes 7 independent prognostic variables, is recommended to assess the risk of major adverse cardiac events and guide treatment decisions 5

Primary PCI is the preferred reperfusion strategy for STEMI patients when performed within 120 minutes of first medical contact 2
For STEMI patients in shock or who are hemodynamically unstable, immediate revascularization is recommended regardless of timing from symptom onset 2, 6
CABG is indicated for STEMI patients when PCI is not feasible, which is the only Class 1 indication for CABG in STEMI outside of mechanical complications 2
Complete revascularization of non-culprit lesions in stabilized STEMI patients with multivessel disease is recommended as a staged PCI procedure (Class 1) or staged CABG (Class 2a) 2
The American Heart Association recommends that for high-risk NSTE-ACS patients without contraindications, an early invasive strategy with coronary angiography and revascularization within 24-48 hours is associated with reduced mortality 1
The decision between PCI and CABG should be based on patient's clinical status and comorbidities, disease severity, and SYNTAX score for complex disease 1
For single-vessel disease, PCI of the culprit lesion is the first choice 9, 8
For left main or triple-vessel disease, CABG is the recommended procedure, particularly in patients with left ventricular dysfunction 9, 7, 8

Radial access is recommended as the standard approach for coronary angiography unless there are overriding procedural considerations 1
Drug-eluting stents (DES) are recommended over bare-metal stents for any PCI regardless of clinical presentation, lesion type, planned non-cardiac surgery, anticipated duration of DAPT, or concomitant anticoagulant therapy 1

For patients with coronary dissection during PCI, consider emergency CABG if PCI is not feasible or fails, especially for dissections involving the left main coronary artery 10
For patients with ACS and heart failure or cardiogenic shock, emergency coronary angiography is recommended, and emergency PCI of the culprit lesion is recommended if coronary anatomy is amenable 7
Routine use of intra-aortic balloon pump in patients with cardiogenic shock and no mechanical complications is not recommended 1