Management of Acute Coronary Syndrome

Initial Assessment and Diagnosis

• The European Society of Cardiology recommends performing immediate ECG (within 10 minutes of first medical contact) to detect ST-segment deviations or other abnormalities 3
• Obtain cardiac biomarkers, preferably high-sensitivity cardiac troponin, with a rapid rule-out and rule-in protocol at 0h and 1h (additional testing after 3-6h if inconclusive), as recommended by the European Heart Journal 1
• Perform echocardiography to evaluate regional and global left ventricular function and rule out differential diagnoses, according to the European Heart Journal 1
• Monitor for arrhythmias with multi-lead ECG monitoring, as suggested by the European Heart Journal 4

Risk Stratification and Timing of Invasive Strategy

• The European Heart Journal recommends an immediate invasive strategy (<2h) for patients with hemodynamic instability or cardiogenic shock 5
• Recurrent or ongoing chest pain refractory to medical treatment requires an immediate invasive strategy (<2h), as recommended by the European Heart Journal 2
• Mechanical complications of MI necessitate an immediate invasive strategy (<2h), according to the European Heart Journal 2
• Recurrent dynamic ST- or T-wave changes, particularly with intermittent ST elevation, require an early invasive strategy (<24h), as recommended by the European Heart Journal 1, 2
• A GRACE score >140 indicates a high-risk criterion for an early invasive strategy (<24h), according to the European Heart Journal 1, 2

Pharmacological Management

• The European Heart Journal recommends aspirin as an initial dose of 150-300 mg non-enteric formulation followed by 75-100 mg/day 3
• A P2Y12 inhibitor (in addition to aspirin for 12 months unless contraindicated) is recommended, with ticagrelor (180 mg loading dose, 90 mg twice daily) being the preferred option for all patients at moderate to high risk of ischemic events, as suggested by the European Heart Journal 1, 2
• Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended in patients proceeding to PCI without contraindications, according to the European Heart Journal 1, 2
• Fondaparinux (2.5 mg daily subcutaneously) is the preferred option for anticoagulation, as recommended by the European Heart Journal 3
• Enoxaparin (1 mg/kg twice daily subcutaneously) is an alternative option for anticoagulation, according to the European Heart Journal 3
• Unfractionated heparin (IV bolus 60-70 IU/kg followed by infusion of 12-15 IU/kg/h) is another option for anticoagulation, as suggested by the European Heart Journal 3
• Bivalirudin is indicated only in patients with planned invasive strategy, according to the European Heart Journal 3
• Beta-blockers should be administered if tachycardic or hypertensive without signs of heart failure, as recommended by the European Heart Journal 3
• Nitrates are recommended for symptom relief in persistent or recurrent chest pain, according to the European Heart Journal 4
• High-intensity statin therapy should be started as early as possible, as suggested by the European Heart Journal 1, 2
• ACE inhibitors are recommended in patients with systolic LV dysfunction, heart failure, hypertension, or diabetes, according to the European Heart Journal 7
• GP IIb/IIIa inhibitors should be considered in high-risk patients while waiting for angiography, as recommended by the European Heart Journal 4

Revascularization Strategies

• The American College of Cardiology recommends a radial approach over femoral approach to reduce bleeding, vascular complications, and death 8, 5
• Intracoronary imaging is recommended to guide PCI in patients with complex coronary lesions, according to the American College of Cardiology 8, 5
• Complete revascularization strategy is recommended in patients with multivessel disease, as suggested by the American College of Cardiology 8, 5
• Coronary Artery Bypass Grafting (CABG) should be considered for patients with multivessel disease based on complexity of coronary artery disease and comorbidities, according to the American College of Cardiology 8, 5

Special Considerations

• Emergency revascularization of the culprit vessel is indicated in patients with cardiogenic shock, as recommended by the American College of Cardiology 8, 5
• Routine PCI of non-infarct-related arteries at the time of PCI is not recommended in patients with cardiogenic shock, according to the American College of Cardiology 8, 5
• Mechanical circulatory support should be considered in selected patients with cardiogenic shock, as suggested by the American College of Cardiology 8, 5
• In patients at risk for gastrointestinal bleeding, a proton pump inhibitor is recommended, according to the American College of Cardiology 5
• For patients who have tolerated dual antiplatelet therapy with ticagrelor, transition to ticagrelor monotherapy is recommended ≥1 month after PCI, as suggested by the American College of Cardiology 5

Long-term Management and Secondary Prevention

• Beta-blockers should be continued, especially in patients with reduced LV function, as recommended by the European Heart Journal 9
• High-intensity statin therapy should be maintained long-term, according to the European Heart Journal 1, 2
• Aggressive risk factor modification, including smoking cessation, is recommended, as suggested by the European Heart Journal 9
• Referral to cardiac rehabilitation is recommended, according to the American College of Cardiology 8, 5
• ACE inhibitors should be considered for secondary prevention, particularly in patients with LV dysfunction, as recommended by the European Heart Journal 9