Acute Coronary Syndrome Management

Introduction to Medications

The American College of Cardiology recommends a core ACS medication regimen consisting of dual antiplatelet therapy, parenteral anticoagulation, high-intensity statin therapy, beta-blockers, and ACE inhibitors or ARBs, with additional therapies including nitrates and proton pump inhibitors for high-risk patients 1, 2, 3

The European Society of Cardiology recommends aspirin loading dose of 150-300 mg orally and maintenance dose of 75-100 mg daily indefinitely for ACS patients 1, 2, 3
The American Heart Association recommends ticagrelor as the preferred first-line P2Y12 inhibitor, with a loading dose of 180 mg orally and maintenance dose of 90 mg twice daily for 12 months 2, 3, 4
Prasugrel is recommended for PCI patients, with a loading dose of 60 mg orally and maintenance dose of 10 mg daily, and should be reduced to 5 mg daily if age ≥75 years or body weight <60 kg 2, 3, 4

The American College of Cardiology recommends fondaparinux as the preferred anticoagulant for medical management, with a dose of 2.5 mg subcutaneously daily, and contraindicated if CrCl <30 mL/min 1, 3
Enoxaparin is an alternative anticoagulant, with a dose of 1 mg/kg subcutaneously every 12 hours, and should be reduced to 1 mg/kg daily if CrCl <30 mL/min 1, 3
Bivalirudin is recommended for PCI support, with a bolus dose of 0.75 mg/kg IV and infusion dose of 1.75 mg/kg/hour during PCI 1, 3

The European Society of Cardiology recommends high-intensity statin therapy should be initiated immediately and maintained long-term for all ACS patients 2, 4, 5
The American Heart Association recommends beta-blockers be initiated early in patients with ongoing ischemic symptoms, and are essential for both angina relief and reducing morbidity/mortality 5, 6, 7
The American College of Cardiology recommends ACE inhibitors or ARBs for all ACS patients, especially with heart failure, hypertension, diabetes, or LV dysfunction post-MI 2, 6, 8

The European Heart Rhythm Association recommends NOAC (apixaban, dabigatran, edoxaban, or rivaroxaban) over VKA for patients with atrial fibrillation requiring oral anticoagulation 3, 6
The American College of Cardiology recommends adjusting anticoagulant and antiplatelet doses based on creatinine clearance for patients with renal impairment 1, 5
The European Society of Cardiology recommends reducing prasugrel dose to 5 mg daily if used in elderly patients (≥75 years) 3, 5