Acute Coronary Syndrome Management

Introduction

• Acute coronary syndrome (ACS) requires prompt diagnosis and treatment to reduce morbidity and mortality, as recommended by the European Society of Cardiology and the American College of Cardiology 1, 2

Indications and Contraindications

• Indicated for worsening ischemia in patients with acute coronary syndrome, as recommended by the European Society of Cardiology 1
• Avoid beta-blockers in patients with hypotension, acute heart failure, AV block, or severe bradycardia, as recommended by the European Society of Cardiology 1

Pharmacological Therapy

• Start ACE inhibitors within 24 hours in patients with heart failure, LV systolic dysfunction, diabetes, or anterior infarct, as recommended by the European Society of Cardiology 1
• Start high-intensity statin therapy as early as possible and target LDL-C <70 mg/dL, as recommended by the European Society of Cardiology 1
• Use dual antiplatelet therapy (DAPT) with aspirin (75-100 mg daily) indefinitely and a P2Y12 inhibitor (preferably ticagrelor or prasugrel) for 12 months, as recommended by the European Society of Cardiology 1
• Beta-blockers are indicated for patients with heart failure and/or LVEF <40%, as recommended by the European Society of Cardiology and the American College of Cardiology 1, 3
• Mineralocorticoid receptor antagonists (MRAs) should be used for patients with LVEF < 40% and heart failure or diabetes, as recommended by the European Society of Cardiology 1

Reperfusion Therapy

• Primary PCI is the preferred reperfusion strategy when available within 120 minutes of first medical contact, with fibrinolytic therapy administered within 30 minutes of hospital arrival if PCI cannot be performed within this timeframe, as recommended by the European Society of Cardiology 1
• Door-to-needle time goal should be less than 30 minutes, and thrombolytic treatment should be initiated within 90 minutes of first medical contact, as suggested by the British Medical Journal 4, 3
• Transfer to a PCI-capable center should be done immediately after fibrinolysis, and rescue PCI should be performed if fibrinolysis fails (< 50% ST-segment resolution at 60-90 min), as recommended by the European Society of Cardiology 1

Diagnostic Tests

• Immediate 12-lead ECG should be performed within 10 minutes of first medical contact to diagnose STEMI, as recommended by the European Society of Cardiology and the American College of Cardiology 1, 2
• Echocardiography should be performed during hospitalization to assess LV function and detect complications, as recommended by the European Society of Cardiology 1
• High-sensitivity cardiac troponin (hs-cTn) is the preferred biomarker for diagnosing myocardial infarction, as recommended by the American College of Cardiology 2
• Myocardial infarction is diagnosed when there is a rise and/or fall of cardiac troponin with at least one value above the 99th percentile upper reference limit (URL), accompanied by symptoms of ischemia, new ECG changes, or imaging evidence of new loss of viable myocardium, as recommended by the American College of Cardiology 2

Lifestyle Modifications

• Smoking cessation with support, nicotine replacement therapies, varenicline, and bupropion, participation in cardiac rehabilitation program, and regular physical activity are recommended, as recommended by the European Heart Society and the American College of Cardiology 1, 3
• A diet low in saturated fat and cholesterol is recommended for patients with STEMI, as suggested by the American College of Cardiology 3
• Blood pressure control (target <130/80 mmHg) and lipid management with high-intensity statins are crucial for reducing cardiovascular risk, as recommended by the American College of Cardiology and the European Heart Society 5, 3

Differential Diagnosis

• Conditions like myocarditis, Takotsubo syndrome, or coronary spasm should be considered in the differential diagnosis, as recommended by the European Society of Cardiology 1
• The following table summarizes the key differences between myocardial infarction and stable coronary artery disease: