Approach to Acute Coronary Syndrome (ACS)
Initial Assessment and Risk Stratification
- The European Society of Cardiology recommends that all patients with suspected ACS require immediate ECG within 10 minutes of presentation, continuous cardiac monitoring, high-sensitivity troponin measurement, and dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor initiated as soon as the diagnosis is confirmed 1, 2, 3
- Obtain 12-lead ECG within 10 minutes to distinguish STEMI from non-ST-elevation ACS (NSTE-ACS) 1, 3
- Administer aspirin 150-300 mg loading dose immediately for all patients unless contraindicated 2
- Initiate continuous cardiac rhythm monitoring to detect life-threatening arrhythmias 1
- Assess vital signs: systolic blood pressure, heart rate, oxygen saturation, and Killip classification 1, 3
Risk-Based Invasive Strategy Timing
- Proceed to immediate coronary angiography if any of the following are present: hemodynamic instability, recurrent or ongoing chest pain, life-threatening arrhythmias, mechanical complications of MI, or acute heart failure 1, 5
- Proceed to coronary angiography within 24 hours if any of the following are present: rise or fall in cardiac troponin, dynamic ST- or T-wave changes, or GRACE score >140 1, 5
Immediate Medical Management
- The European Society of Cardiology recommends dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor for 12 months unless contraindicated 2, 5, 6
- Initiate high-intensity statin therapy immediately regardless of baseline cholesterol 2, 5, 6
- Initiate parenteral anticoagulation with one of the following: fondaparinux, enoxaparin, unfractionated heparin, or bivalirudin 2, 6, 4
Revascularization Strategy
- Radial access is the standard approach for coronary angiography 2
- Drug-eluting stents are recommended over bare-metal stents for any PCI 2
- Revascularization strategy should be based on clinical status, comorbidities, and disease severity (SYNTAX score) 2