Acute Coronary Syndrome Management

Initial Assessment and Diagnosis

The European Society of Cardiology recommends laboratory assessment, including high-sensitivity cardiac troponin, hemoglobin, and markers of myocardial damage, for patients with suspected Acute Coronary Syndrome (ACS) 1, 4
Continuous multi-lead ECG monitoring for ischemia and arrhythmias should be initiated for patients with suspected ACS 5
Echocardiography is recommended to evaluate regional and global left ventricular function and rule out differential diagnoses in patients with suspected ACS 3

The European Society of Cardiology recommends aspirin (150-300 mg loading dose followed by 75-100 mg daily maintenance dose) for all patients with suspected ACS 3, 4
A P2Y12 inhibitor should be added to aspirin for 12 months unless contraindicated, with ticagrelor (180 mg loading dose, 90 mg twice daily) recommended as first choice for moderate to high-risk patients 3
Parenteral anticoagulation is recommended for all ACS patients, with options including unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), bivalirudin, and fondaparinux 2
Nitrates (sublingual followed by intravenous) are recommended for relief of ischemia and symptoms in patients with ACS 6
Morphine is recommended for persistent severe chest pain or acute pulmonary congestion in patients with ACS 6
Beta-blockers are recommended for symptom control and to reduce myocardial oxygen demand in patients with ACS 6, 7

The European Society of Cardiology recommends risk stratification to determine timing of invasive strategy, with very high-risk criteria (e.g. hemodynamic instability, cardiogenic shock) requiring immediate invasive strategy (<2h) 1
High-risk patients (e.g. GRACE score >140) benefit from early invasive approach with coronary angiography within 24-48 hours 1, 3
Intermediate-risk patients (e.g. diabetes mellitus, renal insufficiency) may benefit from invasive strategy within 72 hours 1, 3

The European Society of Cardiology recommends high-intensity statin therapy, started as early as possible and maintained long-term, for patients with ACS 3, 7
Beta-blockers are recommended, especially in patients with reduced left ventricular function (LVEF ≤40%) 4, 7
ACE inhibitors are recommended for patients with LVEF ≤40%, heart failure, hypertension, or diabetes 4, 7
Angiotensin receptor blockers (ARBs) are alternatives for patients who cannot tolerate ACE inhibitors 7
Mineralocorticoid receptor antagonists (preferably eplerenone) are recommended for patients with LVEF ≤35% and either heart failure or diabetes 4
Lifestyle modifications, including smoking cessation, regular physical activity, and healthy diet, are recommended for patients with ACS 4
Cardiac rehabilitation program enrollment is recommended for patients with ACS 7