J Korean Med Assoc.  2017 Jul;60(7):568-576. 10.5124/jkma.2017.60.7.568.

Diagnosis and management of acute coronary syndrome

Affiliations
  • 1Division of Cardiology, Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea. coronary@catholic.ac.kr

Abstract

Acute coronary syndrome (ACS) is characterized by the rapid progression of coronary thrombosis and myocardial ischemia associated with the erosion or rupture of vulnerable atherosclerotic plaques. High-sensitivity cardiac troponin assay-based diagnostic algorithms enable rapid diagnosis within a few hours for patients in whom ACS is suspected. Prompt restoration of blood flow in the occluded artery is the top priority in patients with ST-elevation myocardial infarction, and the recommended first medical contact-to-percutaneous coronary intervention time is within 120 minutes. Since patients with non-ST elevation ACS are heterogeneous in their clinical profiles and severity of myocardial ischemia, the treatment strategy for non-ST elevation ACS is based on risk stratification at presentation. An early invasive strategy is indicated for patient at high risk of cardiac events, whereas an ischemia-guided approach is indicated for stabilized patient with lower risk score. Appropriate antithrombotic medication is critically important in the management of ACS. Dual antiplatelet treatment (DAPT) including aspirin and newer P2Y12 inhibitors should be maintained. Generally, at least 12 months of DAPT is recommended in ACS patients; however, the optimal duration of DAPT depends on weighing the benefits of preventing ischemic events versus the risk of bleeding in individual patient.

Keyword

Acute coronary syndrome; Myocardial infarction; Percutaneous coronary intervention

MeSH Terms

Acute Coronary Syndrome*
Arteries
Aspirin
Coronary Thrombosis
Diagnosis*
Hemorrhage
Humans
Myocardial Infarction
Myocardial Ischemia
Percutaneous Coronary Intervention
Plaque, Atherosclerotic
Rupture
Troponin
Aspirin
Troponin

Figure

  • Figure 1 Treatment algorithm in ST elevation myocardial infarction. PCI, percutaneous coronary intervention; FMCTB, first medical contact to balloon time (Modified from Task Force on the Management of ST-segment Elevation Acute Myocardial Infarction of the European Society of Cardiology, et al. Eur Heart J 2012;33:2569– 2619) [2].

  • Figure 2 Treatment algorithm in non-ST elevation acute coronary syndrome. PCI, percutaneous coronary intervention; GP, glycoprotein. a)The more potent P2Y12 inhibitors (ticagrelor and prasugrel) are preferred over clopidogrel in 2015 European Society of Cardiology guideline (Modified from Amsterdam EA, et al. Circulation 2014;130:e344-e426) [4].

  • Figure 3 Treatment algorithm for duration of P2Y12 inhibitor therapy in acute coronary syndrome (ACS). NSTE-ACS, non-ST elevation myocardial infarction acute coronary syndrome; STEMI, ST elevation myocardial infarction; PCI, percutaneous coronary intervention; BMS, bare metal stent; DES, drug-eluting stent; DAPT, dual antiplatelet treatment. a)The more potent P2Y12 inhibitors (ticagrelor and prasugrel) are preferred over clopidogrel in 2015 European Society of Cardiology guideline (Modified from Levine GN, et al. Circulation 2016;134:e123-e155) [5].


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