Best of the Best: Updates in Acute Coronary Syndrome-Slides

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The 2024 update on Acute Coronary Syndrome (ACS) management, presented by Dr. Dustin T. Smith, highlights key advances across diagnosis, invasive strategies, pharmacotherapy, and long-term care based on the 2023 ESC Guidelines. ACS represents a spectrum including unstable angina, NSTEMI, and STEMI, demanding early assessment and management.<br /><br />Diagnosis emphasizes rapid use of high-sensitivity cardiac troponins with serial measurements (0 h/1 h, extending to 3 h if inconclusive) and recommends coronary CT angiography (CCTA) as a safe, cost-effective modality to exclude ACS in low-risk patients. Echocardiography and cardiac MRI aid in cases with diagnostic uncertainty.<br /><br />Acute-phase treatment for STEMI aims for reperfusion within 60-90 minutes via primary PCI, with thrombolysis as a fallback. For NSTE-ACS, early invasive strategies within 24 hours are advised for high-risk cases. Antithrombotic therapy includes aspirin loading (150–300 mg) and P2Y12 inhibitors (ticagrelor preferred) with anticoagulation (unfractionated heparin standard). Routine GP IIb/IIIa inhibitor use is not recommended except in bailout scenarios. Radial artery access and drug-eluting stents are first-line PCI strategies.<br /><br />For multivessel disease, complete revascularization during index hospitalization or soon after is supported, especially in STEMI. The concept of MINOCA (myocardial infarction with non-obstructive coronary arteries) and type 2 MI (due to supply-demand mismatch) requires tailored management without standard ACS pharmacotherapy.<br /><br />Long-term secondary prevention prioritizes dual antiplatelet therapy (DAPT) for at least 6–12 months, with de-escalation to single antiplatelet (preferably P2Y12 inhibitor) in selected patients, especially those with high bleeding risk. Clopidogrel monotherapy beyond one year post-PCI shows a possible ischemic benefit over aspirin. Blood pressure targets are <130/80 mmHg, LDL cholesterol <55 mg/dL, and HbA1c ~7.0% in ACS patients.<br /><br />Key takeaways include updated DAPT duration recommendations, the role of intravascular imaging to guide PCI, intensified lipid-lowering strategies during ACS, and personalized glucose-lowering therapies based on comorbidities. Early invasive management remains crucial for high-risk patients, supported by guideline-based pharmacotherapy and risk factor modification.

Keywords

Acute Coronary Syndrome

2024 ACS update

ESC Guidelines 2023

high-sensitivity cardiac troponins

coronary CT angiography

primary PCI

dual antiplatelet therapy

MINOCA

multivessel revascularization

lipid-lowering strategies