Diagnosis and management of acute coronary syndrome

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.