Diagnostic and therapeutic approach to the ACS patient
DOI:
https://doi.org/10.33393/grhta.2022.2389Keywords:
Acute coronary syndrome, Diagnostic approach, Revascularization, TreatmentAbstract
The current management strategy of acute coronary syndromes aims at symptoms relief as well as at specifically antagonizing each of the different pathogenic components of myocardial ischemia, including the pro-thrombotic state, poor coronary flow and myocardial damage.
Different approaches are available, including revascularization procedures and pharmacological interventions. Various anti-anginal, anti-thrombotic and anti-coagulant drugs can be used according to individual features and needs, as well as secondary prevention measures based on statin use and ACE-inhibition. The appropriate use of available measures is crucial to reduce mortality and improve long-term prognosis in patients with acute coronary syndromes.
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Thygesen K, Alpert JS, Jaffe AS, et al. Fourth universal definition of myocardial infarction (2018). Eur Heart J. 2019;40(3):237-269. https://doi.org/10.1093/eurheartj/ehy462 DOI: https://doi.org/10.1093/eurheartj/ehy462
Ibanez B, James S, Agewall S, et al; ESC Scientific Document Group. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39(2):119-177. https://doi.org/10.1093/eurheartj/ehx393 PMID:28886621 DOI: https://doi.org/10.1093/eurheartj/ehx393
Collet J-P, Thiele H, Barbato E, et al; ESC Scientific Document Group. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021;42(14):1289-1367. https://doi.org/10.1093/eurheartj/ehaa575 PMID:32860058 DOI: https://doi.org/10.1093/eurheartj/ehaa575
Maron DJ, Hochman JS, Reynolds HR, et al; ISCHEMIA Research Group. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020;382(15):1395-1407. https://doi.org/10.1056/NEJMoa1915922 PMID:32227755 DOI: https://doi.org/10.1056/NEJMoa1915922
Boden WE, O’Rourke RA, Teo KK, et al; COURAGE Trial Research Group. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503-1516. https://doi.org/10.1056/NEJMoa070829 PMID:17387127 DOI: https://doi.org/10.1056/NEJMoa070829
Al-Lamee R, Thompson D, Dehbi H-M, et al; ORBITA investigators. Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial. Lancet. 2018;391(10115):31-40. https://doi.org/10.1016/S0140-6736(17)32714-9 PMID:29103656 DOI: https://doi.org/10.1016/S0140-6736(17)32714-9
Stone GW, Maehara A, Lansky AJ, et al; PROSPECT Investigators. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011;364(3):226-235. https://doi.org/10.1056/NEJMoa1002358 PMID:21247313 DOI: https://doi.org/10.1056/NEJMoa1002358
Stone GW, Maehara A, Ali ZA, et al; PROSPECT ABSORB Investigators. Percutaneous Coronary Intervention for Vulnerable Coronary Atherosclerotic Plaque. J Am Coll Cardiol. 2020;76(20):2289-2301. https://doi.org/10.1016/j.jacc.2020.09.547 PMID:33069847 DOI: https://doi.org/10.1016/j.jacc.2020.09.547
Gershlick AH, Khan JN, Kelly DJ, et al. Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease: the CvLPRIT trial. J Am Coll Cardiol. 2015;65(10):963-972. https://doi.org/10.1016/j.jacc.2014.12.038 PMID:25766941 DOI: https://doi.org/10.1016/j.jacc.2014.12.038
Engstrøm T, Kelbæk H, Helqvist S, et al; DANAMI-3—PRIMULTI Investigators. Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet. 2015;386(9994):665-671. https://doi.org/10.1016/S0140-6736(15)60648-1 PMID:26347918 DOI: https://doi.org/10.1016/S0140-6736(15)60648-1
Valgimigli M, Gagnor A, Calabró P, et al; MATRIX Investigators. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015;385(9986):2465-2476. https://doi.org/10.1016/S0140-6736(15)60292-6 PMID:25791214 DOI: https://doi.org/10.1016/S0140-6736(15)60292-6
Jolly SS, Cairns JA, Yusuf S, et al; TOTAL Investigators. Randomized trial of primary PCI with or without routine manual thrombectomy. N Engl J Med. 2015;372(15):1389-1398. https://doi.org/10.1056/NEJMoa1415098 PMID:25853743 DOI: https://doi.org/10.1056/NEJMoa1415098
Fröbert O, Lagerqvist B, Olivecrona GK, et al; TASTE Trial. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013;369(17):1587-1597. https://doi.org/10.1056/NEJMoa1308789 PMID:23991656 DOI: https://doi.org/10.1056/NEJMoa1308789
Bainey KR, Engstrøm T, Smits PC, et al. Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis. JAMA Cardiol. 2020;5(8):881-888. https://doi.org/10.1001/jamacardio.2020.1251 PMID:32432651 DOI: https://doi.org/10.1001/jamacardio.2020.1251
Mooney M, McKee G, Fealy G, O’ Brien F, O’Donnell S, Moser D. A randomized controlled trial to reduce prehospital delay time in patients with acute coronary syndrome (ACS). J Emerg Med. 2014;46(4):495-506. https://doi.org/10.1016/j.jemermed.2013.08.114 PMID:24411656 DOI: https://doi.org/10.1016/j.jemermed.2013.08.114
Kofoed KF, Kelbæk H, Hansen PR, et al. Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. Circulation. 2018;138(24):2741-2750. https://doi.org/10.1161/CIRCULATIONAHA.118.037152PMID:30565996 DOI: https://doi.org/10.1161/CIR.0000000000000640
Neumann, Franz-Josef, Miguel Sousa-Uva, Anders Ahlsson, Fernando Alfonso, Adrian P. Banning, Umberto Benedetto, Robert A. Byrne, Jean-Philippe Collet, Volkmar Fal, Stuart J. Head PJ., Adnan Kastrati, Akos Koller SDK., Josef Niebauer, Dimitrios J. Richter PMS., Dirk Sibbing, Giulio G. Stefanini, Stephan Windecker, Rashmi Yadav MOZ. 2018 ESC / EACTS Guidelines on myocardial revascularization The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for 2019;40:87–165. Doi: 10.1093/eurheartj/ehy394. DOI: https://doi.org/10.4244/EIJY19M01_01
Mahmarian JJ, Moyé LA, Chinoy DA, et al. Transdermal nitroglycerin patch therapy improves left ventricular function and prevents remodeling after acute myocardial infarction: results of a multicenter prospective randomized, double-blind, placebo-controlled trial. Circulation. 1998;97(20):2017-2024. PMID:9610531 DOI: https://doi.org/10.1161/01.CIR.97.20.2017
McDonagh TA, Metra M, Adamo M, et al; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. PMID:34447992
Held PH, Yusuf S. Effects of β-blockers and calcium channel blockers in acute myocardial infarction. Eur Heart J. 1993;14(suppl F):18-25. https://doi.org/10.1093/eurheartj/14.suppl_F.18PMID:7903243 DOI: https://doi.org/10.1093/eurheartj/14.suppl_F.18
Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Lancet. 1988;2(8607):349-360. PMID:2899772 DOI: https://doi.org/10.1016/S0140-6736(88)92833-4
GUSTO investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med. 1993;329(10):673-682. https://doi.org/10.1056/NEJM199309023291001 PMID:8204123 DOI: https://doi.org/10.1056/NEJM199309023291001
Schüpke S, Neumann F-J, Menichelli M, et al; ISAR-REACT 5 Trial Investigators. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2019;381(16):1524-1534. https://doi.org/10.1056/NEJMoa1908973 PMID:31475799 DOI: https://doi.org/10.1056/NEJMe1911207
Stone GW, Généreux P, Harrington RA, et al. Impact of lesion complexity on peri-procedural adverse events and the benefit of potent intravenous platelet adenosine diphosphate receptor inhibition after percutaneous coronary intervention: core laboratory analysis from 10 854 patients from the CHAMPION PHOENIX trial. Eur Heart J. 2018;39(46):4112-4121. https://doi.org/10.1093/eurheartj/ehy562 PMID:30203006 DOI: https://doi.org/10.1093/eurheartj/ehy562
Steg PG, Bhatt DL, Hamm CW, et al; CHAMPION Investigators. Effect of cangrelor on periprocedural outcomes in percutaneous coronary interventions: a pooled analysis of patient-level data. Lancet. 2013;382(9909):1981-1992. https://doi.org/10.1016/S0140-6736(13)61615-3PMID:24011551 DOI: https://doi.org/10.1016/S0140-6736(13)61615-3
Mach F, Baigent C, Catapano AL, et al; ESC Scientific Document Group. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111-188. https://doi.org/10.1093/eurheartj/ehz455 PMID:31504418 DOI: https://doi.org/10.1093/eurheartj/ehz455
Wood FA, Howard JP, Finegold JA, et al. N-of-1 Trial of a Statin, Placebo, or No Treatment to Assess Side Effects. N Engl J Med. 2020;383(22):2182-2184. https://doi.org/10.1056/NEJMc2031173 PMID:33196154 DOI: https://doi.org/10.1056/NEJMc2031173
Young JB, Dunlap ME, Pfeffer MA, et al; Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) Investigators and Committees. Mortality and morbidity reduction with Candesartan in patients with chronic heart failure and left ventricular systolic dysfunction: results of the CHARM low-left ventricular ejection fraction trials. Circulation. 2004;110(17):2618-2626. https://doi.org/10.1161/01.CIR.0000146819.43235.A9PMID:15492298
Cohn JN, Tognoni G; Valsartan Heart Failure Trial Investigators. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345(23):1667-1675. PMID:11759645 DOI: https://doi.org/10.1056/NEJMoa010713
Hofmann R, James SK, Jernberg T, et al; DETO2X–SWEDEHEART Investigators. Oxygen Therapy in Suspected Acute Myocardial Infarction. N Engl J Med. 2017;377(13):1240-1249. https://doi.org/10.1056/NEJMoa1706222 PMID:28844200 DOI: https://doi.org/10.1056/NEJMoa1706222
Ritsinger V, Malmberg K, Mårtensson A, Rydén L, Wedel H, Norhammar A. Intensified insulin-based glycaemic control after myocardial infarction: mortality during 20 year follow-up of the randomised Diabetes Mellitus Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI 1) trial. Lancet Diabetes Endocrinol. 2014;2(8):627-633. https://doi.org/10.1016/S2213-8587(14)70088-9 PMID:24831989 DOI: https://doi.org/10.1016/S2213-8587(14)70088-9
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Accepted 2022-03-24
Published 2022-05-24
