Acute Coronary Syndrome (ACS)

The diagnosis of ACS is based on a comprehensive assessment that includes clinical symptoms, electrocardiographic changes, cardiac biomarkers, and, when necessary, coronary angiography.

-Electrocardiography (ECG)

A 12-lead ECG is the first-line diagnostic tool of patients with suspected ACS.

Persistent ST-segment elevation indicates STEMI.

ST depression, T-wave inversion, or non-specific changes suggest NSTEMI or unstable angina.

Serial ECGs may be needed to detect evolving changes.

Cardiac Biomarkers 

High-sensitivity troponin I or T is recommended in all patients with suspected ACS

A normal troponin level can help rule out acute myocardial infarction(MI), particularly when measured serially over time.

Coronary Angiography

If MI is suspected based on symptoms, ECG, or troponin, coronary angiography is performed to visualize the coronary arteries, identify obstructive lesions, and guide revascularization strategies such as percutaneous coronary intervention (PCI).

PCI is a non-surgical procedure used to open narrowed or blocked coronary arteries and restore blood flow to the heart. It typically involves the insertion of a balloon catheter followed by the placement of a stent to keep the artery open. In most cases, a drug-eluting stent (DES) is used to help prevent re-narrowing of the artery.

In patients with STEMI, reperfusion therapy should be initiated within 90 minutes of first medical contact to minimize myocardial damage and improve clinical outcomes.

Medication adherence after PCI in ACS patients is critical for preventing complications and improving outcomes.

Dual antiplatelet therapy

Combination of aspirin and P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) are typically continued for at least 12 months after PCI, unless there is a high risk of bleeding. 

Lipid lowering therapy

The target LDL-C level is below 55 mg/dL or a reduction of at least 50% from baseline. To achieve this goal, high intensity statin therapy is the first-line treatment, and ezetimibe and PCSK9 inhibitors may be added in patients with high-risk features or inadequate response to statins.