Assessment and management of acute coronary syndromes (ACS): a Canadian perspective on current guideline-recommended
David H Fitchett1, Pierre Theroux, James M Brophy
1St Michael's Hospital, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada. fitchettd@smh.ca
Insights
Hospital admissions for acute coronary syndromes (ACS) are rising. This review proposes optimal Canadian healthcare strategies for managing ST-segment elevation myocardial infarction (STEMI) and non-ST-elevation ACS (NSTE-ACS) patients, focusing on risk assessment and tailored interventions.
Area of Science:
- Cardiology
- Internal Medicine
- Healthcare Management
Background:
- Despite declining coronary heart disease mortality, hospital admissions for acute coronary syndromes (ACS) are increasing.
- ACS management requires a nuanced approach considering patient-specific risks and healthcare system realities in Canada.
Purpose of the Study:
- To review assessment and management issues for acute coronary syndrome (ACS) patients.
- To propose an optimal, individualized treatment strategy within the Canadian healthcare context.
- To differentiate management between ST-segment elevation myocardial infarction (STEMI) and non-ST-elevation ACS (NSTE-ACS).
Main Methods:
- Categorization of ACS patients into STEMI and NSTE-ACS.
- Risk assessment for recurrent ischemic and bleeding events in NSTE-ACS patients.
- Evaluation of early invasive versus selective invasive strategies based on risk stratification.
Main Results:
- High-risk NSTE-ACS patients benefit from early cardiac catheterization, percutaneous coronary intervention (PCI), and intensive antiplatelet/anticoagulant therapy.
- Lower-risk NSTE-ACS patients may be managed medically with selective angiography if high-risk features emerge.
- Long-term vascular protection including lifestyle changes, lipid lowering, BP/glycemic control, and RAAS blockade is crucial for all ACS patients.
Conclusions:
- An individualized, risk-stratified approach is essential for optimal ACS management.
- Early invasive strategies are recommended for high-risk NSTE-ACS patients.
- Comprehensive long-term vascular protection is paramount for preventing recurrent ischemic events in all ACS survivors.
Abstract:
Despite the reduction of coronary heart disease mortality over the past 40 years, hospital admissions for acute coronary syndromes (ACS) continue to increase. The goal of this 2-part article is to review the issues at each stage of assessment and management of the ACS patient, and to propose an optimal treatment strategy for the individual patient in the context of the realities, culture, and delivery of healthcare in Canada. ACS patients are categorized as either ST segment elevation myocardial infarction (STEMI) or non-ST-elevation ACS (NSTE-ACS). For the patients with NSTE-ACS, prevention of recurrent ischemic events is the primary goal. Assessment of risk for recurrent ischemic and bleeding events helps to determine the net benefit of early cardiac catheterization and percutaneous coronary intervention (PCI) and intensive antiplatelet and anticoagulant treatment. Those with higher ischemic risk features should be considered for an early invasive strategy and receive both dual antiplatelet therapy and an anticoagulant at the time of first medical assessment. Patients without high-risk features could be considered for medical treatment and a selectively invasive strategy; with coronary angiography and revascularization only if high-risk features become apparent. Long-term vascular protection with lifestyle modification (especially smoking cessation), lipid lowering, blood pressure and glycemic control, and the use of renin angiotensin aldosterone system (RAAS) blockade to prevent recurrent ischemic events, is important in all patients with ACS.
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