Acute Coronary Syndromes: Integrated Diagnosis and Management

Saskia Vermeer^*
*Correspondence: Saskia Vermeer, Center for Coronary Research, University of New Rotterdam, Rotterdam, Netherlands, Email:

Introduction

The 2023 European Society of Cardiology (ESC) guidelines offer comprehensive recommendations for managing acute coronary syndromes, emphasizing early diagnosis, risk stratification, and tailored treatment strategies for patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation ACS. They detail pharmacotherapy, invasive procedures, and secondary prevention, integrating the latest evidence to improve patient outcomes. The guidelines also highlight the importance of multidisciplinary care and personalized approaches based on individual patient characteristics[1].

Understanding the pathophysiology of acute coronary syndromes remains crucial for effective management. This review highlights key advances in recognizing plaque rupture, erosion, and calcified nodules as primary mechanisms. It also covers the roles of inflammation, thrombosis, and microvascular dysfunction, offering insights into how these complex processes influence clinical presentation and guide contemporary treatment strategies, from antithrombotic therapy to revascularization[2].

The landscape of biomarkers for acute coronary syndromes continues to evolve, offering refined tools for diagnosis, risk stratification, and prognosis. This review explores the utility of high-sensitivity cardiac troponins, emphasizing their role in rapid rule-in/rule-out protocols. It also touches upon emerging biomarkers that could further enhance early detection and personalized treatment strategies, highlighting their potential impact on clinical decision-making and patient outcomes[3].

Optimizing antiplatelet therapy is a cornerstone in managing acute coronary syndromes, aiming to prevent thrombotic events without increasing bleeding risks. This update reviews current guidelines and emerging evidence on dual antiplatelet therapy (DAPT) duration and intensity, focusing on P2Y12 inhibitors like ticagrelor and prasugrel. It discusses personalized approaches, considering individual patient risk profiles and the balance between ischemic and hemorrhagic complications, crucial for long-term patient care[4].

Choosing the optimal revascularization strategy for acute coronary syndromes, whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), demands careful consideration of patient-specific factors. This article reviews current evidence on immediate versus deferred intervention, complete versus culprit-only revascularization, and the role of imaging guidance. It highlights the importance of shared decision-making and guideline adherence to improve myocardial salvage and long-term prognosis[5].

Effective secondary prevention following an acute coronary syndrome is vital for reducing recurrent events and improving long-term survival. This review synthesizes current evidence on lifestyle modifications, pharmacotherapy including lipid-lowering agents, antiplatelets, and antihypertensives, and the role of cardiac rehabilitation. It emphasizes a multifaceted approach to risk factor management, tailoring interventions to individual patient needs to prevent future cardiovascular events[6].

Acute heart failure frequently complicates acute coronary syndromes, significantly worsening prognosis. This article delves into the mechanisms underlying this dangerous interplay, from extensive myocardial damage to inflammatory responses. It reviews diagnostic approaches, including advanced imaging and biomarker use, and outlines management strategies focusing on hemodynamic support, aggressive revascularization, and pharmacological interventions to stabilize patients and improve their short- and long-term outcomes[7].

Advanced imaging techniques are transforming the diagnosis and management of acute coronary syndromes. This article examines the roles of cardiac magnetic resonance (CMR), computed tomography angiography (CTA), and nuclear imaging in identifying myocardial ischemia, infarction size, and microvascular obstruction. It also explores their utility in risk stratification and guiding revascularization decisions, highlighting how these non-invasive tools provide critical anatomical and functional information for personalized patient care[8].

Patients with diabetes mellitus face unique challenges when experiencing acute coronary syndromes, including atypical presentations, higher risk of complications, and poorer long-term outcomes. This article discusses the amplified atherosclerotic burden and microvascular dysfunction specific to diabetic patients. It emphasizes the need for aggressive risk factor control, tailored pharmacotherapy, and careful consideration of revascularization strategies to improve prognosis in this high-risk population, highlighting emerging therapeutic options[9].

Myocardial infarction with nonobstructive coronary arteries (MINOCA) presents a diagnostic and therapeutic challenge, encompassing a diverse group of underlying pathologies. This review elucidates various mechanisms, including coronary spasm, spontaneous coronary artery dissection, and microvascular dysfunction. It emphasizes the importance of a systematic diagnostic approach using cardiac MRI and intravascular imaging to identify the specific etiology, guiding tailored management strategies to improve prognosis in these often younger patients[10].

Description

The management of acute coronary syndromes (ACS) relies heavily on comprehensive recommendations, such as the 2023 European Society of Cardiology (ESC) guidelines. These guidelines underscore the importance of early diagnosis, precise risk stratification, and individualized treatment plans for patients presenting with ST-elevation myocardial infarction (STEMI) and non-ST-elevation ACS [1]. Such frameworks detail pharmacotherapy, invasive procedures, and vital secondary prevention strategies, all aimed at enhancing patient outcomes. A core tenet is the integration of multidisciplinary care and personalized approaches, adapting to unique patient characteristics [1]. Crucially, a deep understanding of ACS pathophysiology is fundamental for effective management. Recent insights highlight key mechanisms like plaque rupture, erosion, and calcified nodules as primary drivers [2]. The complex roles of inflammation, thrombosis, and microvascular dysfunction are also considered, providing valuable context for clinical presentation and guiding contemporary treatment choices, from antithrombotic therapy to revascularization [2].

The field of biomarkers for ACS continues to advance, offering increasingly refined tools for diagnosis, risk stratification, and prognosis. High-sensitivity cardiac troponins are now central to rapid rule-in/rule-out protocols, significantly improving early detection [3]. Beyond troponins, research into emerging biomarkers aims to further enhance personalized treatment strategies, promising a substantial impact on clinical decision-making and patient outcomes [3]. Optimizing antiplatelet therapy stands as a cornerstone in ACS management. The goal is to effectively prevent thrombotic events without concurrently escalating bleeding risks [4]. Current guidelines and new evidence focus on dual antiplatelet therapy (DAPT), particularly the duration and intensity of P2Y12 inhibitors like ticagrelor and prasugrel. Personalized approaches are key here, taking into account individual patient risk profiles to strike a delicate balance between ischemic and hemorrhagic complications, which is critical for long-term patient care [4].

Determining the most suitable revascularization strategy, whether percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), requires careful evaluation of patient-specific factors [5]. Evidence on immediate versus deferred intervention, complete versus culprit-only revascularization, and the role of imaging guidance informs these critical decisions. Emphasizing shared decision-making and adherence to established guidelines helps improve myocardial salvage and enhance long-term prognosis [5]. Beyond acute care, effective secondary prevention following an ACS event is paramount for reducing recurrent cardiovascular events and improving long-term survival [6]. This involves a comprehensive approach, including sustained lifestyle modifications, targeted pharmacotherapy (such as lipid-lowering agents, antiplatelets, and antihypertensives), and structured cardiac rehabilitation. A multifaceted strategy for risk factor management, tailored to each patient's unique needs, remains essential for preventing future cardiovascular incidents [6].

Acute heart failure often complicates ACS, leading to a significantly worsened prognosis. The underlying mechanisms involve extensive myocardial damage and complex inflammatory responses [7]. Diagnostic strategies include advanced imaging and biomarker usage, while management focuses on hemodynamic support, aggressive revascularization, and pharmacological interventions. These measures aim to stabilize patients and improve both their short- and long-term outcomes [7]. Advanced imaging techniques are revolutionizing the diagnosis and management of ACS. Cardiac Magnetic Resonance (CMR), Computed Tomography Angiography (CTA), and nuclear imaging play crucial roles in identifying myocardial ischemia, assessing infarction size, and detecting microvascular obstruction [8]. These non-invasive tools also prove valuable in risk stratification and guiding revascularization decisions, offering vital anatomical and functional information for personalized patient care [8].

Patients living with diabetes mellitus present distinct challenges when experiencing ACS. They often have atypical presentations, a higher risk of complications, and generally poorer long-term outcomes, primarily due to an amplified atherosclerotic burden and microvascular dysfunction [9]. Effective management requires aggressive risk factor control, specialized pharmacotherapy, and careful consideration of revascularization strategies. Emerging therapeutic options offer hope for improving prognosis in this particularly high-risk population [9]. Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) represents a diagnostic and therapeutic puzzle, stemming from a diverse array of underlying pathologies [10]. This includes mechanisms like coronary spasm, spontaneous coronary artery dissection, and microvascular dysfunction. A systematic diagnostic approach utilizing cardiac MRI and intravascular imaging is crucial to pinpoint the specific etiology, thereby enabling tailored management strategies to improve outcomes in these often younger patients [10].

Conclusion

The management of acute coronary syndromes (ACS) involves comprehensive recommendations from guidelines like the 2023 ESC, which emphasize early diagnosis, risk stratification, and tailored treatment for ST-elevation myocardial infarction (STEMI) and non-ST-elevation ACS, covering pharmacotherapy, invasive procedures, and secondary prevention to improve patient outcomes. Understanding the underlying pathophysiology, including plaque rupture, erosion, and calcified nodules, along with inflammation, thrombosis, and microvascular dysfunction, is crucial for effective treatment. Biomarkers, particularly high-sensitivity cardiac troponins, are essential for rapid diagnosis and risk stratification, with emerging markers promising further enhancements in early detection. Optimizing antiplatelet therapy, often involving dual antiplatelet therapy (DAPT) with P2Y12 inhibitors, is a cornerstone to prevent thrombotic events while balancing bleeding risks, necessitating personalized approaches. Choosing the right revascularization strategy, whether Percutaneous Coronary Intervention (PCI) or Coronary Artery Bypass Grafting (CABG), requires careful consideration of patient factors, including timing and extent of intervention, guided by imaging. Secondary prevention is vital for long-term survival, involving lifestyle changes, pharmacotherapy (lipid-lowering agents, antiplatelets, antihypertensives), and cardiac rehabilitation. Acute heart failure frequently complicates ACS, demanding aggressive management strategies like hemodynamic support and revascularization. Advanced imaging techniques, such as Cardiac Magnetic Resonance (CMR) and Computed Tomography Angiography (CTA), are transforming diagnosis, risk stratification, and revascularization decisions by providing critical anatomical and functional information. Specific patient populations, like those with diabetes mellitus, present unique challenges due to amplified atherosclerotic burden and microvascular dysfunction, requiring tailored interventions. Finally, Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA) poses a diagnostic dilemma, necessitating systematic approaches with cardiac Magnetic Resonance Imaging (MRI) and intravascular imaging to identify diverse etiologies like coronary spasm or spontaneous dissection, leading to personalized management strategies.

Acknowledgement

None

Conflict of Interest

None

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