Overview

This lecture reviews the latest Acute Coronary Syndrome (ACS) guidelines, focusing on diagnosis, acute and long-term management, and secondary prevention strategies.

ACS Diagnosis and Initial Assessment

ACS is classified as STEMI (ST-elevation MI), NSTEMI (non-ST-elevation MI), or unstable angina based on ECG and biomarkers.
High-sensitivity troponin assays have made unstable angina a less frequent diagnosis.
Immediate reperfusion therapy is required for STEMI diagnosis, without waiting for biomarkers.
New left bundle branch block alone is not diagnostic for STEMI; symptoms are required.
Suspected ACS in the field: obtain a 12-lead ECG within 10 minutes of first contact.
Patients with STEMI should be transported to PCI-capable hospitals for reperfusion within 90 minutes.
Serial ECGs are recommended; delays in reperfusion increase mortality.
Use clinical decision pathways and troponin protocols to stratify risk in the ED.

Catheterization Lab and Acute Management

All ACS patients should receive aspirin and a P2Y12 inhibitor; potent options preferred unless contraindicated.
Primary PCI is indicated for STEMI; fibrinolysis if PCI is unavailable and no contraindications.
Anticoagulation during PCI: unfractionated heparin or bivalirudin; radial access is preferred.
Complete revascularization is recommended for STEMI with multi-vessel disease (culprit-only approach in shock).
No routine aspiration thrombectomy during PCI; imaging guidance is recommended for complex lesions.
In ACS with cardiac arrest, immediate PCI is considered based on neurologic status and prognosis.
DAPT (dual antiplatelet therapy) is recommended for 12 months unless high bleeding risk.

Secondary Prevention and Post-Discharge Management

High-intensity statins are recommended for all ACS patients; add non-statin therapy if LDL >70 mg/dL.
Beta blockers, ACE inhibitors/ARBs, and MRAs are recommended in specific high-risk groups.
Transfusion is recommended for hemoglobin <10 g/dL in ACS patients.
Assess left ventricular function before discharge to guide further management.
Refer to cardiac rehabilitation for exercise, education, and psychosocial support; home-based options are reasonable if access is limited.
Encourage ongoing adherence to statin and cardiovascular medications; monitor lipids 4–8 weeks post-discharge.
Influenza vaccination is recommended for all ACS patients within one year of event.
Address social determinants of health to improve adherence and outcomes.

Q&A and Special Considerations

Routine PPI use with DAPT is not required unless GI bleeding risk is high.
Genetic or platelet function testing for P2Y12 inhibitors is not routinely recommended.
Potent P2Y12 inhibitors are not preferred with chronic oral anticoagulation; default to clopidogrel.
No specific guideline address for dental hygiene or coronary CTA in ACS; follow other guidelines as appropriate.
LDL cholesterol <55 mg/dL is a reasonable target, especially post-ACS.

Key Terms & Definitions

ACS (Acute Coronary Syndrome) — includes STEMI, NSTEMI, and unstable angina, presenting with chest pain and ECG changes.
STEMI — ST-elevation myocardial infarction, requires urgent reperfusion.
NSTEMI — Non-ST-elevation myocardial infarction, diagnosed by biomarkers and ECG.
PCI (Percutaneous Coronary Intervention) — mechanical reopening of coronary arteries.
DAPT (Dual Antiplatelet Therapy) — use of aspirin plus a P2Y12 inhibitor for clot prevention.
P2Y12 Inhibitor — antiplatelet drug (e.g., ticagrelor, prasugrel, clopidogrel).
MRA (Mineralocorticoid Receptor Antagonist) — e.g., spironolactone, for heart failure risk reduction.

Action Items / Next Steps

Review local ACS protocols and ensure serial ECG/troponin use in suspected cases.
Prescribe high-intensity statin and consider add-on lipid therapy if LDL remains high.
Schedule early outpatient follow-up to monitor medication adherence and lipid levels.
Refer all eligible ACS patients to cardiac rehabilitation.
Ensure influenza vaccination is administered before or soon after discharge.

Certainly! Here is a more in-depth and comprehensive summary and review of the latest Acute Coronary Syndrome (ACS) guidelines as presented in the lecture:

Comprehensive Summary and Review of ACS Guidelines

1. Introduction and Context

The guidelines represent a collaborative effort by Emory University cardiology faculty and the American College of Cardiology.
They provide updated recommendations on diagnosis, acute management (including catheterization lab strategies), and secondary prevention of ACS.
The guidelines emphasize evidence-based class recommendations (Class I: strong evidence and benefit; Class III: harm or no benefit; Class IIa/IIb: intermediate evidence).

2. Diagnosis and Initial Assessment of ACS

ACS Classification

STEMI (ST-Elevation Myocardial Infarction): Complete occlusion of a coronary artery, diagnosed by ST elevation in two or more contiguous ECG leads.
NSTEMI (Non-ST-Elevation MI): Partial occlusion or non-occlusive thrombus with positive cardiac biomarkers but no ST elevation.
Unstable Angina: Ischemic symptoms without biomarker elevation; becoming less common due to high-sensitivity troponin assays.

Role of Biomarkers and ECG

High-sensitivity troponin assays have improved detection of myocardial injury, reducing the frequency of unstable angina diagnosis.
Troponin elevation alone does not confirm ACS; clinical correlation with symptoms and ECG changes is essential.
New left bundle branch block (LBBB) is not diagnostic of STEMI without symptoms.
Serial ECGs and troponin measurements are critical, especially in patients with initially non-diagnostic ECGs.

Prehospital and Emergency Department Protocols

EMS should obtain a 12-lead ECG within 10 minutes of first medical contact.
STEMI patients should be transported directly to PCI-capable centers with a goal of reperfusion within 90 minutes.
Non-STEMI or non-diagnostic ECG patients are transported to the nearest ED for further evaluation.
Risk stratification in the ED uses troponin levels, ECG findings, and clinical features to categorize patients into low, intermediate, or high risk.

3. Catheterization Lab and Acute Management

Reperfusion Strategies

Primary PCI is the preferred reperfusion method for STEMI when available within guideline timeframes.
Fibrinolysis is reserved for STEMI patients at non-PCI-capable centers with no contraindications and when transfer delays are expected.
Immediate transfer to PCI centers is recommended after fibrinolysis for rescue or early angiography.

Antiplatelet Therapy

All ACS patients should receive aspirin (loading dose followed by low-dose maintenance).
A P2Y12 inhibitor (ticagrelor or prasugrel preferred) should be added to aspirin for dual antiplatelet therapy (DAPT).
Clopidogrel is reserved for patients with contraindications to potent P2Y12 inhibitors or those on fibrinolysis.
In patients on chronic oral anticoagulation (e.g., atrial fibrillation), clopidogrel is preferred over potent P2Y12 inhibitors to reduce bleeding risk.
Routine platelet function or genetic testing to guide P2Y12 inhibitor choice is not recommended.

Anticoagulation

Unfractionated heparin or bivalirudin is recommended during PCI.
Radial artery access is preferred over femoral to reduce bleeding and vascular complications.
Glycoprotein IIb/IIIa inhibitors are reserved for select cases with high thrombus burden or no-reflow phenomena.

PCI Strategy

Complete revascularization is recommended in STEMI patients with multivessel disease, preferably staged rather than simultaneous.
In cardiogenic shock, PCI should be limited to the culprit vessel only.
Routine aspiration thrombectomy is not recommended.
Intracoronary imaging (IVUS or OCT) is recommended for complex lesions to optimize PCI outcomes.

Special Situations: Cardiac Arrest and Coma

Patients with return of spontaneous circulation (ROSC) and STEMI should undergo immediate PCI.
Comatose patients with STEMI and fewer poor prognostic features may also benefit from PCI.
Comatose patients without STEMI on ECG generally do not benefit from immediate coronary angiography.

4. Secondary Prevention and Post-Discharge Management

Lipid Management

High-intensity statins are recommended for all ACS patients.
If LDL cholesterol remains >70 mg/dL, add non-statin therapies such as ezetimibe or PCSK9 inhibitors.
Target LDL <55 mg/dL is reasonable, especially post-ACS.
Lipoprotein(a) testing is not recommended during acute ACS but may be considered later for risk stratification.

Beta Blockers and RAAS Inhibitors

Beta blockers should be started in all ACS patients unless contraindicated; oral agents preferred.
ACE inhibitors or ARBs are recommended in patients with EF <40%, hypertension, diabetes, or anterior MI.
Mineralocorticoid receptor antagonists (MRAs) are recommended for patients with EF <40% and heart failure or diabetes.

Anemia and Transfusion

Transfusion threshold in ACS patients is higher than usual: transfuse to maintain hemoglobin ≥10 g/dL to reduce cardiovascular events.

Left Ventricular Function Assessment

EF should be assessed before discharge by echocardiogram or cardiac MRI.
Identifying complications such as papillary muscle rupture, ventricular septal defect, or LV thrombus is critical for management.

Cardiac Rehabilitation

Cardiac rehab is strongly recommended for all ACS patients.
It includes supervised exercise, nutrition education, medication adherence support, and psychosocial counseling.
Home-based cardiac rehab is a reasonable alternative when access is limited.

Vaccinations

Influenza vaccination is recommended within one year of ACS event to reduce cardiovascular morbidity and mortality.
Pneumococcal and COVID-19 vaccinations should follow national guidelines.

Medication Adherence and Follow-Up

Lipid levels should be rechecked 4–8 weeks after therapy initiation or intensification.
Address clinical inertia by reinforcing medication adherence and intensifying therapy if LDL targets are not met.
Social determinants of health should be assessed to identify barriers to adherence and follow-up.

5. Additional Considerations and Q&A Highlights

Routine use of proton pump inhibitors (PPIs) with DAPT is not recommended unless there is a history or high risk of GI bleeding.
Dental hygiene and coronary CT angiography (CTA) are not specifically addressed in ACS guidelines but are important in overall cardiovascular care.
Genetic testing for P2Y12 inhibitor metabolism is not routinely recommended.
Transitioning from potent P2Y12 inhibitors to clopidogrel can be done with appropriate loading doses if cost or tolerance is an issue.
Mechanical circulatory support (e.g., Impella) may be reasonable in selected patients with cardiogenic shock.
Routine use of intra-aortic balloon pump or ECMO is not recommended due to lack of survival benefit.
Ongoing trials of oral PCSK9 inhibitors may improve early lipid management post-ACS.

6. Summary of Key Class I Recommendations

InterventionIndicationNotesAspirin + P2Y12 inhibitor (ticagrelor/prasugrel)All ACS patients undergoing PCI12 months duration unless bleeding riskPrimary PCISTEMI within 12 hoursGoal door-to-balloon <90 minutesHigh-intensity statinAll ACS patientsAdd non-statin if LDL >70 mg/dLBeta blockersAll ACS patients without contraindicationsOral preferredACEi/ARBEF <40%, hypertension, diabetes, anterior MIMRAEF <40% + HF symptoms or diabetesRadial accessPCIReduces bleeding and mortalityComplete revascularizationSTEMI with multivessel disease (staged)Culprit-only in cardiogenic shockCardiac rehab referralAll ACS patientsHome-based if access limitedInfluenza vaccinationAll ACS patientsWithin 1 year of event

Final Thoughts

These updated ACS guidelines emphasize rapid diagnosis, timely reperfusion, potent antiplatelet and anticoagulant therapy, and comprehensive secondary prevention to reduce recurrent events and improve survival. They also highlight the importance of individualized care, balancing ischemic and bleeding risks, and addressing social factors to optimize long-term outcomes.

Sure! Here is a slide-by-slide summary based on the lecture content:

Slide 1: Introduction

Welcome to Heart and Vascular Grand Rounds.
Presentation by Emory cardiology faculty on the latest ACS guidelines.
Overview of speakers and their roles.

Slide 2: Guideline Classifications

Explanation of Class I (strong benefit), Class III (harm), and Class IIa/IIb (intermediate evidence).
Importance of evidence-based recommendations.

Slide 3: ACS Diagnosis Overview

ACS includes STEMI, NSTEMI, and unstable angina.
High-sensitivity troponin assays reduce unstable angina diagnosis frequency.
STEMI requires immediate reperfusion without waiting for biomarkers.

Slide 4: ECG and STEMI Diagnosis

ST elevation in two or more contiguous leads defines STEMI.
New left bundle branch block alone is not diagnostic without symptoms.
Clinical correlation is essential.

Slide 5: Troponin Protocol (Emory)

Emory’s troponin classification protocol explained.
Use of gender-specific cutoffs for high-sensitivity troponin.
Differentiation between type 1 MI, type 2 MI, and non-ischemic myocardial injury.

Slide 6: Prehospital Assessment

EMS obtains 12-lead ECG within 10 minutes.
STEMI patients transported directly to PCI-capable centers.
Serial ECGs recommended to detect evolving STEMI.

Slide 7: Hospital Assessment and Risk Stratification

Rapid ECG within 10 minutes of hospital arrival.
STEMI patients proceed to immediate reperfusion.
Non-STEMI patients undergo serial ECG and troponin testing.
Risk stratification into low, intermediate, and high risk.

Slide 8: Reperfusion at Non-PCI Centers

Fibrinolysis considered if PCI unavailable within 120 minutes.
Contraindications to fibrinolysis must be assessed.
Transfer to PCI center after fibrinolysis completion.

Slide 9: Catheterization Lab Management Overview

Combined management for STEMI and NSTEMI.
Focus on cardiac arrest patients with return of spontaneous circulation.
Prognostic features guide decision for immediate PCI.

Slide 10: Antiplatelet Therapy

Aspirin is class I for all ACS patients.
P2Y12 inhibitors (ticagrelor, prasugrel) preferred unless contraindicated.
Clopidogrel reserved for fibrinolysis or anticoagulated patients.

Slide 11: Intravenous Antiplatelet and Anticoagulant Therapy

Glycoprotein IIb/IIIa inhibitors reserved for high thrombus burden.
Intravenous cangrelor may be reasonable in select patients.
Unfractionated heparin or bivalirudin recommended during PCI.

Slide 12: PCI Strategy and Timing

Primary PCI within 90 minutes for STEMI.
Complete revascularization recommended for multivessel disease.
Culprit-only PCI in cardiogenic shock.
Radial access preferred to reduce bleeding.

Slide 13: PCI After Fibrinolysis

Immediate transfer to PCI center after fibrinolysis.
Rescue PCI if fibrinolysis fails.
Early angiography within 2–24 hours recommended after successful fibrinolysis.

Slide 14: Non-STEMI Invasive Strategy

Immediate invasive strategy (<2 hours) for very high-risk patients.
Early invasive (<24 hours) for high-risk patients.
Selective invasive or conservative approach for low-risk patients.

Slide 15: Imaging and Procedural Guidance

Intracoronary imaging (IVUS/OCT) recommended for complex lesions.
Routine aspiration thrombectomy not recommended.

Slide 16: Mechanical Circulatory Support

Microaxial flow pumps (Impella) reasonable in selected cardiogenic shock patients.
Routine intra-aortic balloon pump or ECMO not recommended.

Slide 17: Secondary Prevention – Lipid Management

High-intensity statins recommended for all ACS patients.
Add non-statin therapy if LDL >70 mg/dL.
LDL target <55 mg/dL reasonable.

Slide 18: Secondary Prevention – Other Medications

Beta blockers recommended unless contraindicated.
ACE inhibitors/ARBs for EF <40%, hypertension, diabetes, or anterior MI.
MRAs for EF <40% with heart failure or diabetes.

Slide 19: Anemia and Transfusion

Transfusion threshold of hemoglobin ≥10 g/dL recommended in ACS.
Different from usual transfusion thresholds in other settings.

Slide 20: Left Ventricular Function Assessment

EF assessment before discharge by echo or cardiac MRI.
Identify mechanical complications and LV thrombus.

Slide 21: Cardiac Rehabilitation

Strongly recommended for all ACS patients.
Includes exercise, education, medication adherence, and psychosocial support.
Home-based rehab reasonable if access limited.

Slide 22: Vaccinations

Influenza vaccine recommended within 1 year of ACS event.
Pneumococcal and COVID-19 vaccines per national guidelines.

Slide 23: Medication Adherence and Follow-Up

Lipid levels rechecked 4–8 weeks after therapy initiation.
Address clinical inertia and social determinants of health.
Reinforce cardiac rehab participation.

Slide 24: Q&A Highlights

Routine PPI use with DAPT not recommended unless GI risk.
Genetic testing for P2Y12 inhibitors not routinely recommended.
Transitioning from potent P2Y12 inhibitors to clopidogrel possible with loading dose.
No specific guideline on dental hygiene or coronary CTA in ACS.

Slide 25: Closing Remarks

Emphasis on evidence-based, individualized care.
Importance of rapid diagnosis, timely reperfusion, and comprehensive secondary prevention.
Thanks to speakers and attendees.

If you want, I can help you create detailed notes or study guides based on these slide summaries!

ACS Guidelines (Emory cardiology 2025)