Acute Coronary Syndrome: Management.

Aspirin is recommended for all patients with a suspected acute coronary syndrome (ACS) unless contraindicated. Addition of a second antiplatelet (ie, dual antiplatelet therapy) (eg, clopidogrel, ticagrelor, or prasugrel) also is recommended for most patients. Parenteral anticoagulation is recommended with unfractionated heparin, low-molecular-weight heparin, bivalirudin, and fondaparinux. Proton pump inhibitors are recommended to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding. Other medical therapies should include statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin and morphine (to relieve chest pain), and oxygen. For patients with an ST-segment elevation myocardial infarction, percutaneous coronary intervention (PCI) with stent placement should be performed as soon as possible. However, fibrinolytic therapy should be used first if PCI will be delayed for more than 120 minutes. For non-ST-segment elevation ACS, PCI is recommend; fibrinolytic therapy typically is not recommended. If patients require coronary artery bypass graft to reestablish coronary artery flow, it ideally is delayed 3 to 7 days after admission unless the patient has cardiogenic shock, life-threatening arrhythmias, three-vessel disease (with 70% occlusion each), greater than 50% left main coronary artery occlusion, unsuccessful or complicated PCI, or mechanical complications (eg, valve rupture).