30th May 2026

Management

Initial Treatment

• Aspirin: Administer a loading dose unless contraindicated.
• Anticoagulation: Fondaparinux or unfractionated heparin, especially in patients with renal impairment.
• Pain Relief: Glyceryl trinitrate (GTN) and morphine as needed.
• Monitoring: Continuous monitoring for symptom recurrence, dynamic ECG changes, or rising troponin levels.
• Antiplatelet Therapy: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is recommended for high-risk patients. If severe thrombocytopaenia develops, alternative anticoagulation should be considered. In patients at high risk of thrombotic complications, a direct thrombin inhibitor such as bivalirudin should be considered.
• Invasive Strategy: Coronary angiography is indicated within 24-72 hours for high-risk patients based on clinical features and risk stratification.

Long-term Treatment

• Continue aspirin and P2Y12 inhibitors for up to 12 months.
• Consider ACE inhibitors/ARBs, beta-blockers, statins, and aldosterone antagonists for patients with heart failure or diabetes.
• SGLT2 inhibitors (e.g., dapagliflozin) may be used for patients with heart failure, regardless of ejection fraction.
• Stress-testing a few weeks after the event may guide the need for further invasive treatment.

Prevention & Follow-Up

• Primary Prevention: Smoking cessation, a healthy diet, weight management, and regular physical activity are crucial. Statins should be prescribed for high cardiovascular risk patients.
• Secondary Prevention: Cardiac rehabilitation and adherence to long-term medications, including antiplatelet therapy, statins, and ACE inhibitors.
• Follow-Up: Regular outpatient follow-up within 1-2 weeks post-discharge, with lipid monitoring every 6 months. Medication reviews should be conducted at each visit.

Complications

• Short-term: Cardiac arrhythmias, acute heart failure, cardiogenic shock, and post-ischemic pericarditis.
• Variable: Depression and in-stent thrombosis.
• Bleeding: Major bleeding events occur in 3.9% of ACS patients, especially those receiving anticoagulation therapy. Minor bleeding can be managed conservatively without halting anticoagulants or antiplatelet therapy. Major bleeding may require discontinuation of DAPT, as well as measures such as platelet transfusion and resuscitation.