Diagnostic and Therapeutic Approach to Patients Presenting with Acute Coronary Syndrome (ACS) Focusing on Antiplatelet and Antithrombotic Therapy - Flowchart
Diagnostic and Therapeutic Approach to Patients Presenting with Acute Coronary Syndrome (ACS) Focusing on Antiplatelet and Antithrombotic Therapy - Flowchart Diagnostic and Therapeutic Approach to Patients Presenting with Acute Coronary Diagnostic and Therapeutic Approach to Patients Presenting with Acute Coronary
«Flowchart»

ACS Symptoms
ASA 325 mg, ECG cardiac enzymes

ACS Symptoms
ASA 325 mg, ECG cardiac enzymes

ACS Symptoms
ASA 325 mg, ECG cardiac enzymes

ACS Symptoms

Rule out ACS

Rule out ACS

Rule out ACS Rule out ACS

Definitive ACS

Definitive ACS

Definitive ACS Definitive ACS

PCI/Thrombolysis

PCI/Thrombolysis

PCI/Thrombolysis

UA/NSTEMI

UA/NSTEMI

UA/NSTEMI

UA/NSTEMI

+Chest discomfort
+ECG, +enzymes

+Chest discomfort
+ECG, +enzymes


+Chest discomfort

-Chest discomfort
-ECG, -enzymes

-Chest discomfort
-ECG, -enzymes


-Chest discomfort

Moderate to High Risk

Moderate to High Risk

Moderate to High Risk

Low Risk

Low Risk

Low Risk

Routine Invasive Strategy

Routine Invasive Strategy

Routine Invasive Strategy

Routine Invasive Strategy

Ischemia Driven Strategy

Ischemia Driven Strategy

Ischemia Driven Strategy

Ischemia Driven Strategy

UFH or LMWH*
Clopidogrel†

UFH or LMWH*
Clopidogrel†

UFH or LMWH*
Clopidogrel†

* *
† †

Diagnostic Angiography

Diagnostic Angiography

Diagnostic Angiography

End

End

End

Consider angiography or medical mgmt

Consider angiography or medical mgmt

Consider angiography or medical mgmt

+Chest discomfort
+ECG, +enzymes

+Chest discomfort
+ECG, +enzymes


+Chest discomfort

Stress Testing

Stress Testing

Stress Testing Stress Testing

Observe 12-24 hours serial ECG, enzymes

Observe 12-24 hours serial ECG, enzymes

Observe 12-24 hours serial ECG, enzymes

+Stress

+Stress

+Stress

-Stress

-Stress

-Stress

Unlikely cardiac chest pain

Unlikely cardiac chest pain

Unlikely cardiac chest pain

STEMI

STEMI

STEMI STEMI

UA/NSTEMI

UA/NSTEMI

UA/NSTEMI UA/NSTEMI

Assessment of LV function

Assessment of LV function

Assessment of LV function

EF < 40%
+WMA

EF < 40%
+WMA


EF < 40%

EF >40%
-WMA

EF >40%
-WMA


EF >40%

Stress Testing

Stress Testing

Stress Testing

Stress Testing

+Stress

+Stress

+Stress

-Stress

-Stress

-Stress

Medical Rx
ASA
± Clopidogrel

Medical Rx
ASA
± Clopidogrel

Medical Rx Medical Rx

Medical Rx

Non-CAD
Search and treat for other causes of chest pain

Non-CAD
Search and treat for other causes of chest pain

Non-CAD Non-CAD
Non-CAD

* Bivalirudin is an appropriate alternative to UFH and LMWH, or at time of PCI, patients on UFH may be switched to bivalirudin.

* Bivalirudin is an appropriate alternative to UFH and LMWH, or at time of PCI, patients on UFH may be switched to bivalirudin.

* Bivalirudin is an appropriate alternative to UFH and LMWH, or at time of PCI, patients on UFH may be switched to bivalirudin.

*

† Choose either clopidogrel, ticagrelor, or prasugrel as the second antiplatelet agent.

† Choose either clopidogrel, ticagrelor, or prasugrel as the second antiplatelet agent.

† Choose either clopidogrel, ticagrelor, or prasugrel as the second antiplatelet agent.

†

# Indicators of recurrent ischemia include worsening chest pain, increasing cardiac biomarkers, heart failure signs/symptoms, arrhythmia (VT/VF), and dynamic ECG changes.

# Indicators of recurrent ischemia include worsening chest pain, increasing cardiac biomarkers, heart failure signs/symptoms, arrhythmia (VT/VF), and dynamic ECG changes.

# Indicators of recurrent ischemia include worsening chest pain, increasing cardiac biomarkers, heart failure signs/symptoms, arrhythmia (VT/VF), and dynamic ECG changes.

#

CABG
ASA
UFH or LMWH*
Stop clopidogrel 5 days prior to elective cases

CABG
ASA
UFH or LMWH*
Stop clopidogrel 5 days prior to elective cases

CABG CABG

* *
CABG

PCI
ASA
Clopidogrel

PCI
ASA
Clopidogrel

PCI PCI

PCI

Medical Rx (CAD)
ASA
Clopidogrel
UFH or LMWH

Medical Rx (CAD)
ASA
Clopidogrel
UFH or LMWH

Medical Rx (CAD) Medical Rx (CAD)


Medical Rx (CAD)

UFH or LMWH*
Clopidogrel†

UFH or LMWH*
Clopidogrel†

UFH or LMWH*
Clopidogrel†

* *
† †

+Recurrent ischemia#

+Recurrent ischemia#

# # +Recurrent ischemia

-Recurrent ischemia

-Recurrent ischemia

-Recurrent ischemia

ASA, aspirin; CABG, coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction; glycoprotein IIb/IIIa inhibitor; LMWH, low-molecular-weight heparin; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; Rx, treatment; STEMI, ST-segment elevation myocardial infarction; UA, unstable angina; UFH, unfractionated heparin; VT/VF, ventricular tachycardia/ventricular fibrillation; WMA, wall motion abnormality.

ASA, aspirin; CABG, coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction; glycoprotein IIb/IIIa inhibitor; LMWH, low-molecular-weight heparin; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; Rx, treatment; STEMI, ST-segment elevation myocardial infarction; UA, unstable angina; UFH, unfractionated heparin; VT/VF, ventricular tachycardia/ventricular fibrillation; WMA, wall motion abnormality.

ASA, aspirin; CABG, coronary artery bypass grafting; CAD, coronary artery disease; EF, ejection fraction; glycoprotein IIb/IIIa inhibitor; LMWH, low-molecular-weight heparin; NSTEMI, non-ST-segment elevation myocardial infarction; PCI, percutaneous coronary intervention; Rx, treatment; STEMI, ST-segment elevation myocardial infarction; UA, unstable angina; UFH, unfractionated heparin; VT/VF, ventricular tachycardia/ventricular fibrillation; WMA, wall motion abnormality.