Evidence-Based Cardiology: Acute Coronary Syndromes

What combination of parameters is recommended for the diagnosis and initial short-term risk stratification of acute coronary syndrome (ACS)?

What is the recommended target time for recording and interpreting a 12-lead ECG at the point of first medical contact (FMC) for patients with suspected acute coronary syndrome?

In patients with suspected acute coronary syndrome (ACS), when is continuous ECG monitoring and the availability of defibrillator capacity recommended?

In cases of suspected acute coronary syndrome, when is the use of additional ECG leads (V3R, V4R, and V7-V9) recommended?

In patients with suspected acute coronary syndrome, what is recommended in cases with recurrent symptoms or diagnostic uncertainty?

What is recommended regarding the measurement of cardiac troponins in patients with suspected acute coronary syndrome?

What is the recommended approach to rule in and rule out NSTEMI in patients with suspected acute coronary syndrome according to the guideline?

What is recommended if the first two hs-cTn measurements of the 0 h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made?

In patients with suspected acute coronary syndrome, what is recommended for prognosis estimation?

A 60-year-old woman with a history of hypertension and hyperlipidemia presents to the emergency department with a sudden onset of severe, crushing chest pain that began 45 minutes ago. An electrocardiogram (ECG) performed upon arrival shows significant ST-segment elevation in the inferior leads.

What immediate management strategy should be pursued for this patient with suspected ST-elevation myocardial infarction (STEMI)?

In patients with suspected acute coronary syndrome presenting with cardiogenic shock or suspected mechanical complications, what is recommended?

A 70-year-old male with a history of coronary artery disease presents to the emergency department with severe chest pain and profound shortness of breath that began three hours ago. On examination, he is pale and clammy. His blood pressure is 80/50 mmHg, heart rate is 120 beats per minute, and oxygen saturation is 88% on room air. Jugular venous distension is noted, and lung auscultation reveals bilateral crackles. A systolic murmur is also noted. An ECG shows ST-segment elevation in the anterior leads. The patient is immediately transferred to the PCI laboratory.

What is recommended for this patient, in addition to primary PCI?

In patients with suspected acute coronary syndrome (ACS), non-elevated (or uncertain) hs-cTn levels, no ECG changes, and no recurrence of pain, which test should be considered as part of the initial workup?

In patients with suspected acute coronary syndrome, under what circumstances should emergency TTE be considered?

In the initial assessment of patients with suspected acute coronary syndrome (ACS), which of the following is NOT recommended?

In patients with acute coronary syndrome, at what level of SaO2 is oxygen administration recommended?

Which of the following is recommended for relieving pain in patients with acute coronary syndrome?

What should be considered for very anxious patients with acute coronary syndrome?

A 55-year-old male presents to the emergency department with sudden onset chest pain. On arrival, his vital signs are stable with a blood pressure of 130/85 mmHg, heart rate of 85 beats per minute, and oxygen saturation of 98% on room air. An ECG shows ST-segment elevation in the inferior leads. He is promptly diagnosed with an anterior ST-elevation myocardial infarction (STEMI) and is being prepared for primary percutaneous coronary intervention (PPCI). He has no signs of acute heart failure.

What role should intravenous beta-blockers play at the time of presentation?

In the initial management of patients with acute coronary syndrome, what is recommended for patients transferred for primary PCI?

In the initial management of patients with acute coronary syndrome, what is the recommended action for EMS when transporting patients with suspected STEMI?

Which of the following is recommended for ambulance teams managing patients with acute coronary syndromes?

A 62-year-old female with no prior history of cardiac issues presents to the emergency department with acute onset chest pain that started six hours ago. The pain is described as intense and crushing, radiating to her left shoulder and jaw. She is also experiencing shortness of breath and nausea. On examination, her blood pressure is 145/90 mmHg, heart rate is 95 beats per minute, and oxygen saturation is 96% on room air. An electrocardiogram (ECG) shows persistent ST-segment elevation in the anterior leads.

What is the recommended management strategy for this patient?

A 58-year-old male presents to the emergency department with sudden onset of severe chest pain that began 7 hours ago. An ECG reveals ST-segment elevation in the inferior leads. The hospital has a catheterization lab available, and the anticipated time from diagnosis to percutaneous coronary intervention (PCI) is estimated to be 110 minutes.

What reperfusion strategy should be recommended for this patient?

A 64-year-old male presents to the emergency department with severe chest pain that began five hours ago. On examination, his blood pressure is 145/85 mmHg, heart rate is 100 beats per minute, and oxygen saturation is 94% on room air. An ECG shows significant ST-segment elevation in the anterior leads. The nearest hospital can perform primary percutaneous coronary intervention (PPCI) at best within 125 minutes of diagnosis.

What is the recommended reperfusion strategy?

Under which conditions is rescue PCI recommended for patients with STEMI after fibrinolysis?

In patients with a working diagnosis of STEMI and a time from symptom onset >12 hours, when is a PPCI strategy recommended?

In patients with STEMI presenting 12 to 48 hours after symptom onset, what reperfusion strategy should be considered?

What is the recommendation for PCI of an occluded infarct-related artery (IRA) in STEMI patients presenting more than 48 hours after symptom onset and without persistent symptoms?

A 58-year-old female with a history of hypertension presents to a hospital without PCI capabilities, experiencing severe chest pain and shortness of breath. Her ECG shows ST-segment elevation, and she receives fibrinolytic therapy within 90 minutes of symptom onset. ST-segment resolution is satisfactory and the patient is asymptomatic 60 minutes after infusion of the fibrinolytic agent.

What is the recommended subsequent step in the management of this patient?

A 62-year-old male with a history of diabetes presents to the emergency department with severe chest pain and shortness of breath. His ECG shows ST-segment elevation, and he receives fibrinolytic therapy. Despite initial treatment, he develops signs of persistent heart failure and hypotension. His blood pressure drops to 85/60 mmHg, and he has significant pulmonary edema on auscultation.

What is the recommended next step in the management of this patient?

A 55-year-old male presents to the emergency department with severe chest pain that started three hours ago. His ECG shows ST-segment elevation, and he receives fibrinolytic therapy. The treatment is successful, with significant resolution of symptoms and ECG changes. He remains hemodynamically stable.

What is the recommended timing for angiography and potential PCI of the infarct-related artery (IRA) in this patient?

A 68-year-old female with a history of hypertension presents to the emergency department with chest pain that started four hours ago. Her ECG shows nonspecific ST-segment changes. She is diagnosed with non-ST-elevation acute coronary syndrome (NSTE-ACS).

What is the recommended management strategy during hospital admission for this patient?

In patients without very high- or high-risk NSTE-ACS criteria and with a low index of suspicion for NSTE-ACS, what approach is recommended?

According to clinical practice guidelines, in patients with a working diagnosis of NSTE-ACS, an immediate invasive strategy is recommended if they exhibit which of the following very high-risk criteria?

Under which condition should an early invasive strategy within 24 hours not be considered for patients with NSTE-ACS?

What is the recommended initial oral loading dose (LD) of aspirin for patients without contraindications in acute coronary syndrome?

In all ACS patients, what is recommended in addition to aspirin, given as an initial oral loading dose (LD) followed by a maintenance dose (MD) for 12 months unless there is high bleeding risk (HBR)?

In patients at high risk of gastrointestinal bleeding, what is recommended in combination with dual antiplatelet therapy (DAPT)?

What is the recommended dosing regimen of prasugrel in patients proceeding to PCI?

LD = loading dose. MD = maintenance dose.

Which antiplatelet therapy is recommended irrespective of the treatment strategy (invasive or conservative) in patients with acute coronary syndrome, and at what dosages?

In the context of antiplatelet therapy for acute coronary syndrome, when is clopidogrel recommended?

In patients presenting with acute coronary syndrome (ACS) who stop dual antiplatelet therapy (DAPT) to undergo coronary artery bypass grafting (CABG), what is the recommended duration for resuming DAPT after surgery?

Which antiplatelet therapy should be considered in preference for ACS patients who proceed to PCI?

In the context of antiplatelet therapy in acute coronary syndrome, when should GP IIb/ IIIa receptor antagonists be considered?

In P2Y12 receptor inhibitor-nave patients undergoing PCI, which antiplatelet therapy may be considered?

In older ACS patients, especially those with high bleeding risk (HBR), which P2Y12 receptor inhibitor may be considered?

In patients undergoing a primary PCI strategy, what is the role of pretreatment with P2Y12 inhibitors?

In the context of NSTE-ACS, when may pretreatment with a P2Y12 receptor inhibitor be considered?

In the context of acute coronary syndrome, which of the following is NOT recommended as pretreatment?

In patients with NSTE-ACS where coronary anatomy is unknown and early invasive management (<24 hours) is planned, what is the guideline recommendation regarding routine pretreatment with a P2Y12 receptor inhibitor?

In patients diagnosed with acute coronary syndrome (ACS), what is recommended regarding anticoagulation therapy?

In patients undergoing PCI, what is the recommended routine use of a UFH bolus during the procedure?

In patients pretreated with subcutaneous enoxaparin, what is recommended at the time of PCI?

When should discontinuation of parenteral anticoagulation be considered in patients undergoing an invasive procedure?

Which anticoagulant should be considered as an alternative to UFH in patients with STEMI undergoing PPCI?

In patients with STEMI undergoing PPCI, what alternative to UFH should be considered with a full-dose post-PCI infusion?

Which anticoagulant is not recommended in patients with STEMI undergoing PPCI?

For patients with NSTE-ACS in whom early invasive angiography (i.e., within 24 h) is not anticipated, which anticoagulant is recommended?

For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is anticipated, which antithrombotic agent should be considered as an alternative to UFH?

In patients with atrial fibrillation with an indication for oral anticoagulation, what is the recommended strategy for antithrombotic therapy after 1 week of triple antithrombotic therapy (TAT) following an acute coronary syndrome (ACS) event?

TAT = triple antithrombotic therapy.

DAT = dual antithrombotic therapy.

A 70-year-old male with atrial fibrillation presents with acute coronary syndrome and is scheduled for percutaneous coronary intervention (PCI). He is currently taking a non-vitamin K antagonist oral anticoagulant (NOAC).

What is the recommended anticoagulation management strategy during PCI for this patient?

In patients with an indication for OAC with VKA in combination with aspirin and/or clopidogrel, what is the recommended target INR and time in the therapeutic range?

When combining antiplatelets and OAC, which dosage of rivaroxaban should be considered when concerns about high bleeding risk (HBR) prevail over ischemic stroke?

In patients at high bleeding risk (HBR) undergoing combination therapy with antiplatelets and oral anticoagulants (OAC), which dosing regimen of dabigatran should be considered to mitigate bleeding risk?

In patients requiring anticoagulation and treated medically, how long should a single antiplatelet agent in addition to an OAC be considered?

In patients treated with an OAC, for how long should aspirin plus clopidogrel be considered in those with high ischaemic risk or with other anatomical/procedural characteristics that are judged to outweigh the bleeding risk?

In patients requiring OAC, when can antiplatelet therapy be withdrawn while continuing OAC?

In the context of triple antithrombotic therapy (TAT) for acute coronary syndrome, which of the following is NOT recommended?

In patients who are event-free after 3-6 months of DAPT and who are not at high ischaemic risk, what change in antithrombotic therapy may be considered?

What alternative DAPT strategy may be considered to reduce bleeding risk according to the recommendation for de-escalation of P2Y12 receptor inhibitor treatment?

In HBR patients, what antithrombotic therapy regimen may be considered after 1 month of DAPT?

HBR = high bleeding risk.

In the first 30 days after an ACS event, what is the recommendation regarding the de-escalation of antiplatelet therapy?

After an acute coronary syndrome, when is it recommended to discontinue antiplatelet treatment in patients treated with an oral anticoagulant (OAC)?

When should a second antithrombotic agent be added to aspirin for extended long-term secondary prevention?

For extended long-term secondary prevention, in which group of patients may adding a second antithrombotic agent to aspirin be considered?

Which of the following regimens may be considered as an alternative to aspirin monotherapy for long-term antithrombotic therapy?

When fibrinolysis is the reperfusion strategy, what is the recommended target time to initiate treatment after diagnosis in the pre-hospital setting?

Which of the following agents are recommended for fibrinolytic therapy?

Regarding fibrinolytic therapy using tenecteplase, what is recommended for patients over 75 years of age?

Which of the following is recommended as antiplatelet co-therapy with fibrinolysis?

In patients treated with fibrinolysis, for how long is anticoagulation recommended?

Which anticoagulant is recommended as the preferred co-therapy with fibrinolysis?

When enoxaparin is not available, which anticoagulant is recommended as a weight-adjusted i.v. bolus, followed by infusion for fibrinolytic therapy?

In patients treated with streptokinase, what anticoagulation co-therapy should be considered?

A 58-year-old female is resuscitated following a cardiac arrest. Her ECG, after ROSC, shows persistent ST-segment elevations in leads V2-V5). She becomes hemodynamically unstable with low blood pressure despite repeated intravenous epinephrine. The emergency physician suggested fibrinolysis and continued mechanical CPR.

What is the recommended management strategy for this patient?

In the case of resuscitated cardiac arrest, what is the recommendation for routine immediate angiography in hemodynamically stable patients without persistent ST-segment elevation (or equivalents)?

What is recommended for adults who remain unresponsive after return of spontaneous circulation following either out-of-hospital or in-hospital cardiac arrest?

When is the evaluation of neurological prognosis recommended in comatose survivors after cardiac arrest?

What is recommended for patients with cardiogenic shock (CS) complicating acute coronary syndrome (ACS)?

In the management of cardiogenic shock, what is recommended if percutaneous coronary intervention (PCI) of the infarct-related artery (IRA) is not feasible or unsuccessful?

In cases of hemodynamic instability, what is recommended for the repair of mechanical complications of Acute Coronary Syndrome (ACS)?

In patients with STEMI presenting with cardiogenic shock, under what condition should fibrinolysis be considered?

In patients with ACS and severe/refractory cardiogenic shock, what intervention may be considered according to clinical practice guidelines?

In patients with acute coronary syndrome (ACS) and cardiogenic shock (CS) without mechanical complications, what is the recommendation regarding the routine use of an intra-aortic balloon pump (IABP)?

What is recommended for STEMI patients and very high-risk NSTE-ACS patients regarding ECG monitoring?

For high-risk patients with successful reperfusion therapy and an uncomplicated clinical course, how long should they be kept in the CCU/ICCU before being moved to a step-down monitored bed?

Which of the following statements is true regarding the discharge of selected high-risk patients with ACS?

What is recommended for selected stable patients after successful and uneventful PCI?

Which patients should undergo routine echocardiography after an ACS?

When echocardiography is suboptimal or inconclusive, which imaging modality may be considered?

Which access route is recommended as the standard approach for PCI?

In patients undergoing primary percutaneous coronary intervention (PPCI), what is recommended regarding the infarct-related artery (IRA) during the index procedure?

Which type of stent is recommended in all cases according to the guidelines?

A 45-year-old woman presents to the emergency department with severe chest pain and immediate angiography reveals spontaneous coronary artery dissection (SCAD). When is PCI indicated in patients with SCAD?

What is the role of intravascular imaging during primary PCI in acute coronary syndromes?

In patients with ACS and an occluded IRA, what should be considered when primary PCI is not feasible or unsuccessful and there is a large area of myocardium in jeopardy?

Which of the following statements is true regarding the use of thrombus aspiration during primary PCI?

What is recommended for ACS patients presenting in cardiogenic shock with multivessel disease during the index procedure?

What is the recommended timeframe for complete revascularization in hemodynamically stable STEMI patients undergoing PPCI?

How is non-infarct-related artery (non-IRA) stenosis severity evaluated in patients with STEMI?

In patients presenting with NSTE-ACS and multivessel disease (MVD), what is the recommended approach regarding revascularization?

How is non-infarct-related artery (non-IRA) stenosis severity evaluated in patients with NSTE-ACS?

Which imaging modality is recommended for patients presenting with MINOCA (myocardial infarction with non-obstructive coronary arteries) following invasive angiography, if the diagnosis is not clear?