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Review
. 2022 Apr 2;399(10332):1347-1358.
doi: 10.1016/S0140-6736(21)02391-6.

Acute coronary syndromes

Brian A Bergmark  1 , Njambi Mathenge  2 , Piera A Merlini  3 , Marilyn B Lawrence-Wright  4 , Robert P Giugliano  5
Affiliations
Review

Acute coronary syndromes

Brian A Bergmark et al. Lancet. .

Abstract

Although substantial progress has been made in the diagnosis and treatment of acute coronary syndromes, cardiovascular disease remains the leading cause of death globally, with nearly half of these deaths due to ischaemic heart disease. The broadening availability of high-sensitivity troponin assays has allowed for rapid rule-out algorithms in patients with suspected non-ST-segment elevated myocardial infarction (NSTEMI). Dual antiplatelet therapy is recommended for 12 months following an acute coronary syndrome in most patients, and additional secondary prevention measures including intensive lipid-lowering therapy (LDL-C <1·4 mmol/L), neurohormonal agents, and lifestyle modification, are crucial. The scientific evidence for diagnosis and management of acute coronary syndromes continues to evolve rapidly, including adapting to the COVID-19 pandemic, which has impacted all aspects of care. This Seminar provides a clinically relevant overview of the pathobiology, diagnosis, and management of acute coronary syndromes, and describes key scientific advances.

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Conflict of interest statement

Declaration of interests BAB reports grants from Ionis, Abbott Vascular, Pfizer, and AstraZeneca; personal fees from Abiomed, Abbott Vascular, CSI, Quark, Servier, Janssen, Daiichi-Sankyo, and Philips, outside the submitted work. RPG reports grants from Amgen, Ionis, Daiichi-Sankyo, and Anthos; honoraria for Continuing Medical Education Programmes and lectures from Amgen, Centrix, Daiichi Sankyo, Dr. Reddy's Laboratories, Medical Education Resources, Medscape, Menarini, Pfizer, SAJA Pharmaceuticals, Servier, and Voxmedia; and consultant fees from Amarin, Amgen, Bayer, CryoLife, Daiichi Sankyo, Esperion, Gilead, Hengrui, Inari, Pfizer, PhaseBio Pharmaceuticals, St Luke's Hospital (Kansas City, MO, USA), and Sanofi Aventis. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Approach to non-ST elevation acute coronary syndromes using a rapid rule-out strategy. General scheme for a 0 h/1 h rapid rule-out algorithm for patients with suspected NSTEACS. High-sensitivity troponin concentration thresholds are assay-specific. NSTEACS=non-ST-segment elevation acute coronary syndrome. *And symptom duration at least 3 h.
Figure 2
Figure 2
Risk stratification for timing of invasive angiography in non-ST segment elevation acute coronary syndrome Selection of non-ST-segment elevation acute coronary syndrome treatment strategy and timing according to initial risk stratification. GRACE=Global Registry of Acute Coronary Events. TIMI=thrombolysis in myocardial infarction.
Figure 3
Figure 3
Approach to antithrombotic therapy in patients with an indication for oral anticoagulation who have undergone percutaneous coronary intervention for acute coronary syndromes. The strategy for antithrombotic therapy is guided by assessment of each patient's risk for ischaemic events and for bleeding.
Figure 4
Figure 4
Secondary prevention after acute coronary syndromes Bempedoic acid is a novel oral inhibitor of cholesterol synthesis which was approved by the European Medicines Agency and the US Food and Drug Administration in 2020 for lipid-lowering, though clinical efficacy to reduce cardiovascular events is not yet proved. Numerous additional targets for lipid-lowering therapy, including ANGPTL3, lipoprotein(a), APOC3, lipoprotein lipase, and others, are in development., ACEi=angiotensin converting enzyme inhibitor. ACS=acute coronary syndrome. ARB=angiotensin receptor blocker. DAPT=dual antiplatelet therapy. HF=heart failure. LVEF=left ventricular ejection fraction. PCSK9i=proprotein covertase subtilisin/kexin type 9 inhibitor. STEMI=ST-segment elevation myocardial infarction.
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