Intersections and Challenges in the Management of Acute Coronary Syndrome and Stroke: Pathophysiology, Treatment Dilemmas, and Integrated Prevention Strategies

Abstract

Acute coronary syndrome (ACS) and stroke are interconnected conditions that often share risk factors such as atherosclerosis, thrombosis, and systemic inflammation. When these events occur simultaneously, they present unique diagnostic and therapeutic challenges. This review explores the pathophysiological mechanisms linking ACS and stroke, including common pathways like plaque instability, cardioembolism, and endothelial dysfunction, while highlighting the distinct features of ischemic and hemorrhagic strokes. The manuscript provides an overview of diagnostic strategies, emphasizing the role of biomarkers, advanced neuroimaging, and risk stratification tools in guiding acute management. Furthermore, the review delves into treatment approach, emphasizing the need to balance reperfusion therapies for ACS with thrombolysis or thrombectomy for ischemic stroke while carefully managing the challenges posed by anticoagulation in cases complicated by bleeding. Long-term strategies for secondary prevention are examined, including antithrombotic regimens tailored to the dual risk of thrombosis and bleeding, as well as lipid-lowering and blood pressure management. Future perspectives highlight the potential of novel pharmacological agents, neuroprotective therapies, and AI-driven tools to enhance patient outcomes. This review underscores the importance of integrated, multidisciplinary care and identifies key areas for future research to optimize the management of these high-risk patients.

Keywords: acute coronary syndrome; anticoagulation therapy; dual antiplatelet therapy; intracerebral hemorrhage; myocardial infarction; percutaneous coronary intervention; stroke.

Figure 1

Progression of atherosclerosis: from formation of a stable fibrous cap to development of a vulnerable plaque prone to rupture, leading to thrombotic complications. This shared pathophysiological mechanism underlies both acute coronary syndromes and ischemic stroke, particularly large-artery atherosclerosis.

Figure 2

Intravascular and procedural findings in a STEMI patient with left anterior descending artery (LAD) involvement. (A,B) Optical coherence tomography (OCT) images revealing the presence of intracoronary thrombus in the LAD. (C) Aspirated coronary thrombus retrieved from a STEMI patient with LAD occlusion.

Figure 3

Representative neuroimaging findings of different types of strokes. (A) Right frontoparietal intraparenchymal hemorrhage with surrounding perilesional edema, ventricular compression, and midline shift (CT). (B) Sequela of ischemic stroke in left frontal region (CT). (C) Left temporo-occipital intraparenchymal hemorrhage with perilesional edema (CT). (D,E) Subacute bilateral thalamic ischemic stroke shown on FLAIR (Fluid-Attenuated Inversion Recovery) (D, left) and DWI (Diffusion-Weighted Imaging) ((E), right) MRI sequences. (F) Ischemic stroke in right occipital region (CT).

Figure 4

Coronary angiographic findings in a patient with inferior STEMI. (A) Initial angiography showing a thrombotic distal occlusion and a severe proximal stenosis of the right coronary artery. (B) Partial restoration of distal coronary flow following the passage of the coronary guidewire, with a visible radiolucent area at the site of the distal occlusion, suggestive of coronary thrombosis. (C) Final angiographic result after primary PCI with implantation of two drug-eluting stents.

Figure 5

Spontaneous coronary artery dissection (SCAD) of the right coronary artery: a rare but important cause of acute coronary syndrome, predominantly affecting women. Image illustrates characteristic angiographic findings of SCAD, highlighting the arterial wall dissection and lumen narrowing, which can lead to myocardial ischemia.

Figure 6

Flowchart for management of stroke in patients with ACS. ACS: Acute Coronary Syndrome, CT: Computed Tomography, ECG: Electrocardiogram, DAPT: Dual Antiplatelet Therapy, ICH: Intracerebral Hemorrhage, NSTEMI: Non-ST-Elevation Myocardial Infarction, PCI: Percutaneous Coronary Intervention, STEMI: ST-Elevation Myocardial Infarction.