How is moderate- or high-risk acute coronary syndrome (ACS) treated?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Current guidelines for patients with moderate- or high-risk ACS recommend an early invasive approach with concomitant antithrombotic therapy, including aspirin, clopidogrel, and unfractionated or LMWH. The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial evaluated the role of thrombin-specific anticoagulation with bivalirudin in this patient population. In patients with moderate- or high-risk ACS who were undergoing invasive treatment with glycoprotein IIb/IIIa inhibitors, bivalirudin was associated with rates of ischemia and bleeding that were similar to those with heparin. Bivalirudin alone was associated with similar rates of ischemia and significantly lower rates of bleeding. [102] Further, glycoprotein IIb/IIIa inhibitors can be initiated at the time of angiography; routine administration 12-24 hours before the procedure carries an increased risk of bleeding and no improvement in outcome.

Kastrati et al compared the combination of glycoprotein IIb/IIIa inhibitors and heparin with bivalirudin, specifically among patients with NSTEMI undergoing PCI. In a double-blind manner, 1721 patients with acute NSTEMI were randomly assigned to receive abciximab plus unfractionated heparin (861 patients) or bivalirudin (860 patients). The study concluded that abciximab and unfractionated heparin, compared with bivalirudin, failed to reduce death, large recurrent myocardial infarction, urgent target-vessel revascularization, or major bleeding within 30 days. It also increased the risk of bleeding among patients with NSTEMI who were undergoing PCI. [103]

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