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Pharmacotherapy of Acute Coronary Syndrome
*Syndromum coronarium acutum*
For medical students2 min readUpdated 2026-10-10
Acute coronary syndrome encompasses conditions ranging from unstable angina to myocardial infarction. Rapid diagnosis and emergency pharmacotherapy aim to relieve pain, stabilize hemodynamics, and restore coronary blood flow.
The term ACS includes unstable angina and myocardial infarction. This grouping is based on similar clinical presentations and core treatment principles, which accelerates pre-hospital and inpatient care.
Clinical forms are divided into two categories:
ST-elevation (STEMI): corresponds to the development of a transmural myocardial infarction.
Non-ST-elevation (NSTE-ACS): encompasses unstable angina or non-ST-elevation myocardial infarction (subendocardial infarction). Diagnosis is confirmed by blood necrosis markers—troponins T and I—as well as creatine kinase.
Pain Management and Hemodynamics
Relieving pain and associated stress in the initial phase is critically important. Treatment options include:
Neuroleptanalgesia (a combination of an opioid analgesic and a neuroleptic, such as fentanyl plus droperidol).
Opioid analgesics (morphine and analogues).
Inhalation anesthesia using the non-opioid analgesic nitrous oxide.
To control heart rhythm and hemodynamics:
Lidocaine (Class IB) is the drug of choice for ventricular extrasystoles, eliminating them without depressing myocardial contractility.
Nitroglycerin (intravenous) provides hemodynamic unloading and prevents acute heart failure.
Antithrombotic and Thrombolytic Therapy
Pathogenetic treatment starts in the first hours to prevent thrombosis:
Antiplatelets: aspirin, as well as P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor).
Direct anticoagulants: heparin (especially in STEMI), nadroparin calcium, rivaroxaban, dabigatran etexilate. Subsequently, indirect anticoagulants (acenocoumarol, warfarin) may replace direct ones.
Thrombolytic therapy (fibrinolytics such as streptokinase, alteplase) has a strict indication: it is performed exclusively in STEMI to dissolve fresh thrombi and achieve reperfusion.
Mnemonic
"ABCDE" approach: Aspirin and antiplatelets, Blood pressure and pain control (opioids/nitrous oxide), Cardiac drugs (nitroglycerin), Direct anticoagulants and lidocaine.
Frequently asked questions
What is the mechanism of action of alteplase during thrombolytic therapy?
Alteplase (alteplase) is a recombinant tissue plasminogen activator that acts predominantly within the thrombus structure. The drug activates plasminogen that is already bound to fibrin strands, providing fibrin-specific activation and localized action.
How does STEMI differ from NSTE-ACS?
STEMI indicates transmural myocardial infarction and permits thrombolytic therapy. NSTE-ACS involves unstable angina or small myocardial infarction confirmed by troponins and creatine kinase.
Which medications are used for pain relief in acute coronary syndrome?
Options include neuroleptanalgesia (fentanyl combined with droperidol), opioid analgesics (morphine), and the inhalation non-opioid anesthetic nitrous oxide.
When is thrombolytic therapy indicated?
Fibrinolytics (e.g., alteplase or streptokinase) are indicated exclusively for patients with ST-elevation myocardial infarction to dissolve blood clots.
Which antiarrhythmic drug is chosen for ventricular extrasystoles in the acute phase?
Lidocaine (Class IB) is the drug of choice because it effectively suppresses extrasystoles without depressing myocardial contractility.
Go deeper
Differential diagnosis of NSTE-ACS using myocardial necrosis markers
Mechanisms of action of antiplatelet agents and P2Y12 receptor inhibitors
Comparative characteristics of direct and indirect anticoagulants in the acute phase
Indications and limitations of fibrinolytics in reperfusion therapy
The role of neuroleptanalgesia and inhalation anesthetics in reducing cardiac stress
Features of symptomatic therapy based on individual clinical manifestations