Acute Coronary Syndromes Compendium

Antithrombotic therapy is an essential part of the management of the full spectrum of acute coronary syndromes (ACS). Both antiplatelets and anticoagulants seem to be necessary in the management of ACS (Figures 1 and 2), although the exact proportion of antithrombotic effect that each drug and class should ideally provide remains a matter of ongoing study. As a general principle, more potent antithrombotic effect is associated with a decreased risk of ischemic events, particularly among patients who are appropriately risk-stratified. However, there is a tipping point beyond which more potent antithrombotic effect leads to major bleeding complications that diminish or exceed the benefit on ischemic end points. Finding the so-called sweet spot of antithrombotic therapy remains a major challenge. Risk stratification remains problematic because the most powerful predictors for ischemic complications are essentially the same as for bleeding risk. The American College of Cardiology/American Heart Association guidelines provide a useful framework for thinking about antithrombotic choices in ACS (Tables 1 and 2).