Optimal treatment of ACS patients: Issues and considerations for upstream antiplatelet therapy

Acute coronary syndromes (ACS) caused by atherosclerotic plaque rupture are clinically manifested as an ST-elevation myocardial infarction, non-ST-elevation myocardial infarction, or unstable angina. Regardless of the management strategy chosen, antithrombotic therapy is necessary to optimize patient outcomes. The American College of Cardiology/American Heart Association guidelines provide a degree of flexibility in the use of antithrombotic and antiplatelet therapies; although this is largely influenced by the clinical severity of the ACS presentation, it can still be difficult for clinicians to decide which antiplatelet therapy regimen should be used. In this article, current recommendations for the use of antiplatelet therapy in the management of ACS are reviewed, along with an overview of the timing of upstream treatment and the decision points involved in choosing the appropriate antiplatelet regimen.