(P031) MEDICAL MANAGEMENT OF ACUTE CORONARY SYNDROME: A COMPREHENSIVE NARRATIVE REVIEW

Background: Conservative or non-invasive management of ACS is a frequently encountered scenario, although recent literature on this approach is limited. A multitude of patients are unable to benefit from invasive revascularization due to underlying high-risk or prohibitive features. Ischemia with Nonobstructive Coronary Artery Disease (INOCA) also emerges as a novel umbrella term encompassing ACS with no evidence of coronary obstruction. The diagnosis and treatment of INOCA, with its diverse pathophysiological features, are complex and lack consensus regarding both short and long-term medical management. While the refinement of invasive approaches captures most of the attention, efforts to understand and treat ACS patients who are not candidates for invasive procedures have been somewhat sidelined. In light of these significant discrepancies, we conducted a contemporary systematic review focused on the overlooked medical management of ACS, encompassing both atherosclerotic and non-atherosclerotic causes.

METHODS AND RESULTS: A comprehensive narrative review of the medical management of ACS was conducted throughout PubMed, Embase and Medline. Relevant systematic reviews, meta-analyses, randomized controlled trials, and cohort studies were considered. Amongst 4533 articles, 58 full-text studies were assessed for eligibility and 21 articles were retained. These studies regrouped 157,821 patients diagnosed with ACS, in whom 30% were classified under the INOCA umbrella. Evidence regarding the medical management of atherosclerotic ACS is sparse. Age was independently associated with an increase odd of non-invasive management. Medically managed groups included significantly more women, increased comorbidities with higher rates of hypertension, diabetes, and congestive heart failure. Medically managed patients suffering from atherosclerotic ACS were also less likely to be treated with optimal medical therapy upon discharge when compared to their invasively managed counterparts. A pooled prevalence of 51.5% of patients in the medically managed group who had an indication for a P2Y12 inhibitor did not receive a prescription. Moreover, MACE and mortality rates differ between INOCA and obstructive CAD-related ACS patients across studies. The variability in this scenario is partially influenced by the diverse etiologies categorized under the INOCA label. Despite the effectiveness of secondary prevention treatments such as ACE/ARBs and statins, there remains heterogeneity in their utilization at discharge among INOCA patients. the INOCA population is also often undertreated at discharge.

Conclusion: Limited literature exists on medical treatment for non-revascularized ACS, but our ongoing research underscores the need for a more assertive pharmacological strategy in this group. Conversely, there's growing focus on medical treatment for INOCA, suggesting benefits from intensified pharmacotherapy, urging further clinical trials to refine guidelines.