Pathophysiology and management of acute coronary syndromes

Acute coronary syndrome management has evolved from a narrow focus on culprit plaques to a complex understanding of the interplay between upstream arterial events and downstream myocardial damage. While primary angioplasty has become the standard reperfusion therapy for STEMI, achieving over 90% implementation in the UK, significant delays persist in patient pathways, particularly when transfers occur between hospitals. Current diagnostic reliance on angiography often fails to capture the full pathophysiology of myocardial infarction, necessitating a shift toward advanced intracoronary imaging and more specific biomarkers. Moving forward, clinical practice must prioritize rapid, direct access to cardiac catheterization labs and develop targeted biological therapies for microvascular and inflammatory processes. Addressing these gaps requires moving beyond traditional risk factor evaluation to address the underlying biological mechanisms driving myocardial necrosis and long-term patient outcomes.