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Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: closed (31 January 2026) | Viewed by 7855

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Special Issue Editors

Dr. Pierre Sabouret

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Guest Editor

Heart Institute and Action Group, Pitié-Salpétrière, Sorbonne University, 75013 Paris, France
Interests: echocardiography; hypertension; atrial fibrillation; myocardial infarction; heart failure; cardiovascular medicine

Dr. Giuseppe Andò

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Guest Editor

Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
Interests: acute coronary syndrome; percutaneous coronary intervention (PCI); guidelines; oral anticoagulants (OAC); atrial fibrillation
Special Issues, Collections and Topics in MDPI journals

Prof. Dr. Elad Asher

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Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Eisenberg R&D Authority and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9103102, Israel
Interests: ACS; cardiogenic shock; interventional cardiology
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Acute Coronary Syndromes (ACSs) represent a critical spectrum of cardiovascular emergencies, encompassing unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). This Special Issue highlights recent clinical advances in the diagnosis and management of ACS, focusing on precision medicine, rapid risk stratification, and evidence-based therapeutic strategies. Key topics include the role of high-sensitivity cardiac biomarkers (e.g., troponins), coronary imaging modalities (e.g., optical coherence tomography), and the integration of artificial intelligence in early diagnosis. The Special Issue also reviews contemporary treatment paradigms, such as tailored antiplatelet/anticoagulant regimens, early revascularization, and novel pharmacological agents (e.g., P2Y12 inhibitors, SGLT2 inhibitors). Additionally, it addresses disparities in care delivery and emerging technologies like telemedicine for post-ACS monitoring. By synthesizing cutting-edge research and expert consensus, this collection aims to optimize patient outcomes through timely, individualized care while underscoring gaps for future investigation.

Dr. Pierre Sabouret
Dr. Giuseppe Andò
Dr. Elad Asher
Guest Editors

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Keywords

acute coronary syndromes
myocardial infarction
cardiac biomarkers
antiplatelet therapy
revascularization
precision medicine
risk stratification

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Published Papers (6 papers)

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Research

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15 pages, 1044 KB

Open AccessArticle

From Plaque to Perfusion: A Narrative Review of Multimodality Imaging in Acute Coronary Syndromes

by Ahmed Shahin, Salaheldin Agamy, Sheref Zaghloul, Ranin ElShafey, Maha Molda, Zahid Khan and Luciano Candilio

J. Clin. Med. 2026, 15(8), 2905; https://doi.org/10.3390/jcm15082905 - 11 Apr 2026

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Abstract

Background: This narrative review introduces the “From Plaque to Perfusion” framework, a clinically pragmatic approach that maps multimodality imaging technologies to critical decision points in the acute coronary syndrome (ACS) patient journey. By integrating non-invasive assessment, invasive procedural guidance, and post-event tissue characterisation, this framework provides a structured pathway for deep phenotyping of ACS. Artificial intelligence (AI) is highlighted as an essential enabling layer that enhances diagnostic precision, automates quantification, and supports scalable, data-driven care. Contemporary ACS management pathways, while effective, often leave residual clinical uncertainty. The diagnostic objective has evolved beyond confirming myocardial injury to comprehensively phenotyping the entire ACS cascade: defining the plaque substrate, identifying the culprit mechanism, and quantifying the myocardial consequence. This requires a systematic integration of advanced imaging modalities. Methods: This narrative review is based on a comprehensive literature search of major medical databases (PubMed/MEDLINE, Scopus, Embase, Google Scholar) for high-level evidence, including randomized controlled trials, meta-analyses, and international expert consensus documents published between January 2010 and February 2026. Results: The “From Plaque to Perfusion” framework consists of three core stages. First, non-invasive assessment with coronary computed tomography angiography (CCTA), fractional flow reserve (FFR-CT), and PET-CT defines plaque substrate and vascular inflammation. Second, invasive precision in the catheterization laboratory, guided by optical coherence tomography (OCT) and intravascular ultrasound (IVUS), resolves the culprit mechanism and optimizes percutaneous coronary intervention (PCI). Third, post-event tissue characterization with cardiac magnetic resonance (CMR) quantifies myocardial injury and refines prognosis. AI-driven platforms are shown to enhance each stage by automating analysis, standardizing interpretation, and providing actionable metrics for clinical decisions, including complex scenarios like Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). Conclusions: The “From Plaque to Perfusion” framework, enabled by AI, reframes ACS imaging as an integrated, mechanism-driven pathway. This approach moves beyond isolated test interpretation toward a scalable model of precision, phenotype-led care that promises to improve diagnostic certainty and personalize patient management. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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18 pages, 705 KB

Open AccessArticle

Pan-Immune-Inflammatory Value (PIV) and HALP Score as Independent Prognostic Indicators in Acute Coronary Syndrome Patients

by Azmi Eyiol, Hatice Eyiol, Ahmet Yilmaz and Hasan Sari

J. Clin. Med. 2026, 15(4), 1660; https://doi.org/10.3390/jcm15041660 - 22 Feb 2026

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Abstract

Introduction: Acute coronary syndrome (ACS), encompassing unstable angina, NSTEMI, and STEMI, is a major cause of morbidity and mortality worldwide. Novel inflammatory and nutritional biomarkers may provide incremental value for risk stratification beyond conventional predictors. This work sought to determine whether the Pan-Immune-Inflammatory Value (PIV) and the Hemoglobin-Albumin-Lymphocyte-Platelet (HALP) score could serve as independent prognostic indicators in individuals presenting with acute coronary syndrome. Methods: A retrospective multicenter study included ACS patients hospitalized between January 2020 and May 2024. Demographics, clinical data, and laboratory results were collected. PIV was calculated as follows: neutrophils × platelets × monocytes/lymphocytes. HALP score was calculated as follows: hemoglobin × albumin × lymphocytes/platelets. Correlations with clinical parameters and mortality prediction were analyzed. Results: A total of 1134 patients (mean age 62 ± 12 years) were included. PIV showed positive correlations with WBC (Rho = 0.574), troponin (Rho = 0.381), and CRP (Rho = 0.295), and negative correlations with HDL (Rho = –0.101) and ejection fraction (Rho = –0.316) (all p < 0.01). PIV independently predicted mortality with a cut-off ≥1074.2 (AUC = 0.619, sensitivity 45%, specificity 79.9%). HALP score negatively correlated with age, troponin, CRP, and ICU stay, and predicted mortality with a cut-off ≤3.58 (AUC = 0.722, sensitivity 53.8%, specificity 82%). Comparative ROC analysis showed that HALP demonstrated superior discriminative ability for mortality prediction compared with PIV. Conclusions: PIV and HALP score are independent prognostic markers in ACS, reflecting inflammatory burden and nutritional status. Their integration into clinical workflows may enhance risk stratification and support individualized management strategies. Given their simplicity and universal availability, PIV and HALP may serve as practical adjunctive tools to established risk scores, enabling early identification of high-risk ACS patients at the time of admission. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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13 pages, 1207 KB

Open AccessArticle

Pre-Hospital Artificial Intelligence-Guided, Focused Echocardiography in Patients with Acute Chest Pain for Diagnosis of Acute Coronary Syndrome

by Soufiane El Kadi, Mark Zanstra, Arjen Siegers, Berto J. Bouma, Albert C. van Rossum and Otto Kamp

J. Clin. Med. 2025, 14(22), 7938; https://doi.org/10.3390/jcm14227938 - 9 Nov 2025

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Abstract

Background: Acute chest pain is a common emergency with only 10–20% of cases attributable to acute coronary syndrome (ACS). Rapid and accurate pre-hospital diagnosis remains challenging, particularly for non-ST elevation ACS, where ECG findings may be inconclusive. AI-guided focused cardiac ultrasound (FoCUS) using handheld devices offers a potential solution by enabling immediate functional cardiac assessment. The aim was to investigate the feasibility and diagnostic performance of pre-hospital AI-guided FoCUS for detecting ACS in patients with acute chest pain. Methods: In this single-center, prospective pilot study, 75 patients with acute chest pain were enrolled. FoCUS examinations were performed by experienced sonographers (72%) and EMS paramedics (28%) using AI-guidance for obtaining the apical 4-chamber (AP4CH), apical 2-chamber (AP2CH), and apical 3-chamber (AP3CH) views. The quality of the obtained images was assessed, and quantitative measurements—including left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS)—were analyzed. Diagnostic performance was subsequently evaluated using ROC curve analysis. Results: At least one apical view was acquired in 91% of patients, with sonographer achieving higher acquisition rates than paramedics (96% vs. 67% for the AP4CH view). Complete acquisition of all apical views was achieved in 67% of cases (83% vs. 24%), and image quality was high across views, with median scores ranging from 83% to 100%. GLS yielded an AUC of 0.76 (89% sensitivity, 56% specificity) and LVEF yielded an AUC of 0.65 (75% sensitivity, 73% specificity). In patients with intermediate to high HEAR-scores (>3), lower LS-AP4CH values were associated with ACS. Conclusion: Pre-hospital AI-guided FoCUS is feasible and shows promise for ACS detection, although quantitative parameters do not yet outperform established clinical scores. Enhanced training and further refinement of AI algorithms are needed before widespread implementation. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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12 pages, 411 KB

Open AccessArticle

High Sensitive Cardiac Troponin-I (Hs-cTnI) Levels in Asymptomatic Hemodialysis Patients

by Ofir Rabi, Linda Shavit, Ranel Loutati, Louay Taha, Mohammad Karmi, Akiva Brin, Dana Deeb, Nir Levi, Noam Fink, Pierre Sabouret, Mohammed Manassra, Abed Qadan, Motaz Amro, Michael Glikson and Elad Asher

J. Clin. Med. 2025, 14(15), 5470; https://doi.org/10.3390/jcm14155470 - 4 Aug 2025

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Abstract

Background: High-sensitivity cardiac troponin (hs-cTn) is useful for detecting acute myocardial infarction, but chronic hemodialysis patients often have elevated baseline levels that exceed the upper reference limit (URL). This study aimed to determine whether hs-cTnI levels in asymptomatic hemodialysis patients exceed the URL established for the general population, evaluate the impact of high-flux hemodialysis on hs-cTnI concentrations, and examine associations between hs-cTnI levels and subsequent hospitalization or mortality. Methods: A prospective, single-center cohort study was conducted at a tertiary care center from August 2023 to July 2024. Blood samples for hs-cTnI were collected from asymptomatic hemodialysis patients aged ≥ 40 years, measured before and after dialysis within one month. Patients were followed for up to 12 months. Results: Fifty-six patients were enrolled. The mean hs-cTnI levels were 28.4 ng/L pre-dialysis and 27.9 ng/L post-dialysis, with ranges of <6–223 ng/L and <6–187 ng/L, respectively. The mean hs-cTnI delta between pre- and post-dialysis was −0.5 ng/L, with 52% showing a negative delta, 30% no change, and 18% a positive delta. No association was found between baseline hs-cTnI levels and mortality or hospitalization during follow-up. Conclusions: Most asymptomatic hemodialysis patients had hs-cTnI levels in the “gray zone”, thus neither confirming nor excluding acute myocardial infarction. Dialysis did not significantly affect hs-cTnI levels, and elevated baseline hs-cTnI was not linked to increased mortality or hospitalization over 12 months. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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23 pages, 1944 KB

Open AccessSystematic Review

Systematic Review and Meta-Analysis of the Frequency of Thromboembolic Events, Bleeding, and Mortality in Patients with Atrial Fibrillation and End-Stage Renal Disease Undergoing Percutaneous Left Atrial Appendage Closure

by Juan Manuel Martínez-Arango, Laura María Rojas-Echavarría, Carolina García-Mejía, Juan Daniel Castrillón-Spitia and Luis Felipe Higuita-Gutiérrez

J. Clin. Med. 2026, 15(7), 2641; https://doi.org/10.3390/jcm15072641 - 31 Mar 2026

Viewed by 492

Abstract

Background: Atrial fibrillation (AF) and end-stage renal disease (ESRD) are closely related conditions that increase the risk of disability, stroke, and mortality. Anticoagulation management in patients with ESRD and AF is challenging due to the high risk of bleeding. Percutaneous left atrial appendage closure (LAAC) has emerged as an alternative to reduce thromboembolic events; however, evidence in this specific population remains limited. Therefore, we aimed to evaluate the frequency of thromboembolic events, bleeding complications and mortality in patients with AF and ESRD undergoing LAAC through a systematic review and meta-analysis. Methods: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines and registered in PROSPERO (CRD420250640241). A structured search was performed in Medline, EMBASE, Web of Science, SCOPUS, LILACs and institutional repositories through September 2024, with no language restrictions. We included original studies reporting frequencies of thromboembolic events, bleeding and mortality in patients with AF and ESRD undergoing LAAC. A random-effects model was used and heterogeneity was assessed using the I² statistic. Results: Fourteen studies were included in the qualitative analysis and seven in the quantitative synthesis, comprising a total of 2433 patients with AF and ESRD undergoing LAAC. In the qualitative analysis, the mean age was 74 ± 7.6 years; the most common comorbidities were hypertension (74%), diabetes mellitus (47%), and dyslipidemia (53%). Watchman™ devices predominated in North America, whereas Amulet™ devices were more frequently used in Europe and Latin America. Procedural success was 98.4%, with infrequent periprocedural complications: major bleeding in 1.6% and device embolization in 0.5%. In the quantitative analysis, the pooled frequency of thromboembolic events was 3% (95% CI: 1–7%; I² = 81.1%), pooled bleeding frequency was 6% (95% CI: 4–10%; I² = 76.9%), and pooled mortality was 5% (95% CI: 1–22%; I² = 97.8%). After excluding studies with extreme values, adjusted mortality was 2% (95% CI: 1–5%; I² = 76.6%). Despite high heterogeneity, the findings suggest that LAAC may offer protection against embolic events with an acceptable bleeding risk. Conclusions: LAAC in patients with AF and ESRD is associated with a low frequency of thromboembolic events and bleeding when compared with standard anticoagulation therapy and no treatment. Overall mortality is moderate and appears to be primarily attributable to underlying comorbidity rather than the procedure itself. This meta-analysis provides evidence that LAAC may be a safe and effective therapeutic strategy in patients with contraindications or high risk for chronic anticoagulation. However, prospective and comparative clinical trials are needed to confirm these findings and inform future clinical practice guidelines. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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10 pages, 1061 KB

Open AccessSystematic Review

An Updated Meta-Analysis of Randomized Controlled Trials Comparing Direct Oral Anticoagulants Against Warfarin for Left Ventricular Thrombus Resolution

by Joseph Magdy, Maggie He, Sacchin Arockiam, Nanami Harada, Stephen B. Wheatcroft and Heerajnarain Bulluck

J. Clin. Med. 2025, 14(19), 6735; https://doi.org/10.3390/jcm14196735 - 24 Sep 2025

Viewed by 2413

Abstract

Background: Left ventricular thrombus (LVT) remains a well-recognized complication following myocardial infarction (MI). Whilst vitamin K antagonists (VKAs) have traditionally been the cornerstone of management, direct oral anticoagulants (DOACs) have been increasingly utilized despite limited data to support this. We sought to perform an up-to-date meta-analysis of all randomized controlled trials (RCTs) comparing DOACs to VKAs for LVT resolution. Methods: A systematic search of major scientific databases was performed to identify RCTs published until May 2025. The primary efficacy endpoint was complete LVT resolution at 3 months. The risk ratio (RR) and 95% confidence intervals (CIs) of the individual RCTs were pooled via the inverse-variance method and random-effects model. Results: Seven RCTs involving 554 patients with a mean age of 54 years were included in the meta-analysis. At 3 months, there was no difference in the rate of LVT resolution between those in the DOAC arm and the warfarin arm (86% vs. 81%, RR 1.01 [95%CI 0.93–1.10], p = 0.76). There was low heterogeneity at I² = 15%. There was no difference in major or clinically significant bleeding or in the composite of stroke or thromboembolic complications, although the 95%CIs were wide. Conclusions: DOACs appear to be comparable to warfarin in achieving LVT resolution at 3 months. These findings support the consideration of DOACs as alternatives to VKAs in selected patients for LVT resolution. Further adequately powered trials and head-to-head comparisons between DOACs are required to confirm their safety. Full article

(This article belongs to the Special Issue Acute Coronary Syndromes: Clinical Advances in Diagnosis and Treatment)

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