Guidelines for Acute Coronary Syndrome

For the first time, the ESC has issued a guideline that encompasses ST-elevation myocardial infarction (STEMI), non-STEMI, and unstable angina under the umbrella of acute coronary syndrome (ACS). The scope of the new recommendations ranges from invasive treatment and antithrombotic therapy to special situations.

“The main novelty of this guideline is that for the first time, both STEMI and non-ST elevation ACS (NSTE-ACS) are combined into 1 single document,” Prof. Borja Ibañez (Hospital Universitario Fundación Jimenez Diaz, Spain) pointed out [1]. The rationale for this approach is viewing unstable angina, non-STEMI, and STEMI as different presentations within the spectrum of ACS [1–3]. “We believe that, after the acute management and stabilisation of those patients, the majority will undergo a similar management,” Prof. Maria Rubini Gimenez (University of Leipzig, Germany) further explained.

The initial assessment that considers clinical context, stability of the patient, and ECG will lead to a working diagnosis that is then moved forward to a final diagnosis using further investigations with high-sensitivity cardiac troponin (hs-cTn) and possibly angiography and/or imaging. To rule non-STEMI in or out, the ESC algorithm with serial hs-cTn measuring at 0h/1h or 0h/2h is still recommended (class I).

Novelties in invasive treatment

As for the timing of invasive treatment in NSTE-ACS, there has been a revision for patients with at least 1 high-risk criterion: an early invasive strategy within 24h should be considered (class IIa). Other new or revised recommendations on invasive strategies include:

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  • intravascular imaging should be considered to guide percutaneous coronary intervention (PCI) (class IIa);
  • intravascular imaging (preferably optical coherence tomography) may be considered for patients with ambiguous culprit lesions (class IIb); and
  • for patients with suspected ACS, non-elevated (or uncertain) hs-cTn, no ECG changes, and no recurrence of pain, incorporating coronary computed tomography angiography or a non-invasive stress imaging test should be considered as part of the initial workup (class IIa).

For patients with in- or out-of-hospital cardiac arrest, routine immediate angiography after resuscitation is not recommended for haemodynamically stable patients without persistent ST-segment elevation (or equivalents) (class III). In this context, Prof. Ibañez also underlined that hypothermia is no longer advised for these patients, but temperature monitoring with active avoidance of fever is recommended (class I).

Also for ACS patients with multivessel disease, new recommendations have been issued:

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  • when presenting with cardiogenic shock, a staged PCI of non-infarct related artery (IRA) should be considered (class IIa); and
  • for haemodynamically stable STEMI patients undergoing primary PCI, it is recommended that PCI of the non-IRA is based on angiographic severity (class I).

Antithrombotic therapy: a cornerstone of treatment

“One of the key aspects of managing patients with ACS is antithrombotic therapy,” Dr John Joseph Coughlan (Mater Private Hospital, Ireland) stated. He pointed out that antiplatelet therapy and anticoagulation with 12 months of potent, P2Y₁₂ inhibitor-based dual antiplatelet therapy (DAPT) remains the default recommended regimen for all patients with ACS (see Figure). In order to reduce bleeding risk, various new recommendations on alternative strategies have been issued:

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  • for patients who are event-free after 3–6 months of DAPT and who are not at high ischaemic risk, single antiplatelet therapy (preferably with a P2Y₁₂ receptor inhibitor) should be considered (class IIa);
  • P2Y₁₂ inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment (class IIb);
  • for high-bleeding-risk patients, aspirin or a P2Y₁₂ receptor inhibitor monotherapy after 1 month of DAPT may be considered (class IIb);
  • for patients requiring oral anticoagulation, withdrawing antiplatelet therapy at 6 months while continuing oral anticoagulation may be considered (class IIb); and
  • de-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended (class III).

Figure: Recommended antithrombotic therapy for all ACS patients in the short- and long-term. Modified from [3]



ACS, acute coronary syndrome; DAPT, dual antiplatelet therapy.

 

Special ACS situations

As for ACS complications and comorbidities, Prof. Margret Leosdottir (Skåne University Hospital, Sweden) focused on the new recommendations for left ventricular (LV) thrombus, diabetes, cancer, and older patients. Two recommendations were related to imaging:

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  • cardiac magnetic resonance imaging should be considered for patients with equivocal ECG images or in case of high clinical suspicion of LV thrombus (class IIa); and
  • following an acute anterior MI, a contrast ECG may be considered for the detection of LV thrombus if the apex is not well visualised on ECG (class IIb).

“As for the management of patients with ACS and diabetes, there has been substantial progress in diabetes treatment since the publication of the 2017 STEMI and 2020 non-STEMI guidelines,” Prof. Leosdottir noted. A new recommendation has now been added: It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, chronic kidney disease, and obesity (class I). Further new recommendations on comorbidities include:

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  • for frail older patients with comorbidities, a holistic approach is recommended to individualise interventional and pharmacological treatments, after careful evaluation of the risks and benefits (class I);
  • for older ACS patients, especially those with a high bleeding risk, clopidogrel as the P2Y₁₂ receptor inhibitor may be considered (class IIb);
  • an invasive strategy is recommended for cancer patients presenting with high-risk ACS with expected survival ≥6 months (class I);
  • a conservative non-invasive strategy should be considered for ACS patients with poor cancer prognosis (i.e. with expected life survival <6 months) and/or very high bleeding risk (class IIa); and
  • a temporary interruption of cancer therapy is recommended for patients in whom the cancer therapy is suspected to be a contributing cause of ACS (class I).

Various antiplatelet agents are not recommended for ACS patients with cancer: aspirin for patients with a platelet count <10,000/μL, clopidogrel for patients with a platelet count <30,000/μL, and prasugrel or ticagrelor for patients with a platelet count <50,000/μL (all class III).

With regard to long-term management, the new recommendation to intensify lipid-lowering therapy during the index ACS hospitalisation, for patients who were on lipid-lowering therapy before admission (class I), received special acknowledgement.

Last but not least, Prof. Leosdottir pointed to the new chapter on patient perspectives, indicating a strengthening of the focus on patient-centred care and shared decision-making in all aspects of medical care.

1. 
   
   1. Presentations in session: ‘2023 ESC Guidelines Overview,’ ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   2. Presentations in session: ‘2023 ESC Guidelines for the Management of Acute Coronary Syndromes,’ ESC Congress 2023, 25–28 August, Amsterdam, the Netherlands.
   3. Byrne RA, et al. Eur Heart J. 2023; Aug 25. DOI: 10.1093/eurheartj/ehad191.

 

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Posted on 30 October, 202323 April, 2024