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The ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation represent an update of the 2011 version with several renewed recommendations based on evidence published over the past four years.
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ACS remains a worldwide concern with an annual incidence of approximately three per 1000 inhabitants. While the incidence of STEMI has decreased appreciably over a decade, the rate of non-STEMI and unstable angina has only slightly increased.
NSTE-ACS is a heterogeneous disease with a wide spectrum of symptoms, patient characteristics, disease severity, and short- and long-term outcomes. This heterogeneity poses significant challenges on diagnostic pathways and allows for a large variety of approaches ranging from conservative medical treatment to interventional or surgical procedures.
Rapid diagnosis and risk stratification are crucial in NSTE-ACS for life-saving treatment or to tailor treatment to individual risk. In this context, high-sensitive cardiac troponin (hsTrop) assays have received particular attention in this latest guideline. Compared to conventional troponin kits, these assays allow reliable detection of lower ranges of circulating troponin levels, have a higher negative predictive value and reduce the ‘troponin-blind’ interval leading to earlier detection of ACS. Thus, hsTrop assays are currently recommended over conventional ones (class of recommendation (COR) I, level of evidence (LOE) A).
The largest part of the guideline is devoted to the two most important pillars of NSTE-ACS treatment, pharmacological antithrombotic therapy and revascularisation. Dual antiplatelet treatment (DAPT) consisting of aspirin in combination with a P2Y12 inhibitor is recommended in all patients presenting with ACS. Newer P2Y12 inhibitors (ticagrelor, prasugrel) are preferred over clopidogrel because of improved ischaemic outcomes (COR I, LOE B). However, preloading with prasugrel (prior to coronary angiography) in NSTE-ACS is not recommended based on excess bleeding risks documented in the ACCOAST trial (COR III, LOE B). Cangrelor and vorapaxar have recently received marketing authorisation by the EMA, but the guideline task force thought it premature to make any recommendation based on limited and somewhat controversial published data.
The optimal duration of DAPT remains a matter of debate and should be based on individual estimates for ischaemic versus bleeding risks. Extending DAPT over the traditional one-year period may be beneficial and may therefore be considered in patients with high ischaemic risk and low bleeding risk up to 30 months (with prasugrel or clopidogrel) or up to 48 months (with ticagrelor, preferably after the first year at a reduced dose of 60 mg bid) based on the results of the recently published DAPT and PEGASUS trials (COR IIb, LOE A). Conversely, shorter duration may be considered in patients at high bleeding risk (COR IIb, LOE A).
The guideline highlights the importance of invasive coronary angiography with the intention to revascularisation as the routine approach in NSTE-ACS, particularly among intermediate - and high-risk patients. The timing depends on the severity and risk of the NSTE-ACS. An immediate invasive strategy within two hours of presentation is recommended in patients with very high-risk criteria (shock, cardiac arrest, life-threatening arrhythmias, etc.) (COR I, LOE C). An early invasive strategy (within 24 hours of presentation) is recommended in the absence of the above but with any of the following high-risk criteria: rise or fall in troponin, dynamic ST- or T-wave changes, and/or a GRACE score >140 (COR I, LOE A). Radial access resulted in lower bleeding rate and significant reductions in total mortality compared to femoral access in the RIVAL and MATRIX studies - and is preferred in NSTE-ACS patients providing that the intervention is performed by an operator sufficiently experienced with the radial access (COR I, LOE A).
The preferred mode of revascularisation (ie, PCI versus surgical) depends on the clinical condition of the patient, comorbidities, and disease severity. However, no randomised trials have ever compared PCI with CABG in the NSTE-ACS setting. In multivessel disease, the revascularisation strategy (ad hoc culprit-lesion PCI, staged CABG, multivessel PCI, or multivessel CABG) should be discussed according to the local heart-team protocol (COR I, LOE C).
Finally, the guidelines emphasise the important role of secondary prevention to improve longevity and prevent long-term cardiovascular events after NSTE-ACS. These include lifestyle changes, exercise, smoking cessation, and pharmacological agents known to improve prognosis. Among the latter, high-intensity statin therapy is of paramount importance. If LDL goals are not reached with statins alone, ezetimibe could be added, based on the recent IMPROVE-IT study (COR IIa LOE B).
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