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2020 ESC Clinical Practice Guidelines for the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS)

Today, Professor Jean-Philippe Collet (Sorbonne Université, Action Study Group, Institut de Cardiologie, Pitié-Salpêtière [APHP] Paris, France) and Professor Holger Thiele (Heart Centre Leipzig at University of Leipzig, Germany), Chairs of the Guidelines Task Force, presented updated ESC Guidelines on the management of non-ST-segment elevation acute coronary syndromes (NSTE-ACS).1

As they explained, much has changed in the five years since the last version of the guidelines and there are many new key recommendations. For diagnosis with rapid ‘rule-in’ and ‘rule-out’ algorithms, it is now recommended to use the ESC 0 h/1 h algorithm (best option, blood draw at 0 h and 1 h) or the ESC 0 h/2 h algorithm (second-best option, blood draw at 0 h and 2 h) if a high-sensitivity cardiac troponin (hs-cTn) test with a validated algorithm is available (Class I, level B recommendations). The ESC 0 h/3 h algorithm is listed as a Class IIa, level B recommendation.

If elective non-invasive or invasive imaging is needed after the rule-out of myocardial infarction (MI), invasive coronary angiography is deemed to be the best option in patients with very high clinical likelihood of unstable angina. However, stress testing with imaging or coronary computed tomography angiography (CCTA) is seen as the best option in patients with low-to-modest clinical risk.

Now with a Class I recommendation (level C), rhythm monitoring up to 24 h or to percutaneous coronary intervention (whichever comes first) is recommended in patients with NSTE-ACS at low risk for cardiac arrhythmias, while monitoring for >24 h is recommended in patients at increased risk for cardiac arrhythmias.

To lower the risk of major adverse events, the 2020 guidelines recommend an early routine invasive approach within 24 h for any of the following high-risk criteria: non-ST-segment elevation myocardial infarction (NSTEMI) based on hs-cTn measurements, GRACE risk score >140, and dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischaemia or transient ST-segment elevation. A selective invasive strategy after appropriate ischaemia testing or detection of obstructive coronary artery disease by CCTA is recommended in patients considered at low risk.

Regarding pharmacological treatment, it is not recommended to administer routine P2Y12 receptor inhibitor pre-treatment in NSTE-ACS patients in whom coronary anatomy is not known and an early invasive management is planned, given the lack of established benefit, although it may be considered in selected cases and according to bleeding risk. Post-treatment, dual antiplatelet therapy (DAPT) consisting of a potent P2Y12 receptor inhibitor and aspirin is recommended for 12 months, irrespective of the stent type, unless there are contraindications. However, new scenarios have been implemented, such that DAPT duration can be shortened (<12 months), extended (>12 months) or modified by switching DAPT or de-escalation, based on the individual characteristics of the patients and drug availability.

For patients with atrial fibrillation and an indication for oral anticoagulation, the new default recommendation is a dual antithrombotic strategy after a short period of triple antithrombotic therapy (<7 days). For those patients at high ischaemic risk, triple antithrombotic therapy may be extended up to 4 weeks.

Of note, new sections have been added to the guidelines on myocardial infarction with non-obstructive coronary arteries (MINOCA) and spontaneous coronary artery dissection (SCAD). Furthermore, the guidelines now contain a set of quality indicators that are aligned with the current recommendations and take into account the wider NSTE-ACS pathway of care.

Want to know more about the new and revised recommendations? The 2020 ESC Guidelines for the management of NSTE-ACS are now published in the European Heart Journal!


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1. Collet JP, Thiele H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020. doi/10.1093/eurheartj/ehaa575 

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.