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Highlights on ESC Guidelines on ACS in patients presenting without persistent ST-segment elevation

Cardiovascular diseases are the leading cause of death in industrialised countries and are expected to become so in emerging countries by 2020. Among these, coronary artery disease (CAD) is the most prevalent manifestation and is associated with high mortality and morbidity. The clinical  presentation of CAD includes silent ischemia, stable angina pectoris, unstable angina (UA), myocardial infarction (NSTEMI/STEMI), heart failure and sudden death. Patients with chest pain represent a very substantial proportion of all acute medical hospitalisations in Europe.
In 2011 the Task Force for the management of Acute Coronary Syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology(ESC) replaced the document published in 2007 by an updated version.

Acute Coronary Syndromes

New aspects of the 2011 Guidelines

A/ Diagnostic tools

  • hs-Troponin
  • Echocardiography
  • Coronary computer tomography (CT)

B/ Risk stratefication

  • "Fast track" protocol
  • Ischaemic risk score assessment(GRACE score)
  • Bleeding risk score (CRUSADE score)

C/ Drug therapy

  • Ticagrelor
  • Prasugrel

D/ Revascularisation

  • Newly defined time intervals

A/ Biomarkers, especially cardiac troponins, play a central role. They are more specific and sensitive than the traditional cardiac enzymes and allow to distinguish between NSTEMI and unstable angina. By use of high sensitive troponin tests a  "rapid rule-out" protocol (3 hours) can be applied. (Figure 1)

In addition to physical examination and 12–lead ECG an echocardiogram is recommended for all patients to evaluate regional and global function and to rule in or to rule out differential diagnosis. Furthermore coronary CT angiography should be considered an alternative to invasive angiography to exclude ACS when there is a low to intermediate likelihood of CAD and when troponin and ECG are inconclusive.

B/ Risk evaluation includes the quality of chest pain, the assessment of the likelihood of CAD (e.g. age, risk factors, previous MI, CABG, PCI), ECG, the GRACE score and the bleeding risk assessment (e.g. CRUSADE score). Thus, validation of the diagnosis and risk assessment allow specific and early start of antithrombotic and interventional treatment. Use a bleeding score to avoid high bleeding risks by, for example, the choice of special bare metal stents instead of DES stents.

C/ Antithrombotic treatment should be initiated when ACS diagnosis appears likely.

Aspirin: An initial dose of 150-300 mg non-enteric formulation followed by 75-100mg maintenance dose life-long.
P2Y12 Inhibitor: Should be added as soon as possible unless there are contraindications such as extensive bleeding. Loading dose of ticagrelor (180 mg), prasugrel (60 mg), clopidogrel (300 mg) prior to PCI.
Special considerations:
Ticagrelor is recommended for all patients at moderate-to- high risk of ischemic events (e.g. elevated troponin) regardless of initial treatment strategy and including those pre-treated with clopidogrel (which should be discontinued when ticagrelor is commenced). Daily dose of 90 mg twice.
Prasugrel is recommended for PY12-inhibitor naive patients (especially diabetics) in whom coronary anatomy is known and who are proceeding to PCI unless there is a high risk of life- threatening bleeding or other contraindications. Daily dose of 10 mg once.
Clopidogrel is recommended for patients scheduled for an invasive strategy when ticagrelor or prasugrel is not an option. Daily dose of 75 mg.
A 600 mg loading dose of clopidogrel (or a supplementary 300 mg dose at PCI following an initial 300 mg loading dose) is recommended  for patients scheduled for an invasive strategy when ticagrelor or prasugrel is not an option.

D/ Revascularisation
Revascularisation for NSTE-ACS patients relieves symptoms, shortens hospital stay and improves prognosis.
An invasive strategy (within 72 hours after first presentation) is indicated in patients with at least one high-risk criterion
(primary: relevant rise or fall of troponin, dynamic ST-or T-wave changes, symptomatic or silent,
secondary: D.m., renal insufficiency, reduced LV function(EF<40%), early post infarction angina, recent PCI, prior CABG, intermediate to high GRACE risk score, and/or recurrent symptoms.
Urgent coronary angiography (< 2h) is recommended in patients at very high risk (refractory angina with associated heart failure, life-threatening ventricular arrhythmias or haemodynamic instability).
An early invasive strategy (<24h) is recommended in patients with GRACE score >140 or with at least one primary high–risk criterion.

Hospital discharge and post-discharge

Aspirin  Continue life-long 
P2Y12 Inhibitor Continue for 12 months (unless at high risk of bleeding) 
ß-Blocker If LV function is depressed
ACE-Inhibitor If LV function is depressed
ARB Alternative to ACE-inhibitors, consider also for patients devoid of depressed LV function
Aldosterone antagonist / eplerenone If depressed LV function (LVEF<35%) and either diabetes or heart failure, without significant renal dysfunction
Statin Titrate to achive target LDL-C-levels <1.8mmol/l (<70mg/dl)
Lifestyle Risk-factor counseling, referral to cardiac rehabilitation secondary prevention programme 


Drug therapy and intense risk factor modification and lifestyle change are warranted in all patients following the diagnosis of NST- ACS. Enrolment in a cardiac rehabilitation program after discharge can enhance patient adherence to the medical regimen and may be supportive in risk factor modification.

Figure 1 Rapid rule-out of ACS with high-sensivitivy troponin

Figure 2 Decision-making algorithm in ACS