2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of) Guidelines

Preamble

Introduction            

• Definitions
• Universal definition of myocardial infarction
• Unstable angina in the era of high-sensitivity cardiac troponin assays
• Epidemiology
• What is new?
• Number and breakdown of classes of recommendations (Supplementary data)

Diagnosis   

• Clinical presentation (Supplementary data)
• Physical examination (Supplementary data)
• Diagnostic tools
• Electrocardiogram
• Biomarkers: high-sensitivity cardiac troponin
• Rapid ‘rule-in’ and ‘rule-out’ algorithms
• Observe
• Non-invasive imaging
• Differential diagnosis

Risk assessment and outcomes    

• Electrocardiogram indicators (Supplementary data)
• Biomarkers
• Clinical scores for risk assessment (Supplementary data)
• Bleeding risk assessment
• Integrating ischaemic and bleeding risks

Pharmacological treatments

• Antithrombotic treatment
• Antiplatelet drugs and pre-treatment
• Peri-interventional anticoagulant treatment
• Peri-interventional antiplatelet treatment
• Post-interventional and maintenance treatment
• Pharmacological treatment of ischaemia (Supplementary data)
• Supportive pharmacological treatment (Supplementary data)
• Nitrates and beta-blockers (Supplementary data)
• Managing oral antiplatelet agents in patients requiring long-term oral anticoagulants
• Patients with atrial fibrillation without mechanical prosthetic heart valves or moderate-to-severe mitral stenosis undergoing percutaneous coronary intervention or managed (Supplementary data)
• Patients requiring vitamin K antagonists or undergoing coronary artery bypass surgery
• Management of acute bleeding events (Supplementary data)
• General supportive measures (Supplementary data)
• Bleeding events on antiplatelet agents (Supplementary data)
• Bleeding events on vitamin K antagonists (Supplementary data)
• Bleeding events on non-vitamin K antagonist oral anticoagulants (Supplementary data)
• Non-access-related bleeding events (Supplementary data)
• Bleeding events related to percutaneous coronary intervention (Supplementary data)
• Bleeding events related to coronary artery bypass surgery (Supplementary data) 68
• Transfusion therapy (Supplementary data)
• Recommendations for bleeding management and blood transfusion in non-ST-segment elevation acute coronary syndromes for anticoagulated patients

Invasive treatments  

• Invasive coronary angiography and revascularization
• Routine invasive vs. selective invasive approach (Supplementary data)
• Timing of invasive strategy
• Pattern of coronary artery disease in non-ST-segment elevation acute coronary syndrome (Supplementary data)
• How to identify the culprit lesion? (Supplementary data)
• Spontaneous coronary artery dissection
• Fractional flow reserve, instantaneous wave-free ratio, and other resting indices (Supplementary data)
• Intracoronary imaging
• Conservative treatment
• Patients who are not candidates for invasive coronary angiography
• Patients with coronary artery disease not amenable to revascularization
• Technical aspects
• Technical aspects and challenges
• Vascular access
• Revascularization strategies
• Coronary artery bypass grafting
• Percutaneous coronary intervention vs. coronary artery bypass surgery
• Specific situations
• Management of patients with ongoing myocardial ischaemia
• Management of patients with cardiac arrest
• Recommendations for coronary revascularization

Myocardial infarction with non-obstructive coronary arteries and alternative diagnoses

Special populations   

• Heart failure and cardiogenic shock
• Diabetes mellitus
• Chronic kidney disease
• Anaemia
• Thrombocytopenia (Supplementary data)
• Thrombocytopenia related to glycoprotein IIb/IIIa inhibitors (Supplementary data)
• Heparin-induced thrombocytopenia (Supplementary data)
• The older person
• Frailty
• Sex disparities

Long-term management of non-ST-segment elevation acute coronary syndrome (Supplementary data)  

• Lifestyle management (Supplementary data)
• Smoking (Supplementary data)
• Diet and alcohol (Supplementary data)
• Weight management (Supplementary data)
• Physical activity (Supplementary data)
• Cardiac rehabilitation (Supplementary data)
• Psychosocial factors (Supplementary data)
• Environmental factors (Supplementary data)
• Sexual activity (Supplementary data)
• Adherence and sustainability (Supplementary data)
• Influenza vaccination (Supplementary data)
• Pharmacological management (Supplementary data)
• Anti-ischaemic drugs
• Antithrombotic treatments
• Proton pump inhibitors (Supplementary data)
• Statins and other lipid-lowering agents
• Glucose-lowering therapy in patients with diabetes
• Renin-angiotensin-aldosterone system blockers (Supplementary data)
• Mineralocorticoid receptor antagonist therapy (Supplementary data)
• Antihypertensive therapy (Supplementary data)
• Hormone replacement therapy (Supplementary data)

Quality measures       

Management strategy             

Key messages

Gaps in evidence for non-ST-segment elevation acute coronary syndrome care and future research

To do and not to do   

Supplementary data  

Appendix         

References