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

ESC Clinical Practice Guidelines

The clinical presentation of acute coronary syndromes (ACS) is broad. It ranges from cardiac arrest, electrical or haemodynamic instability with cardiogenic shock (CS) due to ongoing ischaemia or mechanical complications such as severe mitral regurgitation, to patients who are already pain free again at the time of presentation.

The leading symptominitiating the diagnostic and therapeutic cascade in patients with suspected ACS is acute chest discomfort described as pain, pressure, tightness, and burning. Chest pain-equivalent symptoms may include dyspnoea, epigastric pain, and pain in the left arm.

For more info read the Full Text and the Supplementary Data documents.

Acute Cardiac Care
Acute Coronary Syndromes
Guidelines version available to download
Published in 2020
Reference doi:10.1093/eurheartj/ehaa575
Published in 2021
Published in 2020
Reference 10.1093/eurheartj/ehaa895
Published in 2020
Reference doi:10.1093/eurheartj/ehaa601
Published in 2020
Reference doi:10.1093/eurheartj/ehaa602
Published in 2020
Reference TOC NSTE-ACS Pocket Guidelines
Published in 2020
Reference ESC Pocket Guidelines App
Published in 2021
Reference 123 Slides
Table of contents: Full Text (ESC Clinical Practice Guidelines)



  • 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)


  • 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  




Previous version available to download
Published in 2015
Reference European Heart Journal, doi/10.1093/eurheartj/ehv320
Published in 2015
Reference Web Addenda - doi:10.1093/eurheartj/ehv320
Published in 2015
Reference Q&A antithrombotic treatment NSTE-ACS GL - doi:10.1093/eurheartj/ehv407
Published in 2015
Reference Q&A myocardial revascularization NSTE-ACS GL - doi:10.1093/eurheartj/ehv408
Published in 2015
Reference Q&A diagnosis and risk assessment NSTE-ACS GL - doi:10.1093/eurheartj/ehv409
Published in 2011
Reference Addenda
Published in 2011
Reference European Heart Journal (2011) 32, 2999–3054