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

1. Preamble
2. Introduction
2.1 Definitions and pathophysiology
2.1.1 Universal definition of myocardial infarction
2.1.1.1 Type 1 MI
2.1.1.2 Type 2 MI
2.1.2 Unstable angina in the era of high-sensitivity cardiac troponin assays
2.1.3 Pathophysiology and epidemiology
3. Diagnosis
3.1 Clinical presentation
3.2 Physical examination
3.3 Diagnostic tools
3.3.1 Electrocardiogram
3.3.2 Biomarkers
3.3.3 ‘Rule-in’ and ‘rule-out’ algorithms
3.3.4 Non-invasive imaging
3.4 Differential diagnosis
4. Risk assessment and outcomes
4.1 Clinical presentation, electrocardiogram and biomarkers
4.1.1 Clinical presentation
4.1.2 Electrocardiogram
4.1.3 Biomarkers
4.2 Ischaemic risk assessment
4.2.1 Acute risk assessment
4.2.2 Cardiac rhythm monitoring
4.2.3 Long-term risk
4.3 Bleeding risk assessment
4.4 Recommendations for diagnosis, risk stratification, imaging
and rhythm monitoring in patients with suspected non-ST elevation
acute coronary syndromes
5. Treatment
5.1 Pharmacologic treatment of ischaemia
5.1.1 General supportive measures
5.1.2 Nitrates
5.1.3 Beta-blockers
5.1.4 Other drug classes (see Web addenda)
5.1.5 Recommendations for anti-ischaemic drugs in
the acute phase of non-ST-elevation acute coronary syndromes
5.2 Platelet inhibition
5.2.1 Aspirin
5.2.2 P2Y12 inhibitors
5.2.3 Timing of P2Y12 inhibitor administration
5.2.4 Monitoring of P2Y12 inhibitors
5.2.5 Premature discontinuation of oral antiplatelet therapy
5.2.6 Duration of dual antiplatelet therapy
5.2.7 Glycoprotein IIb/IIIa inhibitors
5.2.8 Vorapaxar
5.2.9 Recommendations for platelet inhibition in non-ST-elevation acute coronary syndromes
5.3 Anticoagulation
5.3.1 Anticoagulation during the acute phase
5.3.2 Anticoagulation following the acute phase
5.3.3 Recommendations for anticoagulation in non-ST-elevation acute coronary syndromes
5.4 Managing oral antiplatelet agents in patients requiring long-term oral anticoagulants
5.4.1 Patients undergoing percutaneous coronary intervention
5.4.2 Patients medically managed or requiring coronary artery bypass surgery
5.4.3 Recommendations for combining antiplatelet agents
and anticoagulants in non-ST-elevation acute coronary
syndrome patients requiring chronic oral anticoagulation
5.5 Management of acute bleeding events
5.5.1 General supportive measures
5.5.2 Bleeding events on antiplatelet agents
5.5.3 Bleeding events on vitamin K antagonists
5.5.4 Bleeding events on non-vitamin K oral anticoagulants
5.5.5 Non-access-related bleeding events
5.5.6 Bleeding events related to percutaneous coronary intervention
5.5.7 Bleeding events related to coronary artery bypass surgery
5.5.8 Transfusion therapy
5.5.9 Recommendations for bleeding management and blood transfusion in non-ST-elevation acute coronary syndromes
5.6 Invasive coronary angiography and revascularization
5.6.1 Invasive coronary angiography
5.6.2 Routine invasive vs. selective invasive approach
5.6.3 Timing of invasive strategy
5.6.4 Conservative treatment
5.6.5 Percutaneous coronary intervention
5.6.6 Coronary artery bypass surgery
5.6.7 Percutaneous coronary intervention vs. coronary artery bypass surgery
5.6.8 Management of patients with cardiogenic shock
5.6.9 Recommendations for invasive coronary angiography
and revascularization in non-ST-elevation acute coronary syndromes
5.7 Gender specificities
5.8 Special populations and conditions  
5.8.1 The elderly and frail patients
5.8.2 Diabetes mellitus
5.8.3 Chronic kidney disease
5.8.4 Left ventricular dysfunction and heart failure
5.8.5 Atrial fibrillation 
5.8.6 Anaemia
5.8.7 Thrombocytopenia
5.8.8 Patients requiring chronic analgesic or anti-inflammatory treatment
5.8.9 Non-cardiac surgery
5.9 Long-term management
5.9.1 Medical therapy for secondary prevention
5.9.2 Lifestyle changes and cardiac rehabilitation
5.9.3 Recommendations for long-term management after non-ST-elevation acute coronary syndromes
6. Performance measures
7. do and not to do messages from the guidelines