ACVC highlights new aspects in 2020 ESC ACS guidelines

Prof. Ingo Ahrens, Germany

ACVC Research section chairperson

The new 2020 ESC Guidelines on NSTE-ACS have just been released.

We will highlight the major changes for the recommendations in acute cardiovascular care referring to the antithrombotic and invasive treatment of these patients.

A new class III recommendation clearly states that pre-treatment with a P2Y12 receptor antagonist should not be done in patients in whom the coronary anatomy is not known and early invasive treatment is planned.

For NSTE-ACS patients with an indication for oral anticoagulation who PCI and stent implantation, a new class I recommendation advises keeping the duration of “triple” therapy (DAPT + OAC) to a minimum of one week or until hospital discharge (whatever comes first).

This ensures a clear dual antithrombotic treatment strategy for the post-ACS phase consisting of preferably a NOAC and clopidogrel for up to 12 months in patients without a perceived high bleeding risk and low thromboembolic risk.
An early invasive strategy within 24 hours is now the clear preference (class I recommendation) for patients with NSTEMI or ACS patients with transient ECG changes indicating myocardial ischemia or ACS patients with a GRACE risk score > 140.

The wider span of the 72h interval in intermediate-risk patients is not recommended anymore and simplifies the decision whether a patient should undergo early invasive treatment or whether the patient is at such a low risk that alternative testing for coronary artery disease (CAD) with non-invasive methods (e.g. coronary computed tomography angiography, CCTA) may be considered instead of invasive treatment.