While the incidence of ST elevation myocardial infarction (STEMI) has been declining in recent years, there has been an increase in non-ST elevation myocardial infarction (NSTEMI). STEMI and NSTEMI have some similarities in terms of initial diagnostic work-up, antithrombotic strategies and secondary prevention. For this reason, the ACS guidelines published by the European Society of Cardiology (ESC) last year summarized the recommendations for NSTEMI and STEMI in one guideline for the first time.
Acute coronary syndrome (ACS) is caused by reduced perfusion of the myocardium and manifests itself as pectanginal chest pain, possibly accompanied by vegetative symptoms. In patients with suspected ACS, a 12-lead ECG should be performed within 10 minutes of the initial contact if possible, says Prof. Dr. med. Tanja Rudolph, senior physician at the Clinic for General and Interventional Cardiology/Angiology at the Heart and Diabetes Center North Rhine-Westphalia. For cardiac troponin concentration, the speaker favors the determination of the dynamic high-sensitivity (hs) troponin increase (0/1h algorithm) [1]. The higher the 0h value or the absolute change during serial sampling, the higher the probability of the presence of a myocardial infarction [2]. In patients with cardiac arrest or hemodynamic instability, echocardiography should be performed immediately after the 12-lead ECG. If the initial examination indicates an aortic dissection or pulmonary embolism, D-dimers and CT angiography (CCTA) are recommended [2].
Abbreviations |
CCTA = Coronary computed tomography angiography |
CMR = Cardiac magnetic resonance |
DOAC/DOAK = Directly acting oral anticoagulants |
MVD = Multi vessel disease |
NOAC/NOAK = Novel oral anticoagulants |
PCI = Percutaneous coronary intervention |
HBR = High bleeding risk |
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Invasive management and reperfusion in STEMI and NSTEMI
With regard to STEMI (ST elevation myocardial infarction), there are no significant changes in the new guideline: affected patients should undergo coronary revascularization within 60 minutes of diagnosis in the emergency room. If it is not possible to perform percutaneous coronary intervention (PCI) on STEMI patients within 120 minutes, fibrinolytic therapy is indicated within 12 hours of the onset of symptoms [3]. “In NSTEMI, it is important that patients receive risk-adapted invasive treatment,” emphasized Prof. Rudolph [1]. If a very high risk NSTEMI is present (Table 1 ), the patient should receive invasive treatment within 24 hours if possible. The recommendation of this measure, known as the “early invasive strategy”, was downgraded from class IA to class IIA, as no universal difference in the mortality endpoint could be demonstrated in studies [4]. However, the speaker added that patients who took longer to receive invasive treatment were more likely to have a recurrence of ischemia and the overall length of hospitalization proved to be longer [1].
ACS and multivessel disease
Many ACS patients have multi-vessel disease (MVD). In patients with MVD, it is recommended to determine the revascularization strategy (infarct-related arterial PCI, multi-vessel PCI/coronary bypass surgery) according to the clinical status and comorbidities. Several studies describe a survival benefit when STEMI patients with MVD undergo complete revascularization immediately [5,6]. This is also confirmed by a meta-analysis and the results of the COMPLETE study published last year [7]. Preventive complete repair of the coronary arteries significantly reduced the rate of reinfarction (7.8% vs. 10.5%) or cardiovascular death (8.9% vs. 16.7%) compared to the group in which only the stenosis was treated [8]. There is currently little data on the benefits of complete revascularization inNSTEMI. To find out more, the large-scale, randomized COMPLETE-
NSTEMI study launched (ClinicalTrials.gov: NCT05786131) [9].
Monitoring after revascularization
In ACS, routine radial access and the use of drug-eluting stents for PCI are considered standard. Intravascular imaging may be considered to guide PCI and in patients with unclear lesions. Routine thrombus aspiration is not recommended. Coronary bypass surgery should be considered in patients with an occluded infarct-related artery if PCI is not feasible or unsuccessful and a large area of the myocardium is at risk.
After reperfusion, it is recommended that high-risk ACS patients – including all STEMI patients – be placed in an intensive care unit. In all high-risk patients, ECG monitoring for cardiac arrhythmias and ST segment changes is recommended for at least 24 hours after the onset of symptoms. It is also recommended that all ACS patients have their LVEF measured before discharge from hospital.
Secondary prevention after an ACS should be offered to every patient and should start as early as possible after the index event. It includes cardiac rehabilitation, lifestyle management and pharmacological treatment and has been shown to improve quality of life as well as morbidity and mortality.
Antithrombotic therapy for ACS Antithrombotic therapy with antiplatelet agents and anticoagulants is indicated for all ACS patients. In addition to aspirin, a P2Y12 antagonist is recommended for a period of 12 months, provided this is compatible with the bleeding risk (HBR). With regard to the choice of P2Y12 antagonist, prasugrel and ticagrelor are recommended in preference to clopidogrel, and prasugrel is preferable to ticagrelor for patients undergoing PCI. Treatment with a P2Y12 antagonist prior to coronary angiography may be considered in patients with STEMI undergoing primary PCI, but is generally not recommended in patients with NSTEMI. Parenteral anticoagulation is recommended for all patients at the time of diagnosis. Discontinuation of parenteral anticoagulation should be considered immediately after the invasive procedure. In some patients with ACS – usually those with atrial fibrillation – there is also an indication for long-term anticoagulation. The following procedure is recommended for these patients: Triple therapy (DOAC, aspirin plus P2Y12 antagonist), followed by dual therapy with a NOAC for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel). |
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Further key messages of the ESC guideline
The 16-page document “Essential Messages from ESC Guidelines Clinical Practice Guidelines Committee” provides a compact overview of all important points and adjustments to the ESC guideline published in 2023 [3]. In addition to the aspects already mentioned, the following is emphasized:
Patients with coronary dissection: “Not every coronary dissection automatically means that patients need to be treated with a STENT,” says Prof. Rudolph [1]. Spontaneous dissection of the coronary arteries is a rare cause of ACS with a prevalence of 0.1-4% [10]. With a prevalence of 8.7%, young women are a high-risk population [11]. In the current guideline, PCI is recommended for the first time in patients with spontaneous coronary artery dissection only if there are signs of persistent myocardial ischemia, a large myocardial area at risk and reduced anterograde flow [4].
Subpopulations of ACS patients: Over 30% of ACS patients have moderate or severe chronic kidney disease (CKD), which has certain implications for interventional and drug treatment. There are also some aspects that should be given special consideration for patients with cancer.
Unstable ACS: A primary PCI strategy is recommended for resuscitated patients after cardiac arrest and an ECG with persistent ST elevation (or ST elevation equivalents), while immediate angiography is not recommended for an ECG without persistent ST elevation (or equivalents). Continuous monitoring of core body temperature and active prevention of fever (i.e. >37.7°C) is recommended for out-of-hospital cardiac arrest patients. Emergency coronary angiography should be organized for CHD as a complication of ACS, whereas the routine use of intra-aortic balloon counterpulsation in ACS patients with CHD but without mechanical complications is not recommended.
MINOCA: This acronym is used to label infarctions in which the myocardium is damaged by acute ischemia without angiographically relevant coronary stenoses being detectable (myocardial infarction without obstructive atherosclerosis). MINOCA is a working diagnosis that encompasses a heterogeneous group of underlying causes (cardiac and extracardiac) and is found in 1-14% of ACS patients. Cardiovascular magnetic resonance imaging (CMR) is an important diagnostic tool at MINOCA. The most common causes are plaque ruptures and/or coronary spasms.
Congress: DGK Cardio Update
Literature:
- “KHK: Acute coronary syndrome and revascularization”, Prof. Dr. med. Tanja Rudolph, DGK Cario Update, 23-24.02.2024, Mainz.
- “Recommendations for acute care”, German Society of Cardiology (DGK), 2022, https://leitlinien.dgk.org,(last accessed 06.05.2024)
- “Essential Messages from ESC Guidelines Clinical Practice Guidelines Committee”, www.escardio.org,(last accessed 06.05.2024)
- “Comments on the 2023 ESC guidelines for the management of acute coronary syndromes/ Comentarios a la guia ESC 2023 sobre el diagnostico y tratamiento de los sindromes coronarios agudos”, Editorial, Revista Española de Cardiología (English Edition) 2024; 77(Issue 3): 201-205.
- Wald DS et al: Randomized Trial of Preventive Angioplasty in Myocardial Infarction. N Engl J Med 2013; 369: 1115-1123 September 19, 2013. doi: 10.1056/NEJMoa1305520
- Bainey KR et al: Complete vs culprit-only revascularization for patients with multivessel disease undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A systematic review and meta-analysis. American Heart Journal 2014; 167 (1): 1-14.e2.
- Bainey KR, et al: Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction A Systematic Review and Meta-analysis JAMA Cardiol. Published online May 20, 2020. doi:10.1001/jamacardio.2020.1251
- Oqab Z, et al: Complete Revascularization Versus Culprit-Lesion-Only PCI in STEMI Patients With Diabetes and Multivessel Coronary Artery Disease: Results From the COMPLETE Trial. Circ Cardiovasc Interv 2023 Sep; 16(9): e012867.
- “Complete Revascularization Versus Culprit Lesion Only PCI in NSTEMI (CompleteNSTEMI),” https://classic.clinicaltrials.gov/ct2/show/NCT05786131.
- Saw J: Spontaneous coronary artery dissection. Can J Cardiol 2013; 29(9): 1027-1033.
- “Coexistence of calcified and lipid-containing plaque components and their association with incidental rupture points in acute coronary syndrome (ACS)-causing culprit lesions – results of the prospective OPTICO-ACS study”, https://refubium.fu-berlin.de,(last accessed 06.05.2024)
- Byrne RA, et al; ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44(38): 3720-3826.
HAUSARZT PRAXIS 2024; 19(5): 24-25 (published on 25.5.24, ahead of print)