The clinical presentation of acute coronary syndrome (ACS) is broad and ranges from asymptomatic to persistent chest discomfort to cardiac arrest, electrical/hemodynamic instability and cardiogenic shock. The European Society of Cardiology has now published its new guidelines on acute coronary syndrome. One innovation: recommendations that were previously contained in separate guidelines have now been bundled into a single document.
The updated ACS guidelines are the first ESC guidelines to cover the entire spectrum of ACS (unstable angina pectoris, ACS without ST elevation [NSTE-ACS] and myocardial infarction with ST elevation [STEMI]). In terms of antithrombotic therapy, the 2023 ACS guidelines show important changes compared to previous documents, with a certain reluctance to change paradigms supported by data from randomized controlled trials (RCTs).
Joint guideline for STEMI and NSTEMI
The previous separation of the guidelines between STEMI (ST-segment elevation myocardial infarction) and NSTEMI (non-ST-segment elevation myocardial infarction) has been abolished, so that a joint guideline is now available for the first time. The diagnosis of ACS involves several stages and initially involves a working diagnosis based on clinical presentation. However, the final diagnosis is not made until later and is based on the results of further examinations:
Acute coronary syndromes (ACS) encompass a whole spectrum of conditions that include patients presenting with recent changes in clinical symptoms or signs, with or without changes in the 12-lead electrocardiogram (ECG) and with or without acute elevation of cardiac troponin (cTn) (Fig. 1) [1]. Patients with suspected ACS can be diagnosed with acute myocardial infarction (AMI) or unstable angina pectoris (UA). The diagnosis of myocardial infarction (MI) is associated with cTn release and is made on the basis of the fourth universal definition of MI. UA is defined as myocardial ischemia at rest or minimal exertion without acute cardiomyocyte injury/necrosis. It is characterized by specific clinical findings such as prolonged (>20 minutes) angina at rest, new onset of severe angina, angina that increases in frequency, lasts longer or has a lower threshold, or angina that occurs after a recent MI. ACS is associated with a wide spectrum of clinical presentations, from patients who are asymptomatic at presentation, to patients with persistent chest discomfort, to patients with cardiac arrest, electrical/hemodynamic instability or cardiogenic shock (CS) (Fig. 1) [1].
Patients presenting with suspected ACS are usually classified on the basis of the ECG at presentation for the purposes of initial treatment. Patients can then be further classified based on the presence or absence of cardiac troponin elevation (once these results are available), as shown in Figures 1 and 2. These features (ECG changes and cardiac troponin elevation) are important in the initial staging and diagnosis of patients with ACS, as they help to risk stratify patients and determine the initial treatment strategy. However, after the acute treatment and stabilization phase, most aspects of the subsequent treatment strategy are common to all patients with ACS (regardless of the initial ECG pattern or the presence or absence of an elevation of cardiac troponin at presentation) and can therefore be considered as part of a common pathway.
Downgrading of the recommendation for early angiography
Another change concerns the invasive management of NSTE-ACS patients. For these individuals, a class 1 recommendation for an early invasive strategy (coronary angiography and, if necessary, primary percutaneous coronary intervention (PCI) within 24 hours) has so far applied in the event of signs of high risk (including confirmed NSTEMI diagnosis, dynamic ST segment or T wave changes, GRACE score above 140). The class 1 recommendation, which was felt to be too strong compared to the scientific evidence, has now become a class IIa recommendation. STEMI patients, on the other hand, should be taken to a catheterization laboratory as quickly as possible.
Class IIa recommendation for shorter dual platelet inhibition
Despite numerous RCT data demonstrating the safety benefits of various antiplatelet de-escalation strategies in patients with and without high bleeding risk, 12 months of dual antiplatelet therapy (DAPT) (with ASA plus a P2Y12 inhibitor) is still recommended as the standard strategy for ACS patients.
However, alternative strategies are also increasingly being considered. Thus, it is recommended that a switch to antiplatelet monotherapy (preferably with a P2Y12 inhibitor) should be considered in ACS patients who have remained free of clinical events for 3-6 months on dual antiplatelet therapy and are not at high risk of ischemic events. The recommendation that platelet-inhibiting therapy (with ASA or a P2Y12 inhibitor) can be considered after just one month, especially in patients with a high risk of bleeding, is still cautious.
No immediate coronary angiography after unclear cardiac arrest
In resuscitated patients after an out-of-hospital cardiac arrest without ST segment elevation, immediate coronary angiography directly after arrival at the hospital does not necessarily appear to be useful. This is confirmed by studies such as the COACT** study, which has already provided corresponding indications, and the TOMAHAWK& study, which confirmed this. The new ACS guidelines therefore do not recommend routine immediate coronary angiography after cardiac arrest in resuscitated, hemodynamically stable patients without persistent ST segment elevation in the ECG.
** Coronary Angiography After Cardiac Arrest
& Immediate Unselected Coronary Angiography Versus Delayed Triage in Survivors of Out-of-hospital Cardiac Arrest Without ST-segment Elevation
Complete revascularization receives stronger recommendation
Many STEMI patients have coronary multi-vessel disease. The previous guidelines already recommended routine revascularization of coronary lesions in non-infarct arteries. There has been an upgrade here: Complete revascularization is now recommended, either immediately during the index PCI procedure or within 45 days. The basis for revascularization of non-infarct lesions should be coronary angiography.
Recommendations for complications of acute coronary syndrome
Implantation of a permanent pacemaker is recommended if a high-grade AV block does not resolve within a waiting period of at least five days after the MI. Cardiac magnetic resonance imaging should be performed in patients with equivocal echocardiographic images or strong clinical suspicion of LV thrombus. After an acute anterior MI, a contrast echocardiogram may be considered to detect an LV thrombus if the apex is not well recognized on echocardiography. In selected patients with high-grade AV block associated with anterior wall MI and acute heart failure, early device implantation (cardiac resynchronization therapy defibrillator/pacemaker) may be considered. In patients with recurrent life-threatening ventricular arrhythmias, sedation or general anesthesia may be considered to reduce sympathetic drive.
New recommendations on comorbidities
It is recommended that the choice of long-term glucose-lowering treatment should depend on the presence of comorbidities, including heart failure, chronic kidney disease and obesity. For frail elderly patients with comorbidities, a holistic approach to interventional and pharmacological treatments is recommended after careful consideration of the risks and benefits.
The entity of tumor diseases was added as a new comorbidity, in addition to the previous recommendations on the comorbidities of diabetes and chronic kidney disease. An invasive strategy is recommended for cancer patients with high-risk ACS and an expected survival time of ≥6 months. Temporary interruption of cancer therapy is recommended for patients in whom cancer therapy is suspected to be the cause of the ACS. A conservative non-invasive strategy should be considered in ACS patients with a poor cancer prognosis (i.e. with an expected survival time <6 months) and/or a very high risk of bleeding. Aspirin is not recommended for cancer patients with a platelet count <10,000/uL. Furthermore, clopidogrel is not recommended for cancer patients with a platelet count <30,000/uL and prasugrel or ticagrelor are not recommended for ACS patients with cancer and a platelet count <50,000/uL.
Recommendations for long-term treatment
It is recommended that lipid-lowering therapy be intensified during the index ACS hospitalization in patients who were already receiving lipid-lowering therapy prior to admission. Low-dose colchicine (0.5 mg once daily) may be considered, especially if other risk factors are inadequately controlled or if recurrent cardiovascular events occur during optimal therapy.
Recommendations for the patient perspective on treatment
Patient-centered care is recommended, in which the patient’s individual preferences, needs and beliefs are identified and respected, and the patient’s values are incorporated into all clinical decisions. ACS patients should be involved in the decision-making process (as far as their condition allows) and they should be informed about the risk of adverse events, radiation exposure and alternative options. Decision-making aids should be used to facilitate the discussion. It is recommended that symptoms are assessed using methods that help patients describe their experience. The use of the “teach back” technique to support decision-making when obtaining informed consent should be considered. Patients should be informed both verbally and in writing before discharge. Appropriate preparation and education of the patient prior to discharge using the “teach back” technique and/or motivational interviewing, where information should be given piecemeal and understanding checked, should be considered. Assessment of psychological well-being using a validated tool and referral to a psychologist should be considered if appropriate.
Source:
- Byrne RA, et al: 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC). European Heart Journal, Volume 44, Issue 38, October 7, 2023, Pages 3720-3826,
https://doi.org/10.1093/eurheartj/ehad191.
CARDIOVASC 2023; 22(4): 28-30 (published on 29.11.23, ahead of print)
