What are the ESC treatment guidelines for NSTE-ACS?

Updated: Sep 30, 2020
  • Author: David L Coven, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

The 2015 European Society of Cardiology (ESC) guidelines are in general agreement with the 2014 AHA/ACC guidelines. [111] Additional Class I recommendations are summarized below:

  • Base the diagnosis and initial short-term ischemic and bleeding risk stratification on a combination of the clinical history, symptoms, vital signs, other physical findings, and ECG and laboratory results. (Level of evidence: A)
  • Measure cardiac troponin levels with sensitive or high-sensitivity assays, and obtain the results within 60 minutes of presentation. (Level of evidence: A)
  • Perform a rapid rule-out protocol at 0 h and 3 h if high-sensitivity cardiac troponin tests are available. (Level of evidence: B)
  • Perform a rapid rule-out and rule-in protocol at 0 h and 1 h if a high-sensitivity cardiac troponin test with a validated 0 h/1 h algorithm is available. Additional testing after 3–6 h is indicated if the first two troponin measurements are not conclusive and the patient's clinical condition remains suggestive of ACS. (Level of evidence: B)
  • Perform continuous rhythm monitoring until the diagnosis of non–ST-elevation myocardial infarction (NSTEMI) is established or ruled out.(Level of evidence: C)
  • In the absence of signs or symptoms of ongoing ischemia, rhythm monitoring in unstable angina may be considered in selected patients (eg, suspicion of coronary spasm or associated symptoms suggestive of arrhythmic events).

In addition, the ESC guidelines find the Global Registry of Acute Coronary Events (GRACE 2.0) risk calculation provides the most accurate stratification of risk both on admission and at discharge. [111] However, the guidelines caution that although its value as a prognostic assessment tool is clear, the impact of risk score implementation on patient outcomes has not been adequately investigated. Bleeding risk can be stratified using the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) risk score. [111]

Important considerations from the 2017 ESC guidelines for managing acute myocardial infarction in patients presenting with ST-segment elevation are summarized below. [109, 110]

Where fibrinolysis is the reperfusion strategy, the maximum time delay from the diagnosis of STEMI to treatment has been shortened from 30 minutes in 2012 to 10 minutes in 2017.

Complete revascularization in patients with multivessel disease receives a stronger recommendation, moving from class III (should not be performed) to class IIa (should be considered), with non–infarct-related arteries treated during the index procedure or another time point before discharge from the hospital.

Thrombus aspiration is no longer recommended, based on two large trials in more than 15,000 patients.

Deferred stenting, which involved opening the artery and waiting 48 hours to implant a stent, is no longer recommended.

For PCI, the use of drug-eluting stents instead of bare-metal stents has been upgraded from class IIa (should be considered) to class I (is recommended/indicated), as has the use of radial, instead of femoral, arterial access.

Dual antiplatelet therapy beyond 12 months may be considered in selected patients. Bivalirudin has been downgraded from class I to IIa (should be considered), and enoxaparin upgraded from class IIb (may be considered) to IIa (should be considered). Cangrelor (Kengreal), which was not mentioned in the 2012 document, has been recommended as an option in certain patients.

Additional lipid-lowering therapy is recommended in patients with high cholesterol despite taking the maximum dose of statins.

The cutoff for administering oxygen therapy has been lowered from less than 95% to less than 90% arterial oxygen saturation.

Left and right bundle branch block are now considered equal for recommending urgent angiography when patients have ischemic symptoms.


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