New Guidelines: Hs-Troponin, Ticagrelor in; Clopidogrel Out

Shelley Wood

August 31, 2011

August 31, 2011 (Paris, France) — The European task force for the management of ACS patients presenting with non-STEMI has released new guidelines here at the European Society of Cardiology (ESC) 2011 Congress [1]. The guidelines update a previous version issued in 2007, and according to members of the writing group, contain a number of important new recommendations.

Dr Christian Hamm (Kerchkhoff Heart and Thorax Center, Bad Nauheim, Germany), who chaired the task force, noted in a press release that there are a number of "practice-changing" recommendations.

The 56-page document carries through several recommendations from the 2007 update but also includes some novel items.

Chief among them, according to Hamm, is the inclusion of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) risk score to estimate the risk of in-hospital bleeding.

"It’s probably the best validated score, because it's based on more than 70 000 patients of the CRUSADE registry and was validated in a cohort of [more than] 17 000 patients," Hamm said in a statement.

Dr Magnus Ohman, the sole American on the task force, observed that the new European guidelines, as a product of the timing of trial evidence and regulatory decisions, are also slightly more au courant than the American College of Cardiology (ACC)/American Heart Association (AHA) unstable angina/non-STEMI guidelines released earlier this year, as reported by heartwire .

High-Sensitivity Troponin and CT Angiography

Of note, says Ohman, the guidelines recommend the use of high-sensitivity (hs) troponin assays: a rapid rule-out protocol (within zero to three hours of symptoms) using hs-troponin is given a class Ib recommendation in the new guidelines.

They also, for the first time, support a role for coronary CT angiography (CTA) as an alternative to invasive angiography to exclude ACS in patients with a low to intermediate likelihood of CAD, when both troponin tests and an ECG are inconclusive (class IIa, level of recommendation B).

"Traditionally, when you come in for chest-pain evaluation, you get a stress test, but these new European guidelines have gone one step further in saying that you can use CTA to rule out CAD."

Prasugrel and Ticagrelor

Whereas the ACC/AHA guidelines earlier this year included the newer antiplatelet agent prasugrel (Effient, Lilly), the European guidelines make space for both prasugrel and the new, reversible, P2Y12 inhibitor ticagrelor (Brilique, AstraZeneca). Of note, clopidogrel (Plavix, Bristol-Myers Squibb/Sanofi-Aventis) is now recommended only for patients who cannot take ticagrelor or prasugrel (class Ia).

A proton-pump inhibitor (but "preferably not omeprazole") is recommended for patients taking dual antiplatelet therapy with a history of gastrointestinal bleeding or ulcer and "is appropriate" for patients with multiple risk factors for a GI bleed, the new guidelines say.

To heartwire , Ohman also singled out the inclusion of an urgent invasive strategy based on risk scores in the ESC guidance, for patients who, following initial evaluation and validation, are determined to be at especially high risk. "Traditionally we've said cath within 24 hours for non-STEMI, but [the European guidelines] have done this a bit differently, saying that patients should go to the cath lab within 24 hours if they have a high-grade risk score, and that's new, and there's some new trials to support that."

For "very high-risk patients," an "urgent invasive strategy" (<120 minutes after first medical contact) is warranted, the guidelines state.

Physician: Watch Thyself

Finally, the European guidelines also stress the need for physicians to keep tabs on just how well they are actually adhering to evidence-based guidance. "Continuous monitoring of performance indicators is strongly encouraged to enhance the quality of treatment and minimize unwarranted variations in evidence-based care," Hamm et al write.

According to Ohman, that wording is slightly different from what their American counterparts urged, but the message is the same.

"That's a new concept: it's asking you to examine your practice and actually figure out if you are following guidelines or not. That's a healthy change: we're not just supporting physicians to help them do the right thing; we're saying we should actively examine our own practice and have that kind of internal audit of what we're doing. A similar recommendation was made for the first time in the ACC/AHA guidelines, and I think this is an important change."