ESC's Revised NSTE-ACS Guidelines Embrace hsT, Personalized Anti-Ischemia Treatments

Mitchel L. Zoler, PhD

September 01, 2020

The first revision since 2015 to the European Society of Cardiology's guidelines for diagnosing and managing non ST-elevation acute coronary syndrome placed increased reliance on high-sensitivity cardiac troponin testing for diagnosis, and embraced coronary CT to rule out lower-risk patients.

It also highlighted the need for personalized antiplatelet regimens, systems of care, and quality improvement.

The society released the new guidelines on August 29 (Eur Heart J. 2020 Aug 29;doi: 10.1093/eurheartj/ehaa575), and then devoted a session to them the next day at the virtual annual congress of the European Society of Cardiology to highlight some of the key updates, starting with the further emphasis placed on high-sensitivity cardiac troponin (hs-cTn), a reliance that contrasts with what remains inconsistent use of this metric in U.S. practice.

An hs-cTn test is the "preferred" diagnostic test and a "key" testing element, said Marco Roffi, MD, professor and director of interventional cardiology at University Hospital, Geneva, and a member of the guideline committee. He also stressed an update to the time frame of initial hs-cTn testing, which now involves a baseline reading and then a second measure after 2 hours to discern how the marker level is evolving with time. The guidelines advise against measuring any other biomarker of myocardial injury.

U.S. Lags in Measuring High-Sensitivity Cardiac Troponin

U.S. medical systems and centers "are not uniform in adopting hs-cTn," noted Richard J. Kovacs, MD, professor of cardiology at the Indiana University School of Medicine in Indianapolis. "The new European guidelines should spur U.S. institutions to at least take a close look at the advantages of hs-cTn. There is a strong case that it leads to more efficient emergency care and allows for quicker decisions and triage," added Dr. Kovacs in an interview.

The new guideline's emphasis on hs-cTn should hasten broader uptake in U.S. practice, agreed Deepak L. Bhatt, MD, professor of medicine at Harvard Medical School in Boston and a member of the guideline-writing panel

Another plus of the guidelines is its endorsement of an "organized approach to risk assessment" early on in these patients, said Dr. Kovacs, who is also the immediate past-president of the American College of Cardiology (ACC). An ACC committee is developing a new set of recommendations for managing patients with cardiac chest pain and is on track for release in 2021. It would represent the first update to U.S. guidelines for non ST-elevation ACS patients since 2014.

The new ESC guidelines give coronary CT angiography a class Ia rating as an alternative to invasive coronary angiography for assessing patients with a low or intermediate risk of having coronary disease, a "tremendous upgrade," commented Ashish Pershad, MD, an interventional cardiologist at Banner-University Medical Heart Institute in Phoenix. While he welcomes this support for using coronary CT angiography in this setting, he acknowledged that the method remains limited in availability as it requires highly trained technicians to obtain good images and experienced clinicians to interpret the results.

Personalizing Antiplatelet and Antithrombotic Treatments

Notable revisions to medical treatments to minimize ischemia included an admonition not to use routine pretreatment with a P2Y12 receptor inhibitor (such as clopidogrel) before testing determines coronary anatomy.

Not using one of these antiplatelet drugs upfront on all patients "is a tremendous change," Dr. Pershad said in an interview. Many patients currently get these drugs while awaiting an angiogram, but a more selected and deferred antiplatelet approach would be better when angiography shows that some patients need coronary bypass surgery, he noted. Recent study results have shown no added benefit from pretreatment, and its use can be especially problematic for patients who are slated for a planned invasive strategy, said Dr. Bhatt.

Dr. Pershad, Dr. Bhatt, and Dr. Kovacs all praised the overall emphasis on a personalized approach to treating patients with antiplatelet and antithrombotic drugs, with endorsement of a flexible approach to treatment intensity and duration. The guideline acknowledges the need to take into account a patient's bleeding risk and comorbidities, and specifically endorsed the Academic Research Consortium's formula for identifying and stratifying high bleeding risk (Eur Heart J. 2019 Aug 14;40[31]:2632-53).

The new guidelines also provide guidance on how to apply recent study results that addressed balancing efficacy and safety when pairing an antiplatelet drug with a direct-acting oral anticoagulant (DOAC) for patients who potentially need both drug classes, such as patients with atrial fibrillation and a recent ACS event. "It's tremendous to get clarity on this issue; there's been a lot of uncertainty," said Dr. Pershad. The guidelines call for a week of triple therapy with a DOAC, aspirin, and a second antiplatelet drug, followed by 12 months on a DOAC plus a single antiplatelet drug, and then the DOAC alone as the "default" strategy for most patients, but also presents alternative options for patients with high risk for either bleeding or ischemia.

The new guidelines also give much-needed direction on how to apply an invasive strategy, with an emphasis on immediate intervention for within 2 hours for very-high-risk patients, and early intervention within 24 hours for high-risk patients. Adhering to this timetable can mean increasing catheter laboratory availability on an urgent basis over weekends, Dr. Bhatt noted.

Improving Quality of Care

A novel section in the new guidelines was devoted to nine quality measures that can help health systems and medical centers monitor their adherence to the guideline recommendations, track their performance relative to peer institutions, and follow changes in performance that result from quality improvement steps. It's something of a "futuristic" step for a guideline to take, with a goal of persuading administrators to implement tracking of these measures and improve patient outcomes, noted Dr. Bhatt.

"It's very important to see that this is not just a set of guidelines but also a tool to improve quality of care," commented Dr. Kovacs. The key to success in this effort will be to follow registered patients, set benchmarks that systems can aspire to achieve, and use this to improve the quality of care.

Until now, optimizing care for patients with NSTE-ACS has been "challenging," he said. "The focus must be on moving toward systems of care" that can provide consistent patient evaluation and care, and do it quickly, said Dr. Kovacs.

Dr. Roffi has received research funding from Biotronik, Boston Scientific, GE Healthcare, and Medtronic. Dr. Kovacs was formerly an employee of Eli Lilly. Dr. Bhatt has been a consultant to and has received research funding from several companies. Dr. Pershad had no disclosures.

This article originally appeared on, part of the Medscape Professional Network.


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