What’s new in the 2020 ESC Clinical Practice Guideline on the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (NSTE-ACS)?
Reported from the European Society of Cardiology ESC Congress 2020 Digital Experience
Majority of ischemic heart disease patients present with NSTEACS . Management of NSTEACS starts with correct diagnosis, appropriate timely initiation of the right pharmacotherapy, provision of coronary angiography/intervention procedures and secondary preventative care. 5 years on from the last ESC NSTEACS guidelines, what does the new 2020 guidelines offer that will impact or change our practice today?
For the first time ever, the ESC Annual Scientific Congress #ESCCongress is being held virtually (“The Digital Experience”) as a consequence of the COVID-19 pandemic! However this does not seem to have dampened the enthusiasm of attendance at the congress with this year’s ESC Congress showing record number of registrations of >100K on day 1 and perhaps turning it into “The Digital Revolution” of cardiovascular learning and sharing!
In 2020, outwith the pandemic, cardiovascular disease in particular ischaemic (coronary) heart disease still remains world’s number 1 killer! The ESC’s mission is to reduce the global burden of cardiovascular disease. One of the major highlights of the yearly ESC congress is the publication of ESC Clinical Practice Guidelines (CPG) on various topics that provide recommendations on the best care for our patients based on best evidence. This year among the 4 CPGs that are published we have the new 2020 ESC CPG on the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation co-chaired by Professors Collet and Thiele (1). The other 2020 ESC CPGs are on Sports Cardiology/Physical Activity, Atrial Fibrillation and Adult Congenital Heart Disease
How will these new guidelines impact practice today?
Majority of ischemic heart disease patients present with non ST segment elevation acute coronary syndrome (NSTEACS). Management of NSTEACS starts with correct diagnosis, appropriate timely initiation of the right pharmacotherapy, provision of coronary angiography/intervention procedures and secondary preventative care. 5 years on from the last ESC NSTEACS guidelines (2), what does the new 2020 guidelines offer that will impact or change our practice today?
First of all the 2020 ESC NSTEACS guidelines has introduced new sections on the following important topics:
- Myocardial infarction with non-obstructed coronary arteries (MINOCA)
- Spontaneous coronary artery dissection (SCAD)
- Quality indicators in NSTE-ACS treatment
The new ESC NSTEACS guidelines also offers recommendations on new or revised concepts on the following:
- Rapid rule-in and rule-out algorithms
- Risk stratification for an early invasive approach
- Definition of high bleeding risk
- Definition of very high and high-ischaemic risk
- The gap in evidence and corresponding randomized trials to be performed
Clinical evaluation: Always back to basics!
The COVID-19 pandemic resulted in halving heart attack admissions worldwide due to fear of hospital visits among many potential reasons behind this. However, NSTEACS can be a life threatening condition and therefore seeking help when the symptoms occur is vital to save lives and to avoid future complications including heart failure.
The new ESC guidelines have indeed emphasized the importance of evaluation of clinical presentation and provide the following description of clinical presentation in the context of NSTEACS : “Typical chest discomfort is characterized by a retrosternal sensation of pain, pressure or heaviness (‘angina’) radiating to the left arm, to both arms or to the right arm, neck or jaw, which may be intermittent (usually lasting several minutes) or persistent. Additional symptoms such as sweating, nausea, epigastric pain, dyspnoea and syncope may be present. Atypical presentations include isolated epigastric pain, indigestion-like symptoms and isolated dyspnoea or fatigue. Atypical complaints are more often observed in the elderly, in women and in patients with diabetes, chronic renal disease or dementia. The exacerbation of symptoms by physical exertion and their relief at rest increase the probability of myocardial ischaemia”.
Diagnosis and strategy
Starting with the diagnosis, the new 2020 ESC guidelines, recommends ESC 0h/2h-algorithm with blood sampling at 0 h and 2 h from 0h, if a high-sensitivity cardiac troponin test with a validated 0 h/2 h algorithm is available.
Invasive strategy: In terms of the invasive strategy, an immediate invasive strategy (<2 h) is recommended in patients with at least one of the very-high-risk criteria.
- Haemodynamic instability or cardiogenic shock
- Recurrent or refractory chest pain despite medical treatment
- Life-threatening arrhythmias or cardiac arrest
- Mechanical complications of MI
- Heart failure clearly related to NSTE-ACS
- Presence of ST-segment depression >1 mm in ≥6 leads additional to ST-segment elevation in aVR and/or V1
It should however be noted that such patients are often excluded from randomised clinical trials reflecting a gap in robust evidence for the above very high risk patients and the need for further research.
An early invasive strategy within 24 h is recommended in patients with any of the high-risk criteria:
- Dynamic or presumably new contiguous ST/S-segment changes suggesting ongoing ischemia
- Transient ST-segment elevation
- GRACE risk score >140
The above recommendations regarding the timing of early invasive strategy within 24 hours are based on findings from meta-analysis once again emphasising the need for robust RCTs to provide definitive answers. Thus reiterating the need for careful evaluation of patient selection with regards to the timing of invasive strategy in NSTEACS . Of note, none of the meta-analysis observed a benefit with an early invasive strategy with respect to the endpoints death, non-fatal MI, or stroke among unselected NSTE-ACS patients but showed a lower risk of recurrent/refractory ischaemia and a shorter length of hospital stay with invasive strategy. The new guidelines also recommends complete revascularisation should be considered in NSTE-ACS patients without cardiogenic shock and with multi-vessel CAD.
Among low risk patients, a selective invasive strategy or non-invasive imaging to guide invasive coronary angiography is recommended. CCTA is recommended as an alternative to invasive coronary angiography to exclude acute coronary syndrome when there is a low-to-intermediate likelihood of coronary artery disease and when cardiac troponin and/or ECG are normal or inconclusive (IA recommendation). For MINOCA patients, it is recommended to perform CMR in all patients without an obvious underlying cause.
Pharmacotherapy
In terms of pharmacotherapy, it is no longer recommended to administer routine pre-treatment with a P2Y12 receptor inhibitor to patients in whom the coronary anatomy is not known and early invasive management is planned. ASA continues to be recommended for all patients without contraindications for long-term treatment. A P2Y12 inhibitor is recommended in addition to aspirin, and maintained over 12 months unless there are contraindications or an excessive risk of bleeding. Based on the ISAR REACT 5 trial, the new guidelines has recommended Prasugrel should be preferred over ticagrelor for NSTE-ACS patients who proceed to PCI. In patients with non-valvular atrial fibrillation (CHA2DS2-VASC score ≥ 1 in men and ≥2 in women), a very short period of triple therapy (up to 1 week from the acute event) is recommended followed by dual antithrombotic therapy using a NOAC at the recommended dose for stroke prevention and single oral antiplatelet agent (by preference clopidogrel).
Risk assessments
In terms risk assessments, the new guideline continues to support (IIB evidence) regarding the use of GRACE risk score models for estimating prognosis. In terms of bleeding risk, CRUSADE bleeding risk score may be considered in patients undergoing coronary angiography. An alternative score may be the bleeding risk assessment according to the Academic Research Collaboration-High Bleeding Risk (ARC-HBR). The DAPT and the PRECISE-DAPT (PREdicting bleeding Complications In patients undergoing Stent implantation and subsEquent Dual Anti Platelet Therapy), were designed to guide and inform decision making on DAPT duration. However given none of these risk prediction models have been prospectively tested in the setting of RCTs, their value in improving patient outcomes remains unclear.
Treating an ageing population: special groups
Special groups: Our population is ageing. Up to 50% of patients who suffer NSTEACS are aged 70 years of age and over. Though there are many observational studies, adequately powered large RCTs in older patients with NSTEACS is currently lacking. There has been 1 small RCT (the After Eighty Study, n=457) that has been published since the 2015 NSTEACS guidelines which showed reduction in MI and urgent revascularisation using the invasive strategy with no difference in death, stroke or bleeding. Based on this small study, the 2020 NSTEACS guideline committee recommend (Evidence 1B) to offer the same diagnostic and interventional strategies to older patients as younger patients. Importantly, given a lot of the evidence is based on studies among younger patients, the guideline acknowledges the need for more robust studies to definitively answer many unanswered questions in older people with NSTEACS .
Quality Indicators
Finally, Quality indicators (QIs) are sets of measures that enable the quantification of adherence to guideline recommendations. It consists of seven domains: (1) centre organization, (2) the reperfusion/invasive strategy, (3) in-hospital risk assessment, (4) antithrombotic treatment during hospitalization, (5) secondary prevention discharge treatments, (6) patient satisfaction, and (7) composite QI risk-adjusted 30-day mortality. The ESC 2020 NSTEACS guidelines have now incorporated this to measure opportunities to improve care and outcomes for our patients.
Conclusion: despite progress, gaps in knowledge require further evaluation to improve patient outcomes!
Despite significant progress and advances in the care of NSTEACS patients, the ESC 2020 NSTEACS guidelines also highlight a number of gaps in knowledge in NSTEACS care which require further evaluation emphasizing the need for completion of ongoing studies and further ongoing research to continue to improve the care we provide to our patients, to improve their outcomes!
References
- 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)
- 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC)
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