2023 ESC Guidelines for the management of acute coronary syndromes

Reported from ESC Congress 2023

What is new in 2023 ACS guidelines?

1. This is the first time an “ACS” guideline has been published encompassing the full spectrum of the syndrome including unstable angina, non ST- elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI).
2. Think ACS at initial assessment:a. A- Abnormal ECG?b. C-Clinical context?c. S-Stable patient?
3. There is focus on comprehensive complete patient management from the point of admission to follow-up.
4. The concept of working diagnosis to final diagnosis is introduced to ensure a comprehensive evaluation and management of patients with ACS.
5. There is also emphasis on long-term management of patients
6. For the first time, with patient involvement as a member of the task force, the guideline provides patient perspectives.

What difference does it make to interventional cardiology?

1. In the new guidelines, there is an emphasis on comprehensive management from symptom onset through to management and follow-up.
2. NSTEACS patients are classified into:a. Very high riskb. High riskc. Non-high risk

An immediate invasive strategy refers to emergency (i.e. as soon as possible) angiography and PCI if indicated. This is recommended for patients with a working diagnosis of NSTE-ACS and any of the following very high-risk criteria:

1. Haemodynamic instability or cardiogenic shock
2. Recurrent or ongoing chest pain refractory to medical treatment
3. Acute heart failure presumed secondary to ongoing myocardial ischaemia
4. Life-threatening arrhythmias or cardiac arrest after presentation
5. Mechanical complications
6. Recurrent dynamic ECG changes suggestive of ischaemia (particularly with intermittent ST-segment elevation)

An early invasive strategy refers to routine invasive angiography (and PCI if needed) within 24 hours of presentation. This should be considered in patients with a working diagnosis of NSTE-ACS and any of the following high-risk criteria:

1. A confirmed diagnosis of NSTEMI based on current recommended ESC hs-cTn algorithms
2. Dynamic ST-segment or T wave changes
3. Transient ST-segment elevation
4. A GRACE risk score >140

Think invasive management:

• a. In Patients with ACS the primary modality for evaluation of coronary arteries is invasive coronary angiography.
• b. Routine CCTA is not recommended.

Think antithrombotic therapy:

• a. 12 months of dual antiplatelet therapy is recommended as default strategy. Alternative regimens can be used based on bleeding and ischaemic risks
• b. In patients who are event-free after 3–6 months of DAPT and who are not high ischaemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered
• c. In high bleeding risk patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered
• d. Routine pre-treatment with a P2Y12 receptor inhibitor is not recommended in NSTE-ACS patients in whom coronary anatomy is not known and early invasive management (<24 hours) is planned.

Think revascularisation:

• a. In STEMI, complete revascularization is recommended either during the index PCI procedure or within 45 days
• b. In patients with spontaneous coronary artery dissection, PCI is recommended only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow
• c. Intravascular imaging should be considered to guide PCI
• d. In patients with cardiogenic shock, staged PCI of non-IRA should be considered.
• e. In patients with multivessel disease in the context of hemodynamically stable STEMI, it is recommended that PCI of the non-IRA is based on angiographic severity.
• f. Invasive epicardial functional assessment of non-culprit segments of the IRA is not recommended during the index procedure

Think secondary prevention:

• a. It is recommended to intensify lipid-lowering therapy during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission
• b. Low-dose colchicine (0.5 mg once a day) may be considered, particularly if other risk factors are insufficiently controlled or if recurrent cardiovascular disease events occur under optimal therapy
• c. Combination therapy with a high-dose statin plus ezetimibe may be considered during index hospitalization.

MINOCA:

1. In patients with a working diagnosis of MINOCA, CMR imaging is recommended after invasive angiography if the final diagnosis is not clear
2. Management of MINOCA according to the final established underlying diagnosis is recommended, consistent with the appropriate disease-specific guidelines
3. In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to determine the underlying final diagnosis

Special population:

1. It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, chronic kidney disease, and obesity
2. For frail older patients with comorbidities, a holistic approach is recommended to individualize interventional and pharmacological treatments after careful evaluation of the risks and benefits
3. An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months.

Patient perspective:

1. Patient-centred care is recommended by assessing and adhering to individual patient preferences, needs and beliefs, ensuring that patient values are used to inform all clinical decisions.
2. It is recommended to include ACS patients in decision-making (as much as their condition allows) and to inform them about the risk of adverse events, radiation exposure, and alternative options. Decision aids should be used to facilitate the discussion.
3. It is recommended to assess symptoms using methods that help patients to describe their experience.

Gaps in knowledge:

1. Most RCTs consist of men representing nearly 70% of the trial patient population. Therefore more evidence on the best care of women with ACS is needed. Increased representation of female patients in future clinical trials is required to better inform the optimal management of women with ACS.
2. Older people are underrepresented in clinical trials. Therefore more evidence on the best care of older adults with ACS is needed.

In the meantime, the new ACS guidelines provide some important recommendations to improve the health and well-being of our patients with acute coronary syndrome!

References

1. 2023 ESC Guidelines for the management of acute coronary syndromes. Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B; ESC Scientific Document Group.Eur Heart J. 2023 Aug 25:ehad191. doi: 10.1093/eurheartj/ehad191.

Latest news from ESC Congress 2023

Author

Vijay Kunadian

@VijayKunadian

Interventional cardiologist / Cardiologist

High Heaton, United Kingdom

Latest contributions

PCI for complex bifurcation disease - LIVE Case Which device for which patient: DES, BRS or DCB? ACS with normal coronary arteries: angiography done, job done?

View full profile