The 2023 ESC Guidelines for the management of acute coronary syndromes (ACS) mark a significant milestone in the field of cardiology. Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC), these guidelines represent a comprehensive approach to the management of ACS, covering unstable angina, non-ST elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). With a focus on evidence-based recommendations and patient-centered care, these guidelines aim to improve outcomes and standardize practices in managing ACS worldwide. This article overviews the key updates and recommendations outlined in the 2023 ESC Guidelines for ACS.
What’s Fresh in the 2023 ESC Guidelines for Acute Coronary Syndrome?
For the first time, the ACS guidelines encompass the entire syndrome spectrum, covering unstable angina, NSTEMI, and STEMI.
Contemplate ACS at the outset:
a. A – Abnormal ECG
b. C – Clinical context
c. S – Stable patient
- There’s a shift towards comprehensive patient management from admission to follow-up.
- Introducing the working diagnosis concept ensures thorough evaluation and management of ACS patients.
- The guideline incorporates long-term patient management strategies.
- In a groundbreaking move, patient perspectives are integrated into the guideline, with patient involvement in the task force.
What’s the Impact on Interventional Cardiology?
The new guidelines stress comprehensive management from symptom onset to follow-up.
NSTE-ACS patients are categorized as:
a. Very high risk
b. High-risk
c. Non-high risk
- An immediate invasive strategy involves emergency angiography and Percutaneous Coronary Intervention (PCI) for NSTE-ACS patients meeting specific high-risk criteria.
- An early invasive strategy recommends routine angiography within 24 hours for NSTE-ACS patients with high-risk features.
Invasive Management Considerations:
a. In ACS patients, invasive coronary angiography is the primary modality for evaluating coronary arteries.
b. Routine CCTA is discouraged.
Antithrombotic Therapy Reflections:
a. Default strategy: 12 months of dual antiplatelet therapy.
b. Tailored regimens based on bleeding and ischaemic risks.
c. Consider single antiplatelet therapy after 3–6 months of DAPT for low-risk patients.
d. Avoid routine pre-treatment with a Platelet inhibition induced by oral (P2Y12) receptor inhibitor in NSTE-ACS patients undergoing early invasive management.
Revascularisation Insights:
a. Complete revascularization is recommended in STEMI during the index PCI or within 45 days.
b. PCI for spontaneous coronary artery dissection only for symptomatic patients.
c. Consider intravascular imaging for PCI guidance.
d. Staged PCI for non-IRA in cardiogenic shock patients.
e. In hemodynamically stable STEMI with multivessel disease, consider PCI of non-IRA based on angiographic severity.
f. Avoid invasive epicardial functional assessment of non-culprit IRA during the index procedure.
Secondary Prevention Considerations:
a. Intensify lipid-lowering therapy during ACS hospitalization.
b. Consider low-dose colchicine or combination therapy with statin plus ezetimibe during hospitalization.
MINOCA Perspectives
- CMR imaging is recommended after invasive angiography if the Myocardial infarction with non-obstructive coronary arteries (MINOCA) diagnosis is unclear.
- Manage MINOCA based on the final established diagnosis.
- Follow a diagnostic algorithm for all initial MINOCA diagnoses.
Special Populations Considerations
- Tailor glucose-lowering treatment based on comorbidities.
- Adopt a holistic approach for frail older patients.
- Invasive strategy recommended for cancer patients with high-risk ACS and expected survival ≥6 months.
Patient-centered Care Perspective
- Embrace patient-centered care by involving patients in decision-making.
- Educate patients on adverse event risks and alternative options.
- Use decision aids to facilitate discussions.
- Assess symptoms using patient-friendly methods.
Knowledge Gaps Analysis
- More evidence is needed on ACS management in women and older adults.
- Increased female representation in clinical trials is required for better management insights.
- In the interim, the new ACS guidelines offer pivotal recommendations for enhancing ACS patient care and outcomes.
Conclusion
In conclusion, the 2023 ESC Guidelines for managing acute coronary syndromes represent a significant advancement in treating ACS. From initial assessment to long-term management, these guidelines emphasize comprehensive patient care and integration of patient perspectives. With a focus on individualized treatment strategies and consideration of special populations, these guidelines aim to improve outcomes and enhance patient well-being. However, gaps in knowledge remain, particularly regarding the representation of women and older adults in clinical trials. Nonetheless, the recommendations outlined in these guidelines serve as a valuable resource for healthcare professionals in optimizing care for patients with acute coronary syndrome.
Reference
Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. European Heart Journal. 2023 Aug 25;44(38). https://doi.org/10.1093/eurheartj/ehad191
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