2020 ESC Guidelines For The Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment (57-79)

ESC Guidelines 57
It is recommended to select anticoagulation according to both ischaemic and bleeding risks, and according to the efficacysafety pro-
I C
file of the chosen agent.
Crossover of UFH and LMWH is not recommended.196 III B
Recommendations for post-interventional and maintenance treatment in patients with non-ST-segment elevation acute coronary
syndrome
In patients with NSTE-ACS treated with coronary stent implantation, DAPT with a P2Y12 receptor inhibitor on top of aspirin is rec-
I A
ommended for 12 months unless there are contraindications such as excessive risk of bleeding.170,171,225
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Recommendations for anti-ischaemic drugs in the acute phase of non-ST-segment elevation acute coronary syndrome
Sublingual or i.v. nitrates and early initiation of beta-blocker treatment are recommended in patients with ongoing ischaemic symp-
I C
toms and without contraindications.
It is recommended to continue chronic beta-blocker therapy unless the patient is in overt heart failure. I C
i.v. nitrates are recommended in patients with uncontrolled hypertension or signs of heart failure. I C
Recommendations for combining antiplatelet agents and anticoagulants in non-ST-segment elevation acute coronary syndrome
patients requiring chronic oral anticoagulation
Stroke prevention should be offered to AF patients with >_1 non-sex CHA2DS2-VASc stroke risk factors (score of >_1 in males or >_2
I A
in females). For patients with >_2 non-sex stroke risk factors, OAC is recommended.255259
Patients undergoing coronary stenting
Anticoagulation
During PCI, additional parenteral anticoagulation is recommended, irrespective of the timing of the last dose of all NOACs and if INR
I C
is <2.5 in VKA-treated patients.
Antiplatelet treatment
In patients with AF and CHA2DS2-VASc score >_1 in men and >_2 in women, after a short period of TAT (up to 1 week from the
acute event), DAT is recommended as the default strategy using a NOAC at the recommended dose for stroke prevention and a sin- I A
gle oral antiplatelet agent (preferably clopidogrel).238241,244,245
Periprocedural DAPT administration consisting of aspirin and clopidogrel up to 1 week is recommended.238241,244,245 I A
236239,246
Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. I B
The use of ticagrelor or prasugrel as part of TAT is not recommended. III C
Recommendations for coronary revascularization
Timing of invasive strategy
An immediate invasive strategy (<2 h) is recommended in patients with at least one of the following very high-risk criteria:
• Haemodynamic instability or CS.
• Recurrent or refractory chest pain despite medical treatment.
• Life-threatening arrhythmias. I C
• 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.
An early invasive strategy within 24 h is recommended in patients with any of the following high-risk criteria:
• Diagnosis of NSTEMI suggested by the diagnostic algorithm recommended in section 3.
• Dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischaemia. I A
• Transient ST-segment elevation.273,362
• GRACE risk score >140.271,272,277
A selective invasive strategy after appropriate ischaemia testing or detection of obstructive CAD by CCTA is recommended in
I A
patients considered at low risk.267,268,363
Technical aspects
Radial access is recommended as the standard approach, unless there are overriding procedural considerations.336,337 I A
DES are recommended over bare-metal stents for any PCI irrespective of:
• Clinical presentation.
• Lesion type.
I A
• Planned non-cardiac surgery.
• Anticipated duration of DAPT.
• Concomitant anticoagulant therapy.354,365,366
Continued
58 ESC Guidelines
It is recommended to base the revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) on the patient’s clinical
status and comorbidities, as well as their disease severity [i.e. the distribution and angiographic lesion characteristics (e.g. SYNTAX
I B
score)], according to the principles for stable CAD.350 However, the decision on immediate PCI of the culprit stenosis does not
require Heart Team consultation.
Recommendations for myocardial infarction with non-obstructive coronary arteries
In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to differentiate true
I C
MINOCA from alternative diagnoses.

It is recommended to perform CMR in all MINOCA patients without an obvious underlying cause.370 I B
It is recommended to manage patients with an initial diagnosis of MINOCA and a final established underlying cause according to the
I C
disease-specific guidelines.
Recommendations for non-ST-segment elevation acute coronary syndrome patients with heart failure or cardiogenic shock
Emergency coronary angiography is recommended in patients with CS complicating ACS.205,416,417 I B
Emergency PCI of the culprit lesion is recommended for patients with CS due to NSTE-ACS, independent of the time delay from
I B
symptom onset, if the coronary anatomy is amenable to PCI.205,417
Emergency CABG is recommended for patients with CS if the coronary anatomy is not amenable to PCI.205,417 I B
It is recommended to perform emergency echocardiography without delay to assess LV and valvular function and exclude mechanical
I C
complications.
In cases of haemodynamic instability, emergency surgical or catheter-based repair of mechanical complications of ACS is recom-
I C
mended, as decided by the Heart Team.
Routine use of IABP in patients with CS and no mechanical complications due to ACS is not recommended.413,414,415 III B
Routine immediate revascularization of non-culprit lesions in NSTE-ACS patients with multivessel disease presenting with CS is not
III B
recommended.346,408
Recommendations for diabetes mellitus in non-ST-segment elevation acute coronary syndrome patients
It is recommended to screen all patients with NSTE-ACS for diabetes and to monitor blood glucose levels frequently in patients with
I C
known diabetes or admission hyperglycaemia.
Avoidance of hypoglycaemia is recommended.424427 I B
Recommendations for patients with chronic kidney disease and non-ST-segment elevation acute coronary syndrome
Risk stratification in CKD
It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary)
I C
as for patients with normal renal function.
It is recommended to assess kidney function by eGFR in all patients. I C
Myocardial revascularization in patients with CKD
Use of low- or iso-osmolar contrast media (at lowest possible volume) are recommended in invasive strategies.205,441,442,445,446 I A
Recommendations for older persons with non-ST-segment elevation acute coronary syndrome
It is recommended to apply the same diagnostic strategies in older patients as for younger patients.458 I B
It is recommended to apply the same interventional strategies in older patients as for younger patients.463,467 I B
The choice of antithrombotic agent and dosage, as well as secondary preventions, should be adapted to renal function, as well as spe-
I B
cific contraindications.461
Recommendations for lifestyle managements after non-ST-segment elevation acute coronary syndrome
Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended in order to reduce all-
I A
cause and cardiovascular mortality and morbidity and improve health-related quality of life.487497
Cognitive behavioural interventions are recommended to help individuals achieve a healthy lifestyle.498500 I A
Multidisciplinary exercise-based cardiac rehabilitation is recommended as an effective means for patients with CAD to achieve a
healthy lifestyle and manage risk factors in order to reduce all-cause and cardiovascular mortality and morbidity, and improve health- I A
487,497,501
related quality of life.
Involvement of multidisciplinary healthcare professionals (cardiologists, general practitioners, nurses, dieticians, physiotherapists, psy-
chologists, pharmacists) is recommended in order to reduce all-cause and cardiovascular mortality and morbidity, and improve I A
health-related quality of life.492,499,502,503
Psychological interventions are recommended to improve symptoms of depression in patients with CAD in order to improve health-
I B
related quality of life.504,505
Annual influenza vaccination is recommended for patients with CAD, especially in the older person, in order to improve
I B
morbidity.505511
Continued
ESC Guidelines 59
Recommendations for pharmacological long-term management after non-ST-segment elevation acute coronary syndrome (excluding
antithrombotic treatments)
Lipid-lowering drugs
Statins are recommended in all NSTE-ACS patients. The aim is to reduce LDL-C by >_50% from baseline and/or to achieve LDL-C
I A
<1.4 mmol/L (<55 mg/dL).533,534
If the LDL-C goalf is not achieved after 46 weeks with the maximally tolerated statin dose, combination with ezetimibe is
I B
recommended.514,535

If the LDL-C goalf is not achieved after 46 weeks despite maximally tolerated statin therapy and ezetimibe, the addition of a PCSK9
I B
inhibitor is recommended.520,535
ACE inhibitors or ARBs
ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are recommended in patients with heart failure with reduced
LVEF (<40%), diabetes, or CKD unless contraindicated (e.g. severe renal impairment, hyperkalaemia, etc.) in order to reduce all-cause I A
and cardiovascular mortality and cardiovascular morbidity.536538
Beta-blockers
Beta-blockers are recommended in patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%).539541 I A
MRAs
MRAs are recommended in patients with heart failure with reduced LVEF (<40%) in order to reduce all-cause and cardiovascular
I A
mortality and cardiovascular morbidity.548,549
Proton pump inhibitors
Concomitant use of a proton pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, DAT, TAT, or OAC
I A
monotherapy who are at high risk of gastrointestinal bleeding in order to reduce the risk of gastric bleeds.169
ACE = angiotensin-converting enzyme; ACS = acute coronary syndromes; AF = atrial fibrillation; ARB = angiotensin receptor blocker; b.i.d. = bis in die (twice a day); CABG =
coronary artery bypass graft(ing); CAD = coronary artery disease; CCTA = coronary computed tomography angiography; CHA2DS2-VASc = Congestive heart failure,
Hypertension, Age >_75 years (2 points), Diabetes, Stroke (2 points)_Vascular disease, Age 65_74, Sex category (female); CKD = chronic kidney disease; CMR = cardiac mag-
netic resonance; CS = cardiogenic shock; DAPT = dual antiplatelet therapy; DAT = dual antithrombotic therapy; DES = drug-eluting stent; ECG = electrocardiogram/electro-
cardiography; eGFR = estimated glomerular filtration rate; ESC = European Society of Cardiology; FFR = fractional flow reserve; GDF-15 = growth differentiation factor 15;
GP = glycoprotein; GRACE = Global Registry of Acute Coronary Events; h-FABP = heart-type fatty acid-binding protein; hs-cTn = high-sensitivity cardiac troponin; IABP =
intra-aortic balloon pump; ICA = invasive coronary angiography; INR = international normalized ratio; i.v. = intravenous; LD = loading dose; LDL-C = low-density lipoprotein
cholesterol; LMWH = low-molecular-weight heparin; LV = left ventricular; LVEF = left ventricular ejection fraction; MD = maintenance dose; MI = myocardial infarction;
MINOCA = myocardial infarction with non-obstructive coronary arteries; MRA = mineralocorticoid receptor antagonist; NOAC = non-vitamin K antagonist oral anticoagulant;
NSTEMI = non-ST-segment elevation myocardial infarction; NSTE-ACS = non-ST-segment elevation acute coronary syndrome; OAC = oral anticoagulation/anticoagulant;
o.d. = once daily; PCI = percutaneous coronary intervention; PCSK9 = proprotein convertase subtilisin kexin 9; TAT = triple antithrombotic therapy; UFH = unfractionated
heparin; VKA = vitamin K antagonist.
a
Class of recommendation.
b
Level of evidence.
c
Does not apply to patients discharged the same day in whom NSTEMI has been ruled out
d
If none of the following criteria: haemodynamically unstable, major arrhythmias, LVEF <40%, failed reperfusion, additional critical coronary stenoses of major vessels, complica-
tions related to percutaneous revascularization, or GRACE risk score >140 if assessed.
e
If one or more of the above criteria are present.
f
For patients at very high cardiovascular risk (such as patients with ACS), an LDL-C reduction of at least 50% from baseline and an LDL-C goal <1.4 mmol/L (<55 mg/dL) are
recommended.512
15 Supplementary data ..
.. Boston, United States of America; Paul Dendale, Faculty of
Supplementary Data with additional Supplementary Figures, Tables,
.. Medicine and Life Sciences, Hasselt University, Hasselt, Belgium;
.. Maria Dorobantu, Cardiology, "Carol Davila" University of
and text complementing the full text are available on the European ..
Heart Journal website and via the ESC website at www.escardio.org/
.. Medicine and Pharmacy, Bucharest, Romania; Thor Edvardsen,
.. Cardiology, Oslo University Hospital, Oslo, Norway; Thierry
guidelines. ... Folliguet, UPEC, Cardiac surgery, Hôpital Henri Mondor
..
.. (Assistance Publique Hôpitaux de Paris), Créteil, France; Chris P.
..
16 Appendix ..
..
Gale, Leeds Institute of Cardiovascular and Metabolic Medicine,
University of Leeds, Leeds, United Kingdom; Martine Gilard,
Author/Task Force Member Affiliations: Emanuele
..
.. Cardiology, CHU La Cavale Blanche, Brest, France; Alexander
Barbato, Advanced Biomedical Sciences, University Federico II, .. Jobs, Department of Internal Medicine/Cardiology, Heart Center
..
Napoli, Italy; Olivier Barthélémy, Sorbonne Université, ACTION .. Leipzig at University of Leipzig, Leipzig, Germany; Peter Jüni, Li Ka
Study Group, Institut de Cardiologie, Hôpital Pitié-Salp^eetrière .. Shing Knowledge Institute of St. Michael’s Hospital, Toronto, Canada;
..
(Assistance Publique- Hôpitaux de Paris) (AP-HP), Paris, France; .. Ekaterini Lambrinou, Department of Nursing, School of Health
Johann Bauersachs, Department of Cardiology and Angiology, .. Sciences, Cyprus University of Technology, Limassol, Cyprus; Basil
..
Hannover Medical School, Hannover, Germany; Deepak L. Bhatt, .. S. Lewis, Cardiovascular Clinical Trials Institute, Lady Davis Carmel
Brigham and Women’s Hospital and Harvard Medical School, .. Medical Center and the Ruth and Bruce Rappaport School of
60 ESC Guidelines
..
Medicine, Haifa, Israel; Julinda Mehilli, Munich University Clinic, .. Ingibjörg J. Guðmundsdottir; Ireland: Irish Cardiac Society, Aaron J.
Ludwig-Maximilians University, Munich, Germany; Emanuele .. Peace; Israel: Israel Heart Society, Roy Beigel; Italy: Italian
..
Meliga, Interventional Cardiology, AO Mauriziano Umberto I, Turin, .. Federation of Cardiology, Ciro Indolfi; Kazakhstan: Association of
Italy; Béla Merkely, Heart and Vascular Center, Semmelweis .. Cardiologists of Kazakhstan, Nazipa Aidargaliyeva; Kosovo
..
University, Budapest, Hungary; Christian Mueller, Cardiovascular .. (Republic of): Kosovo Society of Cardiology, Shpend Elezi;
Research Institute Basel (CRIB) and Cardiology, University Hospital .. Kyrgyzstan: Kyrgyz Society of Cardiology, Medet Beishenkulov;
..
Basel, University of Basel, Basel, Switzerland; Marco Roffi, Geneva .. Latvia: Latvian Society of Cardiology, Aija Maca; Lithuania:
.. Lithuanian Society of Cardiology, Olivija Gustiene; Luxembourg:

University Hospitals, Geneva, Switzerland; Frans H. Rutten, ..
General Practice, Julius Center for Health Sciences and Primary Care, .. Luxembourg Society of Cardiology, Philippe Degrell; Malta: Maltese
University Medical Center Utrecht, Utrecht University, Utrecht, .. Cardiac Society, Andrew Cassar Maempel; Moldova (Republic
..
Netherlands; Dirk Sibbing, Privatklinik Lauterbacher Mühle am .. of): Moldavian Society of Cardiology, Victoria Ivanov; Netherlands:
Ostersee, Munich, Germany; and Ludwig-Maximilians Universit€at .. Netherlands Society of Cardiology, Peter Damman; North
..
München, Munich, Germany; George C.M. Siontis, Department of .. Macedonia: North Macedonian Society of Cardiology, Sasko
Cardiology, University Hospital of Bern, Inselspital, Bern, Switzerland. .. Kedev; Norway: Norwegian Society of Cardiology, Terje K. Steigen;
..
.. Poland: Polish Cardiac Society, Jacek Legutko; Portugal:
.. Portuguese Society of Cardiology, Jo~ao Morais; Romania:
ESC Committee for Practice Guidelines (CPG): Stephan ..
Windecker (Chairperson) (Switzerland), Victor Aboyans (France), .. Romanian Society of Cardiology, Dragos Vinereanu; Russian
.. Federation: Russian Society of Cardiology, Dmitry Duplyakov; San
Colin Baigent (United Kingdom), Jean-Philippe Collet (France), ..
Veronica Dean (France), Victoria Delgado (Netherlands), Donna .. Marino: San Marino Society of Cardiology, Marco Zavatta; Serbia:
.. Cardiology Society of Serbia, Milan Pavlovic; Slovakia: Slovak
Fitzsimons (United Kingdom), Chris P. Gale (United Kingdom), ..
Diederick E. Grobbee (Netherlands), Sigrun Halvorsen (Norway), .. Society of Cardiology, Marek Orban; Slovenia: Slovenian Society of
..
Gerhard Hindricks (Germany), Bernard Iung (France), Peter Jüni .. Cardiology, Matjaz Bunc; Spain: Spanish Society of Cardiology, Borja
(Canada), Hugo A. Katus (Germany), Ulf Landmesser (Germany),
.. Iba~nez; Sweden: Swedish Society of Cardiology, Robin Hofmann;
..
Christophe Leclercq (France), Maddalena Lettino (Italy), Basil S. .. Switzerland: Swiss Society of Cardiology, Oliver Gaemperli;
Lewis (Israel), Béla Merkely (Hungary), Christian Mueller
.. Syrian Arab Republic: Syrian Cardiovascular Association, Yassin
..
(Switzerland), Steffen E. Petersen (United Kingdom), Anna Sonia .. Bani Marjeh; Tunisia: Tunisian Society of Cardiology and Cardio-
Petronio (Italy), Dimitrios J. Richter (Greece), Marco Roffi
.. Vascular Surgery, Faouzi Addad; Turkey: Turkish Society of
..
(Switzerland), Evgeny Shlyakhto (Russian Federation), Iain A. .. Cardiology, Eralp Tutar; Ukraine: Ukrainian Association of
Simpson (United Kingdom), Miguel Sousa-Uva (Portugal), Rhian M.
.. Cardiology, Alexander Parkhomenko; United Kingdom of Great
..
Touyz (United Kingdom). .. Britain and Northern Ireland: British Cardiovascular Society,
.. Nina Karia.
..
ESC National Cardiac Societies actively involved in the review
..
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2020 ESC Guidelines For The Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment (57-79)

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2020 ESC Guidelines For The Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-segment (57-79)

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ESC Guidelines 57

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07. Nestelberger T, Boeddinghaus J, Badertscher P, Twerenbold R, Wildi K,

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DI, Rentsch K, von Eckardstein A, Osswald S, Reichlin T, Mueller C. 0/1-hour tri-

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Mueller C. Clinical effect of sex-specific cutoff values of high-sensitivity cardiac

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121. Thygesen K, Mair J, Mueller C, Huber K, Weber M, Plebani M, Hasin Y, Biasucci

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joint consensus document of the European Society of Cardiology Working

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discharge mortality risk in non-ST-segment elevation acute coronary syndrome.

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ischemic syndromes with and without ST-segment elevation. Circulation

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EuroObservational Research Programme of the European Society of

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simvastatin monotherapy after acute coronary syndrome among patients 75

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503. Wood DA, Kotseva K, Connolly S, Jennings C, Mead A, Jones J, Holden A, De

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