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.