New ESC ACS guideline combines STEMI and NSTE-ACS

Don’t rush cardiac arrest patients to the cath lab

Another update in the guidelines involves the management of patients with cardiac arrest who have been resuscitated. Dr. Byrne explained that these patients would all receive an immediate ECG, and if it is found that they have ST elevation, they would be sent immediately to the cath lab. But a series of randomized trials has suggested that for patients who don’t have ST elevation, it is not necessary to rush these patients to the cath lab.

“We’ve given a Class III recommendation for this, saying it may be better to stabilize the patients first in the ICU. This is in recognition that a large proportion of these patients turn out not to have an MI. They have had a cardiac arrest for another reason,” Dr. Byrne noted. “Moving them to the cath lab when they are still unstable could be harming these patients rather than helping them.”
 

Revascularization for multivessel disease

Dr. Byrne notes that revascularization remains a critical element in the care for patients with STEMI, and there is a new recommendation in this area for patients with multivessel disease.

“Up to half of patients presenting with STEMI have multivessel disease, and we now have five randomized trials to say that these patients should have complete revascularization rather than just the culprit vessel. There is a new Class I recommendation for this,” he said.

However, the optimal timing of revascularization (immediate vs. staged) has still not been investigated in adequately sized randomized trials, and no recommendation has been made on this, the task force notes.

Dr. Byrne commented: “If you want to do everything in one go, that’s fine, but it’s also okay to do the culprit lesion first and then the other vessels at a later date within 45 days. This might depend on individual circumstances. For example, if there are complex lesions or the vessels are heavily calcified, then it may be best to get the culprit lesion fixed first and let the patient recover, then bring them back in for the rest.”

He pointed out that the results of the MULTISTARS trial, which were not available when the task force was formulating the guidelines, were reported at the ESC Congress and confirmed their recommendation.
 

DAPT after PCI

On the duration of dual antiplatelet therapy (DAPT) after PCI, the new guidelines have largely retained prior recommendations for a default strategy of 12 months for the combination of aspirin and a P2Y12 inhibitor.

“This was the subject of some discussion, as there have been several trials now looking at shorter durations of DAPT and deescalating after a few months to just one of these treatments. And while there is a rationale to do this, we think it’s best to be kept as an alternative strategy rather than the default strategy,” Dr. Byrne said.

He explained that the trials of DAPT deescalation tended to enroll lower-risk patients, which reduced the generalizability of the results.

Most of the trials only randomly assigned patients to shorter durations of DAPT when they were event-free for some period, she said.

“This is a dynamic decision-making process and reflects the real world to some extent. We think it is best to recommend the standard aspirin and a P2Y12 inhibitor for the 12-month duration, but at 3 months, if the patient is doing well but you may be worried about bleeding risk, then you could decide to deescalate to single antiplatelet therapy,” she noted. “So, there is Class IIa recommendation that this can be considered, but it is not recommended as the default position.”