New ESC ACS guideline combines STEMI and NSTE-ACS

Invasive management in NSTE-ACS

He pointed out that a small change has been made in the advice on invasive management for patients with non–ST-elevation ACS.

Dr. Byrne explained that patients with ST elevation should be sent immediately to a cath lab for PCI. If this is not possible within 120 minutes, then the patient should receive thrombolysis. This recommendation is the same as in previous guidelines.

He added, however, that there is some novelty in recommendations for patients who don’t have ST elevation but do have a positive troponin. For this group, previous guidelines gave a Class I recommendation that all such patients undergo an angiogram within the first 24 hours. However, an additional meta-analysis that was published in 2022 showed that the evidence for triaging all patients to the cath lab within 24 hours is somewhat limited, Dr. Byrne noted.

“At the end of the day, the task force felt that a Class I recommendation to get all patients to the cath lab within 24 hours was too strong and couldn’t be sustained, so it has been downgraded to a Class IIa recommendation, which we thought was more appropriate,” he said.

“So, while all patients should still have an angiogram during the hospital admission, if they are high-risk ACS, the imperative to get everyone to the cath lab within 24 hours – which many of our colleagues were finding difficult to achieve – does not seem to be backed up by the evidence,” he added.
 

Antithrombotic therapy

Addressing administration of antithrombotics, the guidelines emphasize that at the time of initial diagnosis, all patients should receive antithrombotic therapy, usually aspirin and a parenteral antithrombotic, such as heparin, enoxaparin, bivalirudin, or fondaparinux. Dr. Byrne noted that the guidelines have a new algorithm as to which of these antithrombotics to give, depending on the clinical presentation of the patient.

On the use of upfront P2Y12 inhibitors, Dr. Byrne said the new guidelines only give a weak recommendation for this.

“Giving a P2Y12 inhibitor up front does not have a strong evidence base, and it’s not unreasonable to wait, do the angiogram, see where you are, and then start the P2Y12 inhibitor. This is something that’s not widely done in clinical practice,” he commented.

“The last 2020 guideline gave a Class III recommendation for upfront P2Y12 inhibitor therapy for ACS patients who do not have STEMI. We’ve generally maintained that with the introduction of the exception that if you are in a health care system where there is a long wait to get to the cath lab – 5 ,6 or 7 days – then it’s reasonable to make an exception and give a P2Y12 inhibitor, but otherwise we’ve sustained the Class III recommendation,” he noted.

Also, for patients who have STEMI, there is a new Class IIb recommendation that upfront P2Y12 inhibitors may be considered.

“This is also rather a weak recommendation. There isn’t a strong rationale to give a P2Y12 inhibitor it in ST elevation either. It’s also reasonable to wait,” he added.