The following are key points to remember from the 2020 European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation:

1. The pathological correlate for ACS in patients presenting without persistent ST-segment elevation (NSTE-ACS) at the myocardial level is cardiomyocyte necrosis, measured by troponin release, or, less frequently, myocardial ischemia without cell damage (unstable angina). In general, individuals with unstable angina have a substantially lower risk of death and derive less benefit from an aggressive pharmacological and invasive approach.
2. High-sensitivity troponin (hs-Tn) assay measurements are recommended over less sensitive ones, as they provide higher diagnostic accuracy at identical low cost. Of note, many cardiac pathologies other than myocardial infarction (MI) also result in cardiomyocyte injury and, therefore, cardiac troponin (cTn) elevations.
3. Other biomarkers may have clinical relevance in specific clinical settings when used in combination with non–hs-cTn T/I. Creatine kinase-myocardial band (CK-MB) shows a more rapid decline after MI and may provide added value for detection of early reinfarction. The routine use of copeptin as an additional biomarker for the early rule-out of MI is recommended in the very uncommon setting where hs-cTn assays are not available.
4. The time interval to the second cTn assessment can be shortened with the use of hs-cTn assays due to the higher sensitivity and diagnostic accuracy for the detection of MI at presentation. It is recommended to use the 0 h/1 h algorithm (best option, blood draw at 0 h and 1 h) or the 0 h/2 h algorithm (second-best option, blood draw at 0 h and 2 h). Used in conjunction with clinical and electrocardiography (ECG) findings, the 0 h/1 h and 0 h/2 h algorithm allows the identification of appropriate candidates for early discharge and outpatient management.
5. Four clinical variables significantly affect hs-cTn concentrations including age (differences between healthy very young vs. ‘healthy’ very old individuals up to 300%), renal dysfunction (differences with very high vs. very low estimated glomerular filtration rate (eGFR) up to 300%), chest pain onset (>300%), and sex (~40%).
6. Initial cTn levels add prognostic information in terms of short- and long-term mortality to clinical and ECG variables. The higher the hs-cTn levels, the greater the risk of death. Serum creatinine and eGFR should also be determined in all patients with NSTE-ACS because they affect prognosis and are key elements of the GRACE risk score, in which assessment is superior to (subjective) physician assessment for the occurrence of death or MI. In addition, natriuretic peptides may provide incremental prognostic information.
7. The use of Academic Research Consortium for High Bleeding Risk (ARC-HBR) assessment is a pragmatic approach for bleeding risk assessment that includes the most recent trials performed in high bleeding risk patients, who were previously excluded from clinical trials of dual antiplatelet therapy (DAPT) duration or intensity. The PRECISE-DAPT score may be used to guide and inform decision making on DAPT duration with a modest predictive value for major bleeding, but their value in improving patient outcomes remains unclear.
8. Clinical assessment may indicate elective noninvasive or invasive imaging even after the rule-out of MI. Cardiac computed tomography angiography (CCTA) may be an option in patients with low to- modest clinical likelihood of unstable angina, as a normal scan excludes coronary artery disease (CAD). CCTA has a high negative predictive value to exclude ACS (by excluding CAD) and predicts an excellent outcome in patients presenting to the emergency department with low-to-intermediate pretest probability for ACS and a normal CCTA. Stress imaging by cardiac magnetic resonance imaging (CMR), stress echocardiography, or nuclear imaging may also be an option based on risk assessment.
9. An early routine invasive approach within 24 hours of admission is recommended for NSTEMI based on hs-cTn measurements, GRACE risk score >140, and dynamic new, or presumably new, ST-segment changes, as it improves major adverse cardiac events and possibly early survival. Immediate invasive angiography is required in highly unstable patients according to hemodynamic status, arrhythmias, acute heart failure, or persistent chest pain. In all other clinical presentation, a selective invasive approach may be performed according to noninvasive testing or clinical risk assessment.
10. The principal technical aspects of percutaneous coronary intervention (PCI) in NSTE-ACS patients do not differ from the invasive assessment and revascularization strategies for other CAD presentations. Radial access is recommended as the preferred approach in NSTE-ACS patients undergoing invasive assessment with or without PCI. As multivessel disease is frequent in NSTE-ACS, timing and completeness of revascularization should be decided according to functional relevance of all stenoses, age, general patient condition, comorbidities, and left ventricular function.
11. MI with nonobstructive coronary arteries (MINOCA) incorporates a heterogeneous group of underlying causes that may involve both coronary and noncoronary pathological conditions, with the latter including cardiac and extracardiac disorders. By consensus, myocarditis and Takotsubo syndrome are excluded. CMR is one of the key diagnostic tools, as it identifies the underlying cause in >85% of patients and the subsequent appropriate treatment.
12. Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic, nontraumatic, or iatrogenic separation of the coronary arterial tunics secondary to vasa vasorum hemorrhage or intimal tear, and accounts for up to 4% of all ACS, but the incidence is reported to be much higher (22-35% of ACS) in women <60 years of age. Intracoronary imaging is very useful for the diagnosis and treatment orientation. Medical treatment is not well established.
13. Routine pretreatment with a P2Y₁₂ receptor inhibitor in NSTE-ACS patients in whom coronary anatomy is not known and an early invasive management is planned is not recommended given the lack of established benefit. However, it may be considered in selected cases and according to the bleeding risk of the patient.
14. DAPT consisting of a potent P2Y₁₂ receptor inhibitor in addition to aspirin is generally recommended for 12 months, irrespective of the stent type, unless there are contraindications. However, new scenarios have been implemented. DAPT duration can be shortened (<12 months), extended (>12 months), or modified by switching DAPT or de-escalation. These decisions depend on individual clinical judgment driven by the patient’s ischemic and bleeding risk, the occurrence of adverse events, comorbidities, comedications, and the availability of the respective drugs.
15. In at least 6-8% of patients undergoing PCI, long-term oral anticoagulation is indicated and should be continued. In general, novel oral anticoagulants (NOACs) are preferred over vitamin K antagonists vitamin K antagonists (VKAs) in terms of safety when patients are eligible. Dual antithrombotic therapy with a NOAC at the recommended dose for stroke prevention and single antiplatelet therapy (preferably clopidogrel, chosen in >90% of cases in available trials) is recommended as the default strategy up to 12 months after a short period up to 1 week of triple antithrombotic therapy (TAT) (with NOAC and DAPT). TAT may be prolonged up to 1 month when the ischemic risk outweighs the bleeding risk.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Stable Ischemic Heart Disease, Anticoagulation Management and ACS, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Magnetic Resonance Imaging, Nuclear Imaging, Chronic Angina

Keywords: ESC20, ESC Congress, Acute Coronary Syndrome, Angina, Stable, Anticoagulants, Chest Pain, Coronary Angiography, Diagnostic Imaging, Dissection, Echocardiography, Electrocardiography, Heart Failure, Hemorrhage, Magnetic Resonance Imaging, Myocardial Infarction, Myocardial Ischemia, Myocarditis, Percutaneous Coronary Intervention, Platelet Aggregation Inhibitors, Primary Prevention, Renal Insufficiency, Risk Assessment, Stroke, Thrombosis, Tomography, X-Ray Computed, Troponin, Vascular Diseases

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