European Heart Journal doi:10.

1093/eurheartj/ehr236

ESC GUIDELINES

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)
Authors/Task Force Members: Christian W. Hamm (Chairperson) (Germany)*, Jean-Pierre Bassand (Co-Chairperson)*, (France), Stefan Agewall (Norway), Jeroen Bax (The Netherlands), Eric Boersma (The Netherlands), Hector Bueno (Spain), Pio Caso (Italy), Dariusz Dudek (Poland), Stephan Gielen (Germany), Kurt Huber (Austria), Magnus Ohman (USA), Mark C. Petrie (UK), Frank Sonntag (Germany), Miguel Sousa Uva (Portugal), Robert F. Storey (UK), William Wijns (Belgium), Doron Zahger (Israel).
ESC Committee for Practice Guidelines: Jeroen J. Bax (Chairperson) (The Netherlands), Angelo Auricchio (Switzerland), Helmut Baumgartner (Germany), Claudio Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai (Israel), Arno Hoes (The Netherlands), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh (UK), Cyril Moulin (France), Don Poldermans (The Netherlands), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes (Norway), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland). Document Reviewers: Stephan Windecker (CPG Review Coordinator) (Switzerland), Stephan Achenbach (Germany), Lina Badimon (Spain), Michel Bertrand (France), Hans Erik Btker (Denmark), Jean-Philippe Collet (France), Filippo Crea, (Italy), Nicolas Danchin (France), Erling Falk (Denmark), John Goudevenos (Greece), Dietrich Gulba (Germany), Rainer Hambrecht (Germany), Joerg Herrmann (USA), Adnan Kastrati (Germany), Keld Kjeldsen (Denmark), Steen Dalby Kristensen (Denmark), Patrizio Lancellotti (Belgium), Julinda Mehilli (Germany), Bela Merkely (Hungary), Gilles Montalescot (France), Franz-Josef Neumann (Germany), Ludwig Neyses (UK), Joep Perk (Sweden), Marco Rof (Switzerland), Francesco Romeo (Italy), Mikhail Ruda (Russia), Eva Swahn (Sweden), Marco Valgimigli (Italy), Christiaan JM Vrints (Belgium), Petr Widimsky (Czech Republic).
* Corresponding authors. Christian W. Hamm, Kerckhoff Heart and Thorax Center, Benekestr. 2 8, 61231 Bad Nauheim, Germany. Tel: +49 6032 996 2202, Fax: +49 6032 996 2298, E-mail: [email protected]. Jean-Pierre Bassand, Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, 25000 Besancon, France. Tel: +33 381 668 539, Fax: +33 381 668 582, E-mail: [email protected]
ESC entities having participated in the development of this document: Associations: Heart Failure Association, European Association of Percutaneous Cardiovascular Interventions, European Association for Cardiovascular Prevention & Rehabilitation. Working Groups: Working Group on Cardiovascular Pharmacology and Drug Therapy, Working Group on Thrombosis, Working Group on Cardiovascular Surgery, Working Group on Acute Cardiac Care, Working Group on Atherosclerosis and Vascular Biology, Working Group on Coronary Pathophysiology and Microcirculation. Councils: Council on Cardiovascular Imaging, Council for Cardiology Practice. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC. Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and, where appropriate and necessary, the patients guardian or carer. It is also the health professionals responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

& The European Society of Cardiology 2011. All rights reserved. For permissions please email: [email protected].

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ESC Guidelines

The disclosure forms of the authors and reviewers are available on the ESC website www.escardio.org/guidelines

Keywords Acute coronary syndrome Angioplasty Aspirin Bivalirudin Bypass surgery Chest pain unit Clopidogrel Diabetes Enoxaparin European Society of Cardiology Fondaparinux Guidelines Heparin Non-STelevation myocardial infarction Prasugrel Stent Ticagrelor Troponin Unstable angina

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Table of Contents
Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . 1. Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Epidemiology and natural history . . . . . . . . . . . . . . 2.2. Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . 3. Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Clinical presentation . . . . . . . . . . . . . . . . . . . . . . . 3.2. Diagnostic tools . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Physical examination . . . . . . . . . . . . . . . . . . . . 3.2.2. Electrocardiogram . . . . . . . . . . . . . . . . . . . . . 3.2.3. Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.4. Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Differential diagnoses . . . . . . . . . . . . . . . . . . . . . . 4. Prognosis assessment . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Clinical risk assessment . . . . . . . . . . . . . . . . . . . . . 4.2. Electrocardiogram indicators . . . . . . . . . . . . . . . . . 4.3. Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4. Risk scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.5. Long-term risk . . . . . . . . . . . . . . . . . . . . . . . . . . 5. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Anti-ischaemic agents . . . . . . . . . . . . . . . . . . . . . . 5.2. Antiplatelet agents . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1. Aspirin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2. P2Y12 receptor inhibitors . . . . . . . . . . . . . . . . 5.2.2.1. Clopidogrel . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2.2. Prasugrel . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2.3. Ticagrelor . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2.4. Withholding P2Y12 inhibitors for surgery . . . . . 5.2.2.5. Withdrawal of chronic dual antiplatelet therapy 5.2.3. Glycoprotein IIb/IIIa receptor inhibitors . . . . . . . 5.3. Anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1. Indirect inhibitors of the coagulation cascade . . . 5.3.1.1. Fondaparinux . . . . . . . . . . . . . . . . . . . . . . . 5.3.1.2. Low molecular weight heparins . . . . . . . . . . . 5.3.1.3. Unfractionated heparin . . . . . . . . . . . . . . . . . 5.3.2. Direct thrombin inhibitors (bivalirudin) . . . . . . . 5.3.3. Anticoagulants under clinical investigation . . . . . . 5.3.4. Combination of anticoagulation and antiplatelet treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4. Coronary revascularization . . . . . . . . . . . . . . . . . . 5.4.1. Invasive versus conservative approach . . . . . . . . 5.4.2. Timing of angiography and intervention . . . . . . . 5.4.3. Percutaneous coronary intervention versus coronary artery bypass surgery . . . . . . . . . . . . 5.4.4. Coronary artery bypass surgery . . . . . . . . . . . . 5.4.5. Percutaneous coronary intervention technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 4 5 6 6 6 6 7 7 7 7 8 9 10 10 10 10 11 14 14 14 15 15 16 16 18 18 19 21 21 23 23 23 25 26 27 27 5.5. Special populations and conditions . . . . . . . . . . . . . . 5.5.1. The elderly . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.2. Gender issues . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.3. Diabetes mellitus . . . . . . . . . . . . . . . . . . . . . . . 5.5.4. Chronic kidney disease . . . . . . . . . . . . . . . . . . . 5.5.5. Left ventricular systolic dysfunction and heart failure 5.5.6. Extreme body weights . . . . . . . . . . . . . . . . . . . 5.5.7. Non-obstructive coronary artery disease . . . . . . . 5.5.8. Anaemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.5.9. Bleeding and transfusion . . . . . . . . . . . . . . . . . . 5.5.10. Thrombocytopenia . . . . . . . . . . . . . . . . . . . . . 5.6. Long-term management . . . . . . . . . . . . . . . . . . . . . Performance measures . . . . . . . . . . . . . . . . . . . . . . . . . . Management strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 32 32 33 35 36 37 37 37 38 40 40 42 43 46 46

6. 7. 8. 9.

Abbreviations and acronyms

ABOARD Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention American College of Cardiology angiotensin-converting enzyme acute coronary syndromes activated clotting time Acute Catheterization and Urgent Intervention Triage strategY atrial brillation American Heart Association Apixaban for Prevention of Acute Ischemic Events activated partial thromboplastin time angiotensin receptor blocker Academic Research Consortium Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Aspirin With or Without Thienopyridine Therapy in Subjects with Acute Coronary Syndrome Bypass Angioplasty Revascularization Investigation 2 Diabetes bare-metal stent brain natriuretic peptide coronary bypass graft coronary artery disease condence interval

ACC ACE ACS ACT ACUITY AF AHA APPRAISE aPTT ARB ARC ATLAS

. 28 . 29 . 29 . 29 . . . 30 30 31

BARI-2D BMS BNP CABG CAD CI

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CK CKD CK-MB COX CMR COMMIT

creatinine kinase chronic kidney disease creatinine kinase myocardial band cyclo-oxygenase cardiac magnetic resonance Clopidogrel and Metoprolol in Myocardial Infarction Trial CPG Committee for Practice Guidelines CrCl creatinine clearance CRP C-reactive protein CRUSADE Can Rapid risk stratication of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines CT computed tomography CURE Clopidogrel in Unstable Angina to Prevent Recurrent Events CURRENT Clopidogrel Optimal Loading Dose Usage to Reduce Recurrent Events CYP cytochrome P450 DAPT dual (oral) antiplatelet therapy DAVIT Danish Study Group on Verapamil in Myocardial Infarction Trial DES drug-eluting stent DTI direct thrombin inhibitor DIGAMI Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction EARLY-ACS Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndrome ECG electrocardiogram eGFR estimated glomerular ltration rate ELISA Early or Late Intervention in unStable Angina ESC European Society of Cardiology Factor Xa activated factor X FFR fractional ow reserve FRISC Fragmin during Instability in Coronary Artery Disease GP IIb/IIIa glycoprotein IIb/IIIa GRACE Global Registry of Acute Coronary Events HINT Holland Interuniversity Nifedipine/Metoprolol Trial HIT heparin-induced thrombocytopenia HORIZONS Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction HR hazard ratio hsCRP high-sensitivity C-reactive protein ICTUS Invasive vs. Conservative Treatment in Unstable coronary Syndromes INR international normalized ratio INTERACT Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment ISAR-COOL Intracoronary Stenting With Antithrombotic Regimen Cooling Off ISARIntracoronary stenting and Antithrombotic RegimenREACT Rapid Early Action for Coronary Treatment i.v. intravenous LDL-C low-density lipoprotein cholesterol LMWH low molecular weight heparin LV left ventricular

LVEF MB MDRD MERLIN

left ventricular ejection fraction myocardial band Modication of Diet in Renal Disease Metabolic Efciency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes MI myocardial infarction MINAP Myocardial Infarction National Audit Project MRI magnetic resonance imaging NNT numbers needed to treat NSAID non-steroidal anti-inammatory drug NSTE-ACS non-ST-elevation acute coronary syndromes NSTEMI non-ST-elevation myocardial infarction NT-proBNP N-terminal prohormone brain natriuretic peptide OASIS Organization to Assess Strategies for Ischaemic Syndromes OPTIMA Optimal Timing of PCI in Unstable Angina OR odds ratio PCI percutaneous coronary intervention PENTUA Pentasaccharide in Unstable Angina PLATO PLATelet inhibition and patient Outcomes PURSUIT Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy RCT randomized controlled trial RE-DEEM Randomized Dabigatran Etexilate Dose Finding Study In Patients With Acute Coronary Syndromes (ACS) Post Index Event With Additional Risk Factors For Cardiovascular Complications Also Receiving Aspirin And Clopidogrel REPLACE-2 Randomized Evaluation of PCI Linking Angiomax to reduced Clinical Events RIKS-HIA Register of Information and Knowledge about Swedish Heart Intensive care Admissions RITA Research Group in Instability in Coronary Artery Disease trial RR relative risk RRR relative risk reduction STE-ACS ST-elevation acute coronary syndrome STEMI ST-elevation myocardial infarction SYNERGY Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors trial SYNTAX SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery TACTICS Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy TARGET Do Tiroban and ReoPro Give Similar Efcacy Outcomes Trial TIMACS Timing of Intervention in Patients with Acute Coronary Syndromes TIMI Thrombolysis In Myocardial Infarction TRITON TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with PrasugrelThrombolysis In Myocardial Infarction UFH unfractionated heparin VKA vitamin K antagonist VTE venous thrombo-embolism

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ESC Guidelines

Table 1

Classes of recommendations
Denition Evidence and/or general agreement that a given treatment or procedure is benecial, useful, effective. Conicting evidence and/or a divergence of opinion about the usefulness/efcacy of the given treatment or procedure. Suggested wording to use Is recommended/is indicated

Classes of recommendations Class I

Class II

Class IIa Class IIb

Class III

Weight of evidence/opinion is in favour of usefulness/efcacy. Usefulness/efcacy is less well established by evidence/opinion.

Evidence or general agreement that the given treatment or procedure is not useful/effective, and in some cases may be harmful.

Should be considered May be considered Is not recommended

Table 2

Levels of evidence
Data derived from multiple randomized clinical trials or meta-analyses. Data derived from a single randomized clinical trial or large non-randomized studies. Consensus of opinion of the experts and/ or small studies, retrospective studies, registries.

Level of Evidence A Level of Evidence B Level of Evidence C

1. Preamble
Guidelines summarize and evaluate all available evidence, at the time of the writing process, on a particular issue with the aim of assisting physicians in selecting the best management strategies for an individual patient, with a given condition, taking into account the impact on outcome, as well as the risk benet ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes but are complements for textbooks and cover the European Society of Cardiology (ESC) Core Curriculum topics. Guidelines and recommendations should help the physicians to make decisions in their daily practice. However, the nal decisions concerning an individual patient must be made by the responsible physician(s). A great number of Guidelines have been issued in recent years by the ESC as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for the development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines can be found on the ESC website (http://www.escardio.org/guidelines-surveys/esc-guidelines/about/

Pages/rules-writing.aspx). ESC Guidelines represent the ofcial position of the ESC on a given topic and are regularly updated. Members of this Task Force were selected by the ESC to represent professionals involved with the medical care of patients with this pathology. Selected experts in the eld undertook a comprehensive review of the published evidence for diagnosis, management, and/or prevention of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed including assessment of the risk benet ratio. Estimates of expected health outcomes for larger populations were included, where data exist. The level of evidence and the strength of recommendation of particular treatment options were weighed and graded according to pre-dened scales, as outlined in Tables 1 and 2. The experts of the writing and reviewing panels lled in declarations of interest forms of all relationships which might be perceived as real or potential sources of conicts of interest. These forms were compiled into one le and can be found on the ESC website (http://www.escardio.org/guidelines). Any changes in declarations of interest that arise during the writing period must be notied to the ESC and updated. The Task Force received its entire nancial support from the ESC without any involvement from the healthcare industry. The ESC CPG supervises and coordinates the preparation of new Guidelines produced by Task Forces, expert groups, or consensus panels. The Committee is also responsible for the endorsement process of these Guidelines. The ESC Guidelines undergo extensive review by the CPG and external experts. After appropriate revisions, it is approved by all of the experts involved in the Task Force. The nalized document is approved by the CPG for publication in the European Heart Journal. The task of developing ESC Guidelines covers not only the integration of the most recent research, but also the creation of educational tools and implementation programmes for the

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recommendations. To implement the guidelines, condensed pocket guidelines versions, summary slides, booklets with essential messages, and an electronic version for digital applications (smartphones, etc.) are produced. These versions are abridged and, thus, if needed, one should always refer to the full text version, which is freely available on the ESC website. The National Societies of the ESC are encouraged to endorse, translate, and implement the ESC Guidelines. Implementation programmes are needed because it has been shown that the outcome of disease may be favourably inuenced by the thorough application of clinical recommendations. Surveys and registries are needed to verify that real-life daily practice is in keeping with what is recommended in the guidelines, thus completing the loop between clinical research, writing of guidelines, and implementing them in clinical practice. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with that patient, and, where appropriate and necessary, the patients guardian or carer. It is also the health professionals responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

2. Introduction
Cardiovascular diseases are currently the leading cause of death in industrialized countries and are expected to become so in emerging countries by 2020.1 Among these, coronary artery disease (CAD) is the most prevalent manifestation and is associated with high mortality and morbidity. The clinical presentations of CAD include silent ischaemia, stable angina pectoris, unstable angina, myocardial infarction (MI), heart failure, and sudden death. Patients with chest pain represent a very substantial proportion of all acute medical hospitalizations in Europe. Distinguishing patients with acute coronary syndromes (ACS) within the very large proportion with suspected cardiac pain are a diagnostic challenge, especially in individuals without clear symptoms or electrocardiographic features. Despite modern treatment, the rates of death, MI, and readmission of patients with ACS remain high. It is well established that ACS in their different clinical presentations share a widely common pathophysiological substrate. Pathological, imaging, and biological observations have demonstrated that atherosclerotic plaque rupture or erosion, with differing degrees of superimposed thrombosis and distal embolization,

Admission

Chest Pain

Working diagnosis

Acute Coronary Syndrome

ECG

persistent ST-elevation

ST/T abnormalities

normal or undetermined ECG

Bio-chemistry

troponin rise/fall

troponin normal

Diagnosis

STEMI

NSTEMI

Unstable Angina

Figure 1 The spectrum of ACS. ECG electrocardiogram; NSTEMI non-ST-elevation myocardial infarction; STEMI ST-elevation myocardial infarction.

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resulting in myocardial underperfusion, form the basic pathophysiological mechanisms in most conditions of ACS. As this may be a life-threatening state of atherothrombotic disease, criteria for risk stratication have been developed to allow the clinician to make timely decisions on pharmacological management as well as coronary revascularization strategies, tailored to the individual patient. The leading symptom that initiates the diagnostic and therapeutic cascade is chest pain, but the classication of patients is based on the electrocardiogram (ECG). Two categories of patients may be encountered: 1. Patients with acute chest pain and persistent (>20 min) ST-segment elevation. This is termed ST-elevation ACS (STE-ACS) and generally reects an acute total coronary occlusion. Most of these patients will ultimately develop an ST-elevation MI (STEMI). The therapeutic objective is to achieve rapid, complete, and sustained reperfusion by primary angioplasty or brinolytic therapy. 2. Patients with acute chest pain but without persistent ST-segment elevation. These patients have rather persistent or transient ST-segment depression or T-wave inversion, at T waves, pseudo-normalization of T waves, or no ECG changes at presentation. The initial strategy in these patients is to alleviate ischaemia and symptoms, to monitor the patient with serial ECGs, and to repeat measurements of markers of myocardial necrosis. At presentation, the working diagnosis of non-ST-elevation ACS (NSTE-ACS), based on the measurement of troponins, will be further qualied as non-ST-elevation MI (NSTEMI) or unstable angina (Figure 1). In a certain number of patients, coronary heart disease will subsequently be excluded as the cause of symptoms.

ESC Guidelines

similar in both conditions (12% and 13%, respectively).4,6,7 Longterm follow-up showed that death rates were higher among patients with NSTE-ACS than with STE-ACS, with a two-fold difference at 4 years.8 This difference in mid- and long-term evolution may be due to different patient proles, since NSTE-ACS patients tend to be older, with more co-morbidities, especially diabetes and renal failure. The lessons from epidemiological observations are that treatment strategies for NSTE-ACS not only need to address the acute phase but with the same intensity impact on longer term management. Further data regarding the epidemiology and natural history of NSTE-ACS have been presented in the previous guidelines3 and are also covered in The ESC Textbook of Cardiovascular Medicine.9

2.2 Pathophysiology
ACS represents a life-threatening manifestation of atherosclerosis. It is usually precipitated by acute thrombosis induced by a ruptured or eroded atherosclerotic coronary plaque, with or without concomitant vasoconstriction, causing a sudden and critical reduction in blood ow. In the complex process of plaque disruption, inammation was revealed as a key pathophysiological element. In rare cases, ACS may have a non-atherosclerotic aetiology such as arteritis, trauma, dissection, thrombo-embolism, congenital anomalies, cocaine abuse, or complications of cardiac catheterization. The key pathophysiological concepts such as vulnerable plaque, coronary thrombosis, vulnerable patient, endothelial dysfunction, accelerated atherothrombosis, secondary mechanisms of NSTE-ACS, and myocardial injury have to be understood for the correct use of the available therapeutic strategies. The lesions predicting ACS are usually angiographically mild, characterized by a thin-cap broatheroma, by a large plaque burden, or by a small luminal area, or some combination of these characteristics.10 These are described in more detail in the previous guidelines3 as well as in The ESC Textbook of Cardiovascular Medicine.9

The management of patients with STEMI is addressed in the ESC Guidelines for management of STE-ACS.2 The present document deals with the management of patients with suspected NSTE-ACS, replacing the document rst published in 2000 and updated in 2002 and 2007.3 It includes all scientic evidence fully published as peer-reviewed papers, before May 2011. The class A level of evidence in this document is based primarily on randomized, double-blind studies of adequate size using contemporary adjunctive treatment and endpoints that are not subject to observer bias, such as death and MI. These studies were considered to represent the greatest weight of evidence. Studies that were randomized, but not double blind, and/or studies using less robust endpoints (e.g. refractory ischaemia or need for revascularization) were considered to confer a lower weight of evidence. If only smaller studies were available, meta-analyses were used. However, even the largest controlled trials do not cover all aspects seen in real life. Therefore, some recommendations are derived from subset analyses of larger trials, in the absence of sufciently powered independent studies.

3. Diagnosis
The leading symptom of ACS is typically chest pain. The working diagnosis of NSTE-ACS is a rule-out diagnosis based on the ECG, i.e. lack of persistent ST elevation. Biomarkers (troponins) further distinguish NSTEMI and unstable angina. Imaging modalities are used to rule out or rule in differential diagnoses. Diagnosis nding and risk stratication are closely linked (see Section 4).

3.1 Clinical presentation

The clinical presentation of NSTE-ACS encompasses a wide variety of symptoms. Traditionally, several clinical presentations have been distinguished: Prolonged (.20 min) anginal pain at rest; New onset (de novo) angina (Class II or III of the Classication of the Canadian Cardiovascular Society11); Recent destabilization of previously stable angina with at least Canadian Cardiovascular Society Class III angina characteristics (crescendo angina); or Post-MI angina.

2.1 Epidemiology and natural history

Registry data consistently show that NSTE-ACS is more frequent than STE-ACS.4 The annual incidence is 3 per 1000 inhabitants, but varies between countries.5 Hospital mortality is higher in patients with STEMI than among those with NSTE-ACS (7% vs. 3 5%, respectively), but at 6 months the mortality rates are very

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medical services in the pre-hospital setting) and immediately interpreted by a qualied physician.17 The characteristic ECG abnormalities of NSTE-ACS are ST-segment depression or transient elevation and/or T-wave changes.6,18 The nding of persistent (.20 min) ST-elevation suggests STEMI, which mandates different treatment.2 If the initial ECG is normal or inconclusive, additional recordings should be obtained if the patient develops symptoms and these should be compared with recordings obtained in an asymptomatic state.18 Comparison with a previous ECG, if available, is valuable, particularly in patients with co-existing cardiac disorders such as LV hypertrophy or a previous MI. ECG recordings should be repeated at least at (3 h) 69 h and 24 h after rst presentation, and immediately in the case of recurrence of chest pain or symptoms. A pre-discharge ECG is advisable. It should be appreciated that a completely normal ECG does not exclude the possibility of NSTE-ACS. In particular, ischaemia in the territory of the circumex artery or isolated right ventricular ischaemia frequently escapes the common 12-lead ECG, but may be detected in leads V7 V9 and in leads V3R and V4R, respectively.18 Transient episodes of bundle branch block occasionally occur during ischaemic attacks. The standard ECG at rest does not adequately reect the dynamic nature of coronary thrombosis and myocardial ischaemia. Almost two-thirds of all ischaemic episodes in the phase of instability are clinically silent, and hence are unlikely to be detected by a conventional ECG. Accordingly, online continuous computer-assisted 12-lead ST-segment monitoring is also a valuable diagnostic tool. 3.2.3 Biomarkers Cardiac troponins play a central role in establishing a diagnosis and stratifying risk, and make it possible to distinguish between NSTEMI and unstable angina. Troponins are more specic and sensitive than the traditional cardiac enzymes such as creatine kinase (CK), its isoenzyme MB (CK-MB), and myoglobin. Elevation of cardiac troponins reects myocardial cellular damage, which in NSTE-ACS may result from distal embolization of platelet-rich thrombi from the site of a ruptured or eroded plaque. Accordingly, troponin may be seen as a surrogate marker of active thrombus formation.19 In the setting of myocardial ischaemia (chest pain, ECG changes, or new wall motion abnormalities), troponin elevation indicates MI.18 In patients with MI, an initial rise in troponins occurs within 4 h after symptom onset. Troponins may remain elevated for up to 2 weeks due to proteolysis of the contractile apparatus. In NSTE-ACS, minor troponin elevations usually resolve within 48 72 h. There is no fundamental difference between troponin T and troponin I. Differences between study results are explained by varying inclusion criteria, variances in sampling patterns, and the use of assays with different diagnostic cut-offs. In the clinical setting, a test with high ability to rule out (negative predictive value) and correctly diagnose ACS (positive predictive value) is of paramount interest. The diagnostic cut-off for MI is dened as a cardiac troponin measurement exceeding the 99th percentile of a normal reference population (upper reference limit) using an assay with an imprecision (coefcient of variation) of 10% at the upper reference limit.18 The value of this cut-off has been substantiated in several studies.20,21 Many of the earlier generation troponin

Prolonged pain is observed in 80% of patients, while de novo or accelerated angina is observed in the remaining 20%.12 The typical clinical presentation of NSTE-ACS is retrosternal pressure or heaviness (angina) radiating to the left arm, neck, or jaw, which may be intermittent (usually lasting for several minutes) or persistent. These complaints may be accompanied by other symptoms such as diaphoresis, nausea, abdominal pain, dyspnoea, and syncope. However, atypical presentations are not uncommon.13 These include epigastric pain, indigestion, stabbing chest pain, chest pain with some pleuritic features, or increasing dyspnoea. Atypical complaints are more often observed in older (.75 years) patients, in women, and in patients with diabetes, chronic renal failure, or dementia.13,14 Absence of chest pain leads to under-recognition and under-treatment of the disease.15 The diagnostic and therapeutic challenges arise especially when the ECG is normal or nearly normal, or conversely when the ECG is abnormal at baseline due to underlying conditions such as intraventricular conduction defects or left ventricular (LV) hypertrophy.16 Certain features, in terms of the symptoms, may support the diagnosis of CAD and guide patient management. The exacerbation of symptoms by physical exertion, or their relief at rest or after the administration of nitrates, supports a diagnosis of ischaemia. It is important to identify clinical circumstances that may exacerbate or precipitate NSTE-ACS, such as anaemia, infection, inammation, fever, and metabolic or endocrine (in particular thyroid) disorders. When faced with a symptomatic patient, the presence of several clinical ndings increases the probability of CAD and therefore NSTE-ACS. These include older age, male sex, a positive family history, and known atherosclerosis in non-coronary territories, such as peripheral or carotid artery disease. The presence of risk factors, in particular diabetes mellitus and renal insufciency as well as prior manifestation of CAD [i.e. previous MI, percutaneous intervention (PCI), or coronary bypass graft (CABG) surgery], also raises the likelihood of NSTE-ACS.

3.2 Diagnostic tools

3.2.1 Physical examination The physical examination is frequently normal. Signs of heart failure or haemodynamic instability must prompt the physician to expedite diagnosis and treatment. An important goal of the physical examination is to exclude non-cardiac causes of chest pain and non-ischaemic cardiac disorders (e.g. pulmonary embolism, aortic dissection, pericarditis, valvular heart disease) or potentially extracardiac causes such as acute pulmonary diseases (e.g. pneumothorax, pneumonia, or pleural effusion). In this regard, differences in blood pressure between the upper and lower limbs, an irregular pulse, heart murmurs, a friction rub, pain on palpation, and abdominal masses are physical ndings that may suggest a diagnosis other than NSTE-ACS. Other physical ndings such as pallor, increased sweating, or tremor may point towards precipitating conditions such as anaemia and thyrotoxicosis. 3.2.2 Electrocardiogram The resting 12-lead ECG is the rst-line diagnostic tool in the assessment of patients with suspected NSTE-ACS. It should be obtained within 10 min after rst medical contact (either on arrival of the patient in the emergency room or at rst contact with emergency

Page 8 of 56

ESC Guidelines

Table 3 Possible non-acute coronary syndrome causes of troponin elevation (bold: important differential diagnoses)
Chronic or acute renal dysfunction Severe congestive heart failure acute and chronic Hypertensive crisis Tachy- or bradyarrhythmias Pulmonary embolism, severe pulmonary hypertension Inammatory diseases, e.g. myocarditis Acute neurological disease, including stroke, or subarachnoid haemorrhage Aortic dissection, aortic valve disease or hypertrophic cardiomyopathy Cardiac contusion, ablation, pacing, cardioversion, or endomyocardial biopsy Hypothyroidism Apical ballooning syndrome (Tako-Tsubo cardiomyopathy) Inltrative diseases, e.g. amyloidosis, haemochromatosis, sarcoidosis, sclerodermia Drug toxicity, e.g. adriamycin, 5-uorouracil, herceptin, snake venoms Burns, if affecting >30% of body surface area Rhabdomyolysis Critically ill patients, especially with respiratory failure, or sepsis

Other life-threatening conditions presenting with chest pain, such as dissecting aortic aneurysm or pulmonary embolism, may also result in elevated troponins and should always be considered as differential diagnoses. Elevation of cardiac troponins also occurs in the setting of non-coronary-related myocardial injury (Table 3). This reects the sensitivity of the marker for myocardial cell injury and should not be labelled as a false positive. False-positive results have been documented in the setting of skeletal myopathies or chronic renal failure. Troponin elevation is frequently found when the serum creatinine level is .2.5 mg/dL (221 mmol/L) in the absence of proven ACS, and is also associated with an adverse prognosis.28,29 Point-of-care (bedside) biomarker testing It is most important to establish the diagnosis of NSTE-ACS rapidly and to assign appropriate treatment. Point-of-care tests allow measurement of biomarkers at minimal turnaround times.30 Point-of-care tests for troponins should be implemented when a central laboratory cannot consistently provide test results within 60 min.31 No special skill or prolonged training is required to read the results of these assays. Accordingly, these tests can be performed by various members of the healthcare team after adequate training. However, reading of these mostly qualitative tests is performed visually and is therefore observer dependent. Optical reading devices for the emergency room setting that give quantitative results are also available. The tests are usually reliable when positive. However, in the presence of a remaining suspicion of unstable CAD, negative tests should be repeated at a later time and veried by a dedicated laboratory. A rapid rule-out protocol (2 h) by using a point-of-care biomarker test, a risk score, and ECG was recently shown to be safe in identifying a low risk group.32 3.2.4 Imaging Non-invasive imaging techniques Among non-invasive imaging techniques, echocardiography is the most important modality in the acute setting because it is rapidly and widely available. LV systolic function is an important prognostic variable in patients with CAD and can be easily and accurately assessed by echocardiography. In experienced hands, transient segmental hypokinesia or akinesia may be detected during ischaemia. Furthermore, differential diagnoses such as aortic dissection, pulmonary embolism, aortic stenosis, hypertrophic cardiomyopathy, or pericardial effusion may be identied.33 Therefore, echocardiography should be routinely available in emergency rooms or chest pain units, and used in all patients. In patients with non-diagnostic 12-lead ECGs and negative cardiac biomarkers but suspected ACS, stress imaging may be performed, provided the patient is free of chest pain. Various studies have used stress echocardiography, showing high negative predictive values and/or excellent outcome in the presence of a normal stress echocardiogram.34 Cardiac magnetic resonance (CMR) imaging can integrate assessment of function and perfusion, and detection of scar tissue in one session, but this imaging technique is not yet widely available. Various studies have demonstrated the usefulness of magnetic resonance imaging (MRI) to exclude or detect ACS.35 In addition, CMR imaging is useful to assess myocardial viability and to detect myocarditis.

T and troponin I assays do not full the precision criteria. Recently, high-sensitivity or ultrasensitive assays have been introduced that have a 10- to 100-fold lower limit of detection and full the requirements of analytical precision. Therefore, MI can now be detected more frequently and earlier in patients presenting with chest pain.20,21 The superiority of these new assays, particularly in the early phase of pain onset, was prospectively demonstrated.20,21 The negative predictive value for MI with a single test on admission is .95% and thereby at least as high as with previous assays achieved only by serial measurements. Only very early presenters may escape detection. By including a second sample within 3 h of presentation the sensitivity for MI approaches 100%.22,23 Owing to the improved analytical sensitivity, low troponin levels can now also be detected in many patients with stable angina24,25 and in healthy individuals.26 The underlying mechanisms of this troponin release are not yet sufciently explained, but any measurable troponin is associated with an unfavourable prognosis.24 In order to maintain specicity for MI, there is now an emerging need to distinguish chronic from acute troponin elevation. Therefore, the magnitude of change depending on the initial value gains importance to differentiate acute from chronic myocardial damage. The relevant change in levels from baseline is still debated. In particular at borderline levels, the change must exceed the natural biological variation and needs to be dened for each assay.27

ESC Guidelines

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with multivessel disease as well as those with left main stenosis are at the highest risk of serious cardiac events. Coronary angiography in conjunction with ECG ndings and regional wall motion abnormalities frequently allows identication of the culprit lesion. Typical angiographic features are eccentricity, irregular borders, ulceration, haziness, and lling defects suggestive of the presence of intracoronary thrombus. In lesions whose severity is difcult to assess, intravascular ultrasound or fractional ow reserve (FFR) measurements carried out .5 days after the index event44 are useful in order to decide on the treatment strategy. The choice of vascular access site depends on operator expertise and local preference, but, due to the large impact of bleeding complications on clinical outcome in patients with elevated bleeding risk, the choice may become important. Since the radial approach has been shown to reduce the risk of bleeding when compared with the femoral approach, this access site should be preferred in patients at high risk of bleeding provided the operator has sufcient experience with this technique. The radial approach has a lower risk of large haematomas at the price of higher radiation dose for the patient and the staff.45 The femoral approach may be preferred in haemodynamically compromised patients to facilitate the use of intra-aortic balloon counterpulsation.

Similarly, nuclear myocardial perfusion imaging has been shown to be useful, but is also not widely available on 24 h service. Rest myocardial scintigraphy was shown to be helpful for initial triage of patients presenting with chest pain without ECG changes or evidence of ongoing ischaemia or MI.36 A stressrest study has the advantage that it also provides information on inducible ischaemia. Multidetector computed tomography (CT) is not currently used for the detection of ischaemia, but offers direct visualization of the coronary arteries. Therefore, this technique has the potential to exclude the presence of CAD. Various studies reported high negative predictive values and/or excellent outcome in the presence of a normal scan.37 41 Accordingly, CT angiography, if available at a sufcient level of expertise, may be useful to exclude ACS or other causes of chest pain. Invasive imaging (coronary angiography) Coronary angiography provides unique information on the presence and severity of CAD and therefore remains the gold standard. It is recommended to perform angiograms before and after intracoronary administration of vasodilators (nitrates) in order to attenuate vasoconstriction and offset the dynamic component that is frequently present in ACS. In haemodynamically compromised patients (e.g. with pulmonary oedema, hypotension, or severe lifethreatening arrhythmias) it may be advisable to perform the examination after placement of an intra-aortic balloon pump, to limit the number of coronary injections, and to abstain from LV angiography. Angiography should be performed urgently for diagnostic purposes in patients at high risk and in whom the differential diagnosis is unclear (see Section 5.4). The identication of acute thrombotic occlusions (e.g. circumex artery) is particularly important in patients with ongoing symptoms or relevant troponin elevation but in the absence of diagnostic ECG changes. Data from the Thrombolysis In Myocardial Infarction (TIMI)-3B42 and Fragmin during Instability in Coronary Artery Disease-2 (FRISC-2)43 studies show that 30 38% of patients with unstable coronary syndromes have single-vessel disease and 4459% have multivessel disease (.50% diameter stenosis). The incidence of left main narrowing varies from 4% to 8%. Patients

3.3 Differential diagnoses

Several cardiac and non-cardiac conditions may mimic NSTE-ACS (Table 4). Underlying chronic conditions such as hypertrophic cardiomyopathy and valvular heart disease (i.e. aortic stenosis or aortic regurgitation) may be associated with typical symptoms of NSTE-ACS, elevated cardiac biomarkers, and ECG changes.46 Sometimes paroxysmal atrial brillation (AF) mimics ACS. Since some of these patients also have CAD, the diagnostic process can be difcult. Myocarditis, pericarditis, or myopericarditis of different aetiologies may be associated with chest pain that resembles the typical angina of NSTE-ACS, and can be associated with a rise in cardiac biomarker levels, ECG changes, and wall motion abnormalities. A u-like, febrile condition with symptoms attributed to the upper respiratory tract often precedes or accompanies these conditions. However, infections, especially of the upper respiratory tract, also

Table 4

Cardiac and non-cardiac conditions that can mimic non-ST-elevation acute coronary syndomes
Cardiac Pulmonary Pulmonary embolism Pulmonary infarction Pneumonia Pleuritis Pneumothorax Haematological Sickle cell crisis Anaemia Vascular Aortic dissection Aortic aneurysm Gastro-intestinal Oesophageal spasm Oesophagitis Orthopaedic/ infectious Cervical discopathy Rib fracture Muscle injury/ inammation Costochondritis

Myocarditis Pericarditis Cardiomyopathy Valvular disease Tako-Tsubo cardiomyopathy Cardiac trauma

Cerebrovascular disease Peptic ulcer Pancreatitis

Cholecystitis

Herpes zoster

Page 10 of 56
often precede or accompany NSTE-ACS. The denitive diagnosis of myocarditis or myopericarditis may frequently only be established during the course of hospitalization. Non-cardiac life-threatening conditions must be ruled out. Among these, pulmonary embolism may be associated with dyspnoea, chest pain, and ECG changes, as well as elevated levels of cardiac biomarkers similar to those of NSTE-ACS. D-dimer levels, echocardiography, and CT are the preferred diagnostic tests. MRI angiography of the pulmonary arteries may be used as an alternative imaging technique, if available. Aortic dissection is the other condition to be considered as an important differential diagnosis. NSTE-ACS may be a complication of aortic dissection when the dissection involves the coronary arteries. Furthermore, stroke may be accompanied by ECG changes, wall motion abnormalities, and a rise in cardiac biomarker levels. Conversely, atypical symptoms such as headache and vertigo may in rare cases be the sole presentation of myocardial ischaemia.

ESC Guidelines

4. Prognosis assessment
NSTE-ACS is an unstable coronary condition prone to ischaemic recurrences and other complications that may lead to death or MI in the short and long term. The management, which includes antiischaemic and antithrombotic pharmacological treatments as well as various strategies for coronary revascularization, is directed to prevent or reduce such complications and to improve outcomes. The timing and intensity of these interventions should be tailored to an individual patients risk. As many treatment options increase the risk of haemorrhagic complications, this needs to be carefully balanced on an individual basis. Since the spectrum of risk associated with NSTE-ACS is wide and particularly high in the early hours, risk must be carefully assessed immediately after rst medical contact. Risk assessment is a continuous process until hospital discharge that may modify the treatment strategy at any time. Dedicated chest pain units or coronary care units may improve care of ACS patients.47 Even after discharge, the NSTE-ACS patient remains at elevated risk and deserves special attention.

and extent of ECG changes.52,53 The number of leads showing ST depression and the magnitude of ST depression are indicative of the extent and severity of ischaemia and correlate with prognosis.52 ST-segment depression 0.05 mV in two or more contiguous leads, in the appropriate clinical context, is suggestive of NSTE-ACS and linked to prognosis. Minor (0.05 mV) ST depression may be difcult to measure in clinical practice. More relevant is ST depression of .0.1 mV, which is associated with an 11% rate of death and MI at 1 year. ST depression of .0.2 mV carries about a six-fold increased mortality risk.53 ST depression combined with transient ST elevation identies an even higher risk subgroup. Patients with ST depression have a higher risk for subsequent cardiac events compared with those with isolated T-wave inversion (.0.1 mV) in leads with predominant R waves, who in turn have a higher risk than those with a normal ECG on admission. Some studies have cast doubt on the prognostic value of isolated T-wave inversion. However, deep symmetrical inversion of the T waves in the anterior chest leads is often related to a signicant stenosis of the proximal left anterior descending coronary artery or main stem. Other features, such as elevation (.0.1 mV) in lead aVR, have been associated with a high probability of left main or triple-vessel CAD and worse clinical prognosis.53 Stress testing for ischaemia In patients who continue to have typical ischaemic rest pain, no stress test should be performed. However, a stress test for inducible ischaemia has predictive value and is therefore useful before hospital discharge in patients with a non-diagnostic ECG provided there is no pain, no signs of heart failure, and normal biomarkers (repeat testing). Early exercise testing has a high negative predictive value. Parameters reecting myocardial contractile performance provide at least as much prognostic information as those reecting ischaemia, while the combination of these parameters gives the best prognostic information.54,55 Continuous ST-segment monitoring Several studies using continuous ST-segment monitoring revealed that 1530% of patients with NSTE-ACS have transient episodes of ST-segment changes, predominantly ST-segment depression. These patients have an increased risk of subsequent cardiac events, including cardiovascular death.56 ST monitoring adds independent prognostic information to that provided by the ECG at rest, troponins, and other clinical variables.56,57

4.1 Clinical risk assessment

In addition to some universal clinical markers of risk, such as advanced age, diabetes, renal failure, or other co-morbidities, the initial clinical presentation is highly predictive of early prognosis. Symptoms at rest carry a worse prognosis than symptoms elicited only during physical exertion. In patients with intermittent symptoms, an increasing number of episodes preceding the index event also has an impact on outcome. The presence of tachycardia, hypotension, or heart failure upon presentation indicates a poor prognosis and calls for rapid diagnosis and management.48 50 In younger patients presenting with ACS, cocaine use may be considered, which is linked to more extensive myocardial damage and higher rates of complications.51

4.3 Biomarkers
Biomarkers reect different pathophysiological aspects of NSTE-ACS, such as myocardial cell injury, inammation, platelet activation, and neurohormonal activation. Troponin T or I are the preferred biomarkers to predict short-term (30 days) outcome with respect to MI and death.30,58 The prognostic value of troponin measurements has also been conrmed for the long term (1 year and beyond). NSTEMI patients with elevated troponin levels but no rise in CK-MB (who comprise 28% of the NSTEMI population), although undertreated, have a higher risk prole and lower in-hospital mortality than patients with both markers

4.2 Electrocardiogram indicators

The initial ECG presentation is predictive of early risk. Patients with a normal ECG on admission have a better prognosis than those with negative T waves. Patients with ST-segment depression have an even worse prognosis, which is dependent on the severity

ESC Guidelines

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hospital stay are strongly predictive of outcome, and persistently abnormal fasting glucose levels carry a particularly ominous prognosis.67 A number of routine haematological variables are also predictors of worse prognosis. Patients with anaemia have consistently been shown to be at higher risk.69,70 Similarly, higher white blood cell counts or lower platelet counts on admission are associated with worse outcomes.70 Impaired renal function is a strong independent predictor of long-term mortality in ACS patients.60,71 Serum creatinine concentration is a less reliable indicator of renal function than creatinine clearance (CrCl) or estimated glomerular ltration rate (eGFR) because it is affected by a multitude of factors including age, weight, muscle mass, race, and various medications. Several formulae have been devised to improve the accuracy of the serum creatinine level as a surrogate for eGFR, including the CockcroftGault and the abbreviated Modication of Diet in Renal Disease (MDRD) equations. Long-term mortality increases exponentially with decreasing eGFR/CrCl. Novel biomarkers A large number of biomarkers have been tested with the aim of further improving risk assessment as well as earlier exclusion of ACS. Biomarkers more specically reecting vascular inammation processes or markers of oxidative stress have the greatest potential by better reecting the underlying mechanisms. Among these, myeloperoxidase, growth differentiation factor 15, and lipoproteinassociated phospholipase A-2 present promising options.72 75 Early diagnosis of ACS may be improved by measurements of fatty acid-binding protein76 or ischaemia-modied-albumin77 as well as markers of systemic stress (copeptin).78 However, the incremental valueparticularly over highly sensitive troponin testshas not been evaluated, thereby presently precluding any recommendation for routine use.

elevated.59 The increased risk associated with elevated troponin levels is independent of and additive to other risk factors, such as ECG changes at rest or on continuous monitoring, or markers of inammatory activity.60 Furthermore, the identication of patients with elevated troponin levels is also useful for selecting appropriate treatment in patients with NSTE-ACS. However, troponins should not be used as the sole decision criterion, because in-hospital mortality may be as high as 12.7% in certain high risk troponin-negative subgroups.61 Due to low sensitivity for MI, a single negative test on rst contact with the patient is not sufcient for ruling out NSTE-ACS, as in many patients an increase in troponins can be detected only in the subsequent hours. Therefore, repeated measurements after 6 9 h have been advocated.27,30 The recently introduced high-sensitivity troponin assays better identify patients at risk and provide reliable and rapid prognosis prediction allowing a fast track rule-out protocol (3 h). For further details, see Section 3.2.3 and Figure 5. While cardiac troponins are the key biomarkers for initial risk stratication, multiple other biomarkers have been evaluated for incremental prognostic information. Of these, high-sensitivity C-reactive protein (hsCRP) and brain natriuretic peptide (BNP) have both been extensively validated and are routinely available. Natriuretic peptides such as BNP or its N-terminal prohormone fragment (NT-proBNP) are highly sensitive and fairly specic markers for the detection of LV dysfunction. Robust retrospective data in NSTE-ACS show that patients with elevated BNP or NT-proBNP levels have a three- to ve-fold increased mortality rate when compared with those with lower levels independent of troponin and hsCRP measurements.62 The level is strongly associated with the risk of death even when adjusted for age, Killip class, and LV ejection fraction (LVEF).60 Values taken a few days after onset of symptoms seem to have superior predictive value when compared with measurements on admission. Natriuretic peptides are useful markers in the emergency room in evaluating chest pain or dyspnoea and were shown to be helpful in differentiating cardiac and non-cardiac causes of dyspnoea. However, as markers of long-term prognosis, they have limited value for initial risk stratication and hence for selecting the initial therapeutic strategy in NSTE-ACS.62 Of the numerous inammatory markers investigated over the past decade, CRP measured by high-sensitivity assays is the most widely studied and is linked to adverse events. There is solid evidence that even among patients with troponin-negative NSTE-ACS, elevated levels of hsCRP (.10 mg/L) are predictive of long-term mortality (.6 months up to 4 years).60,63,64 The FRISC study conrmed that elevated hsCRP levels are associated with increased mortality at the time of the index event and continuously increase over 4 years.65 This was also observed in large cohorts of patients submitted to planned PCI. Patients with persistently elevated hsCRP levels carry the highest risk.66 However, hsCRP has no role for the diagnosis of ACS. Hyperglycaemia on admission is a strong predictor of mortality and heart failure even in non-diabetic patients.67,68 More recently it became apparent that fasting glucose levels, obtained early during the hospital course, may predict mortality even better than admission levels.68 Furthermore, uctuations of fasting glucose during

4.4 Risk scores

Quantitative assessment of risk is useful for clinical decision making. Several scores have been developed from different populations to estimate ischaemic and bleeding risks, with different outcomes and time frames. In clinical practice, simple risk scores may be more convenient and preferred. Risk scores of outcome Among several risk scores predicting short- or mid-term risk of ischaemic events, the Global Registry of Acute Coronary Events (GRACE)50 and the TIMI49 risk scores are the most widely used. There are some differences with respect to populations, outcomes, and time frames, as well as predictors derived from baseline characteristics, history, clinical or haemodynamic presentation, ECG, laboratory measures, and treatment. Based on direct comparisons,79,80 the GRACE risk score provides the most accurate stratication of risk both on admission and at discharge due to its good discriminative power (Table 5). However, the complexity of the estimation requires the use of computer or personal digital assistant software for risk calculations, which can also be performed online (http://www.outcomes.org/ grace). The addition of biomarkers (e.g. NT-proBNP) can further

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ESC Guidelines

Table 5 Mortality in hospital and at 6 months50 in low, intermediate, and high risk categories in registry populations, according to the GRACE risk score
Risk category (tertile) Low Intermediate High Risk category (tertile) Low Intermediate High GRACE risk score 108 109140
>140

Table 6 CRUSADE registry bleeding risk score83

Algorithm used to determine the risk score of CRUSADE In-Hospital major bleeding Predictor Baseline haematocrit, % <31 3133.9 3436.9 3739.9 40 Creatinine clearance,a mL/min 15 >1530 >3060 >6090 >90120 >120 Heart rate (b.p.m.) 70 7180 8190 91100 101110 111120 121 Sex Male Female Signs of CHF at presentation No Yes Prior vascular diseaseb No Yes Diabetes mellitus No Yes Systolic blood pressure, mmHg 90 91100 101120 121180 181200 201 Score 9 7 3 2 0 39 35 28 17 7 0 0 1 3 6 8 10 11 0 8 0 7 0 6 0 6 10 8 5 1 3 5

In-hospital death (%) <1 13

>3
Post-discharge to 6-month death (%) <3 3-8

GRACE risk score 88 89118 >118

>8

enhance the discriminative power of the GRACE score and improve long-term risk prediction.81 The TIMI risk score (using only six variables in an additive scoring system) is simpler to use, but its discriminative accuracy is inferior to that of the GRACE risk score.80 This is the consequence of not including key risk factors such as Killip class, heart rate, and systolic blood pressure.82

Bleeding risk scores Bleeding is associated with an adverse prognosis in NSTE-ACS, and all efforts should be made to reduce bleeding whenever possible. A few variables can help to classify patients into different levels of risk for major bleeding during hospitalization. Bleeding risk scores have been developed from registry or trial cohorts in the setting of ACS and PCI. The Can Rapid risk stratication of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) bleeding risk score (www.crusadebleedingscore.org/) was developed from a cohort of 71 277 patients from the CRUSADE registry (derivation cohort) and further validated in a cohort of 17 857 patients (validation cohort) from the same registry (Table 6).83 The rate of major bleeding increased gradually with rising bleeding risk score (Figure 2). The C statistics for the major bleeding model (derivation 0.72 and validation 0.71) and risk score (derivation 0.71 and validation 0.70) were similar. This score has relatively high accuracy for estimating bleeding risk by incorporating admission and treatment variables. In this bleeding risk score, age is not listed among the predictors, but is contained in the creatinine clearance calculation.83 Another bleeding risk score has also been derived from a pooled cohort of 17 421 patients with ACS recruited in Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) and Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS) trials.84 Six independent baseline predictors (female sex, advanced age,

Used with permission of Circulation 2009. CRUSADE Can Rapid risk stratication of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines

elevated serum creatinine, white blood cell count, anaemia, NSTEMI or STEMI) and one treatment-related variable [use of heparin and a glycoprotein (GP) IIb/IIIa receptor inhibitor rather than bivalirudin alone] were identied. This risk score identied patients at increased risk for non-CABG-related bleeding and subsequent 1-year mortality, but has not been validated in an independent cohort. Both risk scores were developed from cohorts where femoral access was predominantly or exclusively used. Their predictive

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50% 45% 40%

Risk of Major Bleeding

35% 30% 25% 20% 15% 10% 5% 0% 0 10 20 30 40 50 60 70 80 90 100

Probability of In-Hospital Major Bleeding

CRUSADE Bleeding Score

Figure 2 Risk of major bleeding across the spectrum of CRUSADE bleeding score (www.crusadebleedingscore.org/). CRUSADE Can Rapid risk stratication of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines.

Recommendations for diagnosis and risk stratication

Recommendations In patients with a suspected NSTE-ACS, diagnosis and short-term ischaemic/bleeding risk stratication should be based on a combination of clinical history, symptoms, physical ndings, ECG (repeated or continuous ST monitoring), and biomarkers. ACS patients should be admitted preferably to dedicated chest pain units or coronary care units. It is recommended to use established risk scores for prognosis and bleeding (e.g. GRACE, CRUSADE). A 12-lead ECG should be obtained within 10 min after rst medical contact and immediately read by an experienced physician. This should be repeated in the case of recurrence of symptoms, and after 69 and 24 h, and before hospital discharge. Additional ECG leads (V3R, V4R, V7V9) are recommended when routine leads are inconclusive. Blood has to be drawn promptly for troponin (cardiac troponin T or I) measurement. The result should be available within 60 min. The test should be repeated 69 h after initial assessment if the rst measurement is not conclusive. Repeat testing after 1224 h is advised if the clinical condition is still suggestive of ACS. A rapid rule-out protocol (0 and 3 h) is recommended when highly sensitive troponin tests are available (see Figure 5). An echocardiogram is recommended for all patients to evaluate regional and global LV function and to rule in or rule out differential diagnoses. Coronary angiography is indicated in patients in whom the extent of CAD or the culprit lesion has to be determined (see Section 5.4). Coronary CT angiography should be considered as an alternative to invasive angiography to exclude ACS when there is a low to intermediate likelihood of CAD and when troponin and ECG are inconclusive. In patients without recurrence of pain, normal ECG ndings, negative troponins tests, and a low risk score, a noninvasive stress test for inducible ischaemia is recommended before deciding on an invasive strategy.
a

Class a I I I

Level b A C B

Ref C 16, 18, 27, 30, 58 56, 57 47 50, 83

I I I I I I IIa I

B C A B C C B A

17, 18 18 27, 30 20, 21, 23 3741 35, 54, 55

Class of recommendation. Level of evidence. c References. ACS acute coronary syndromes; CAD coronary artery disease; CRUSADE Can Rapid risk stratication of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines; CT computed tomography; ECG electrocardiogram; GRACE Global Registry of Acute Coronary Events; LV left ventricular; NSTE-ACS non-ST-segment elevation acute coronary syndrome.
b

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value may be lower in a radial access setting. Any score cannot replace the clinical evaluation, but rather they do present an objective clinical tool to assess bleeding risk in individuals or in a given population.

ESC Guidelines

4.5 Long-term risk

In addition to the early risk factors, a number of other factors are associated with long-term risk over many years of follow-up. These are important for rening early risk stratication on top of established risk scores, and may lead to intensication of the initial therapeutic and interventional strategy. Such factors include a complicated clinical course, LV systolic function, severity of CAD, revascularization status, and evidence of residual ischaemia on non-invasive testing.

5. Treatment
5.1 Anti-ischaemic agents
Anti-ischaemic drugs either decrease myocardial oxygen demand (by decreasing heart rate, lowering blood pressure, reducing preload, or reducing myocardial contractility) or increase myocardial oxygen supply (by inducing coronary vasodilatation). b-Blockers b-Blockers competitively inhibit the myocardial effects of circulating catecholamines and reduce myocardial oxygen consumption by lowering heart rate, blood pressure, and contractility. The evidence for the benecial effects of b-blockers is extrapolated from early studies in STEMI and stable angina patients.85,86 Two double-blind randomized trials have compared b-blockers with placebo in unstable angina.87,88 A meta-analysis suggested that b-blocker treatment was associated with a 13% relative risk reduction (RRR) of progression to STEMI.89 Although no signicant effect on mortality in NSTE-ACS has been demonstrated in these relatively small trials, the results may be extrapolated from larger randomized trials of b-blockers in patients with unselected MI.90 In the CRUSADE registry, which monitored treatment of patients with NSTEMI/unstable angina at 509 US hospitals from 2001 to 2004, patients selected to receive acute b-blockade by their care providers had a 34% reduction in in-hospital mortality after adjusting for risk (3.9% vs. 6.9%, P ,0.001).91 A systematic review failed to demonstrate a convincing in-hospital mortality benet for using b-blockers early in the course of an acute or suspected MI and concluded that the available evidence does not support giving b-blockers to patients presenting with ACS within the rst 8 h.92 The reservation to give b-blockers is extrapolated from the Chinese Clopidogrel and Metoprolol in Myocardial Infarction Trial (COMMIT) study in mostly STEMI patients, which resulted in a signicantly higher rate of cardiogenic shock in the metoprolol (5.0%) vs. control group (3.9%; P ,0.0001).93 A sensitivity analysis, excluding the COMMIT study data from the meta-analysis, changed the pooled relative risk (RR) of in-hospital mortality [RR 0.86; 95% condence interval (CI) 0.77 0.96] to favour rather b-blocker administration.92

Nitrates The use of nitrates in unstable angina is largely based on pathophysiological considerations and clinical experience. The therapeutic benets of nitrates and similar drug classes such as syndonimines are related to their effects on the peripheral and coronary circulation. The major therapeutic benet is probably related to the venodilator effects that lead to a decrease in myocardial preload and LV enddiastolic volume, resulting in a decrease in myocardial oxygen consumption. In addition, nitrates dilate normal as well as atherosclerotic coronary arteries and increase coronary collateral ow. Studies of nitrates in unstable angina have been small and observational. There are no randomized placebo-controlled trials to conrm efcacy of this class of drugs in reducing risk of major adverse cardiac events. While an older analysis of the TIMI-7 study did not nd a protective effect of chronic oral nitrate treatment against unstable angina or MI,94 the GRACE registry showed that chronic nitrate use was associated with a shift away from STEMI in favour of NSTE-ACS and with lower release of markers of cardiac necrosis.95 In patients with NSTE-ACS who require hospital admission, intravenous (i.v.) nitrates are more effective than sublingual nitrates with regard to symptom relief and regression of ST depression.96 The dose should be titrated upwards until symptoms (angina and/or dyspnoea) are relieved unless side effects (notably headache or hypotension) occur. A limitation of continuous nitrate therapy is the phenomenon of tolerance, which is related to both the dose administered and the duration of treatment. Nitrates should not be given to patients on phosphodiesterase-5 inhibitors (sildenal, vardenal, or tadalal) because of the risk of profound vasodilatation and critical blood pressure drop. Calcium channel blockers Calcium channel blockers are vasodilating drugs. In addition, some have direct effects on atrioventricular conduction and heart rate. There are three subclasses of calcium blockers, which are chemically distinct and have different pharmacological effects: dihydropyridines (such as nifedipine), benzothiazepines (such as diltiazem), and phenylethylamines (such as verapamil). The agents in each subclass vary in the degree to which they cause vasodilatation, decrease myocardial contractility, and delay atrioventricular conduction. Atrioventricular block may be induced by nondihydropyridines. Nifedipine and amlodipine produce the most marked peripheral arterial vasodilatation, whereas diltiazem has the least vasodilatory effect. All subclasses cause similar coronary vasodilatation. Therefore, calcium channel blockers are the preferred drugs in vasospastic angina. Diltiazem and verapamil show similar efcacy in relieving symptoms and appear equivalent to b-blockers.97,98 The effect on prognosis of calcium channel blockers in NSTE-ACS patients has only been investigated in smaller randomized trials. Most of the data collected with dihydropyridines derive from trials with nifedipine. None showed signicant benet in either MI or post-MI secondary prevention, but a trend for harm, with the Holland Interuniversity Nifedipine/Metoprolol Trial (HINT) stopped early because of an excess of reinfarctions with nifedipine compared with metoprolol.88 In contrast, the Danish Study Group on Verapamil in Myocardial Infarction Trial

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the primary pacemaker current in the sinus node and may be used in selected patients with b-blocker contraindications.102 Ranolazine exerts antianginal effects by inhibiting the late sodium current. It was not effective in reducing major cardiovascular events in the Metabolic Efciency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndromes (MERLIN)TIMI 36 study, but reduced the rate of recurrent ischaemia.103

Recommendations for anti-ischaemic drugs

Recommendations Oral or intravenous nitrate treatment is indicated to relieve angina; intravenous nitrate treatment is recommended in patients with recurrent angina and/or signs of heart failure. Patients on chronic -blocker therapy admitted with ACS should be continued on -blocker therapy if not in Killip class III. Oral -blocker treatment is indicated in all patients with LV dysfunction (see Section 5.5.5) without contraindications. Calcium channel blockers are recommended for symptom relief in patients already receiving nitrates and -blockers (dihydropyridines type), and in patients with contraindications to -blockade (benzothiazepine or phenylethylamine type). Calcium channel blockers are recommended in patients with vasospastic angina. Intravenous -blocker treatment at the time of admission should be considered for patients in a stable haemodynamic condition (Killip class <III) with hypertension and/or tachycardia. Nifedipine, or other dihydropyridines, are not recommended unless combined with -blockers.
a

Class a

Level b

Ref C

5.2 Antiplatelet agents

I B 91

86, 90 , 91

88

IIa

93

Platelet activation and subsequent aggregation play a dominant role in the propagation of arterial thrombosis and consequently are the key therapeutic targets in the management of ACS. Antiplatelet therapy should be instituted as early as possible when the diagnosis of NSTE-ACS is made in order to reduce the risk of both acute ischaemic complications and recurrent atherothrombotic events. Platelets can be inhibited by three classes of drugs, each of which has a distinct mechanism of action. Aspirin (acetylsalicylic acid) targets cyclo-oxygenase (COX-1), inhibiting thromboxane A2 formation and inducing a functional permanent inhibition in platelets. However, additional complementary platelet aggregation pathways must be inhibited to ensure effective treatment and prevention of coronary thrombosis. ADP binding to the platelet P2Y12 receptor plays an important role in platelet activation and aggregation, amplifying the initial platelet response to vascular damage. The antagonists of the P2Y12 receptor are major therapeutic tools in ACS. The prodrug thienopyridines such as clopidogrel and prasugrel are actively biotransformed into molecules that bind irreversibly to the P2Y12 receptor. A new class of drug is the pyrimidine derivative ticagrelor, which without biotransformation binds reversibly to the P2Y12 receptor, antagonizing ADP signalling and platelet activation. I.v. GP IIb/IIIa receptor antagonists (abciximab, eptibatide, and tiroban) target the nal common pathway of platelet aggregation.

III

88

Class of recommendation. Level of evidence. References. ACS acute coronary syndrome; LV left ventricular.
b c

(DAVIT)-I and DAVIT-II studies with verapamil, taken together, showed signicant reductions in sudden death, reinfarction, and total mortality, with the largest benet observed in patients with preserved LV function.99 Similar trends were seen in studies with diltiazem.100 Unlike b-blockers, there seems to be no class effect with calcium channel antagonists. Other antianginal drugs Nicorandil, a potassium channel opener, reduced the rate of the primary composite endpoint in patients with stable angina, but was never tested in ACS patients.101 Ivabradine selectively inhibits

5.2.1 Aspirin Based on studies performed 30 years ago, aspirin reduces the incidence of recurrent MI or death in patients with what was then called unstable angina [odds ratio (OR) 0.47; CI 0.370.61; P , 0.001].104 106 A loading dose of chewed, plain aspirin between 150 and 300 mg is recommended.107 I.v. aspirin is an alternative mode of application, but has not been investigated in trials and is not available everywhere. A daily maintenance dose of 75 100 mg has the same efcacy as higher doses and carries a lower risk of gastrointestinal intolerance,108 which may require drug discontinuation in up to 1% of patients. Allergic responses to aspirin (anaphylactic shock, skin rash, and asthmatic reactions) are rare (,0.5%). Desensitization is an option in selected patients. Since aspirin reliably inhibits COX-1, no monitoring of its effects is required unless a diagnosis of non-compliance is likely to aid management. Non-steroidal anti-inammatory drugs (NSAIDs) such as ibuprofen may reversibly block COX-1 and prevent irreversible inhibition by aspirin as well as causing potentially prothrombotic effects via COX-2 inhibition. Consequently NSAIDs may increase the risk of ischaemic events and should be avoided.109

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5.2.2 P2Y12 receptor inhibitors 5.2.2.1 Clopidogrel An overview of the P2Y12 receptor inhibitors is given in Table 7. Ticlopidine was the rst thienopyridine investigated in ACS, but was replaced by clopidogrel because of side effects. Today ticlopidine may still be used in patients who are allergic to clopidogrel, although cross-reactions are possible. In the Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial, a clopidogrel hydrogen sulfate 300 mg loading dose followed by 75 mg daily maintenance for 912 months in addition to aspirin reduced the incidence of cardiovascular death and non-fatal MI or stroke compared with aspirin alone (9.3% vs. 11.4%; RR 0.80; 95% CI 0.72 0.90; P , 0.001) in patients with NSTE-ACS associated with elevated cardiac markers or ST-segment depression on ECG or age .60 years with prior CAD history.110 The risk reduction was signicant for MI, and there was a trend towards reduction in rates of cardiovascular death and stroke. The benet was consistent across all risk groups, and among all subsets of patients (elderly, ST-segment deviation, with or without elevated cardiac biomarkers, with or without PCI, diabetic patients). The benet was consistent during the rst 30 days, as well as the following 11 months.111 There may be a rebound of events after cessation of clopidogrel, particularly in conservatively treated patients.112 However, there is no solid evidence to support treatment beyond 12 months. An increase in the rate of major bleeding events was observed with clopidogrel (3.7% vs. 2.7%; RR 1.38; 95% CI 1.131.67; P 0.001), but with a non-signicant increase in life-threatening and fatal bleeds.110 However, in the entire cohort, including patients submitted to revascularization by either PCI or CABG, the benet of clopidogrel treatment outweighed the risk of bleeding. Treating 1000 patients resulted in 21 fewer cardiovascular deaths, MIs, or strokes, at the cost of an excess of seven patients requiring transfusion and a trend for four patients to experience life-threatening bleeds.113 The 600 mg loading dose of clopidogrel has a more rapid onset of action and more potent inhibitory effect than the 300 mg dose.114,115 A 150 mg daily maintenance dose of clopidogrel also achieves a slightly greater and more consistent inhibitory effect compared with the 75 mg dose.116 In the CURRENT/Optimal Antiplatelet Strategy for Interventions (CURRENT-OASIS)117 trial, clopidogrel given as a 600 mg loading dose followed by 150 mg daily for 7 days and 75 mg daily thereafter was compared with the conventional doses in patients with STEMI or NSTE-ACS. Either ECG changes compatible with ischaemia or elevated levels of cardiac biomarkers were required for eligibility. Coronary angiography, with a plan to perform PCI, had to be carried out as early as possible, but no later than 72 h after randomization. Overall, the higher dose regimen was no more effective than the conventional dose regimen, with a similar 30 day rate of the composite endpoint of cardiovascular death, MI, or stroke [4.2% vs, 4.4%, respectively; hazard ratio (HR) 0.94; 0.83 1.06; P 0.30], but was associated with increased 30 day rates of major bleeding as assessed by either CURRENT criteria (2.5% vs. 2.0%; HR 1.24; 1.051.46; P 0.01) or TIMI criteria (1.7% vs. 1.3%; HR 1.26; 1.031.54; P 0.03), and the need for blood transfusion (2.2% vs. 1.7%; HR 1.28; 1.07 1.54; P 0.01). A pre-specied subgroup analysis of

ESC Guidelines

17 263 patients (of whom 63.1% had NSTE-ACS) undergoing PCI demonstrated a reduction in the combined primary endpoint of cardiovascular death/MI/stroke of 3.9% vs. 4.5% (HR 0.86; 95% CI 0.74 0.99; P 0.039) driven by a reduction in MI rate with the higher dose regimen (2.0% vs. 2.6%; HR 0.69; 95% CI 0.56 0.87; P 0.001). The rate of stent thrombosis [according to the Academic Research Consortium (ARC) denition] was reduced signicantly, irrespective of the nature of the stent, for denite or probable stent thrombosis (HR 0.69; 95% CI 0.56 0.87; P 0.001) and for denite stent thrombosis (HR 0.54; 95% CI 0.390.74; P 0.0001). CURRENT-dened major bleeding was more common with double-dose clopidogrel than with the standard dose (1.6% vs. 1.1%; HR 1.41; 95% CI 1.09 1.83; P 0.009). However, the rates of TIMI major bleeding did not differ signicantly between groups (1.0% vs. 0.7%; HR 1.36; 95% CI 0.971.90; P 0.074). There was no signicant excess risk of fatal or intracranial bleeding or of CABG-related bleeding with the higher dose regimen of clopidogrel. There was no heterogeneity between results for STEMI and NSTE-ACS patients. The primary composite endpoint was reduced to the same extent in both subgroups (STEMI, 4.2% vs. 5.0%; HR 0.83; 95% CI 0.66 1.05; P 0.117; NSTE-ACS, 3.6% vs. 4.2%; HR 0.87; 95% CI 0.721.06; P 0.167).108 There is wide variability in the pharmacodynamic response to clopidogrel linked to several factors, including genotype polymorphisms. Clopidogrel is converted to its active metabolite through two steps in the liver, which are dependent on cytochrome P450 (CYP) isoenzymes including CYP3A4 and CYP2C19. In addition, clopidogrel (and prasugrel) absorption is regulated by P-glycoprotein (encoded by ABCB1), which is an ATP-dependent efux pump that transports various molecules across extracellular and intracellular membranes. It is expressed, among other places, on intestinal epithelial cells, where increased expression or function can affect the bioavailability of drugs that are substrates. As a result, the efciency of active metabolite formation varies widely between individuals and is inuenced (among other factors such as age, diabetic status, and renal function) by genetic variations that affect P-glycoprotein, and CYP2C19 function.118 ABCB1 and CYP2C19 single nucleotide polymorphisms with partial or total loss of function were shown to be associated with reduced inhibition of platelet aggregation and increased risk of cardiovascular events, although contradictory reports have been published on this issue.119,120 While genetic testing is not routine in clinical practice, efforts have been made to identify poor responders to clopidogrel by ex vivo platelet function assays.121 High levels of platelet reactivity after clopidogrel administration were shown to be associated with increased risk of stent thrombosis and other ischaemic events.122,123 However, the clinical role of platelet function testing remains ill dened. In the only randomized trial testing dose adaptation of clopidogrel according to residual platelet reactivity, no clinical advantage was achieved by increasing the dose of clopidogrel in patients with a low response despite a modest increase in platelet inhibition.124 Several trials currently under way may clarify the impact of adapting therapy on the basis of the results of platelet reactivity assays, but, so far, the routine clinical use of platelet function tests in clopidogrel-treated patients with ACS cannot be recommended.

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Table 7

Overview of P2Y12 studies

Trial Cure (2001)
110

Population 12 562 NSTE-ACS

Comparison Clopidogrel 75 mg (300 mg loading) vs. placebo

Primary endpoint CV death, MI, CVA Clopidogrel 9.3% Placebo 11.4% (P < 0.001) ARR 2.1%; RRR 20%; NNT 48 CV death, MI, or urgent TVR in 30 days Clopidogrel 4.5% Placebo 6.4% ARR 1.9%; RRR 30%; NNT 53 CV death, MI, CVA Prasugrel 9.9% Clopidogrel 12.1% (P < 0.001) ARR 2.2%; RRR 27%; NNT 45

Mortality CV causes Clopidogrel 5.1% Placebo 5.5% (P = NS)

MI Clopidogrel 5.2% Placebo 6.7% (P not given)

CVA

Stent thrombosis a

Bleeding Major bleedingb Clopidogrel 3.7% Placebo 2.7% (P = 0.001) NNH: 100 Major bleedingb Clopidogrel 2.7% Placebo 2.5% (P = 0.69)

PCI Cure146 2658 (2001) NSTE-ACS undergoing PCI

Like CURE (after PCI clopidogrel in both groups for 1 month)

Clopidogrelc 2.4% Clopidogrelc Placebo 2.3% 4.5% (P = NS) Placebo 6.4% (P not given)

Clopidogrel Not given 1.2% Placebo 1.4% (P not given) Not given Not given

TRITON130 13 608 (2007) undergoing PCI NSTE-ACS 74% STEMI 26%

Prasugrel 10 mg (60 mg loading) vs. clopidogrel 75 mg (300 loading)

CV causes Prasugrel 2.1% Clopidogrel 2.4% (P = 0.31) Any cause Prasugrel 3.0% Clopidogrel 3.2% (P = 0.64)

Prasugrel 7.3% Clopidogrel 9.5% (P < 0.001)

Prasugrel 1.0% Clopidogrel 1.0% (P = 0.93)

Prasugrel 1.1% Clopidogrel 2.4% (P < 0.001)

PLATO132 (2009)

18 624 NSTE-ACS: 59% STEMI: 38% (invasive and non-invasive)

Ticagrelor 90 mg b.i.d. (180 mg loading) vs. clopidogrel 75 mg (300600 mg loading)

Death from vascular causes, MI, CVA Ticagrelor 9.8% Clopidogrel 11.7% (P < 0.001) ARR 1.9%; RRR 16%; NNT 53

Vascular causes Ticagrelor 4.0% Clopidogrel 5.1% (P = 0.001) Any cause Ticagrelor 4.5% Clopidogrel 5.9% (P < 0.001)

Ticagrelor 5.8% Clopidogrel 6.9% (P = 0.005)

Ticagrelor See below 1.5% Clopidogrel 1.3% (P = 0.22)

PLATO planned invasive strategy133 (2010)

13 408 (invasive strategy) NSTE-ACS 50.9% STEMI 49.1%

Like PLATO

CURRENT 25 086 OASIS 7117 (invasive (2010) strategy) NSTE-ACS 63% STEMI 37% CURRENT 17 263 undergoing PCI108 (2010) PCI, 95% stents NSTE-ACS 63% STEMI 37%
a

Clopidogrel double dose (600 mg loading, 150 mg day 27, then 75 mg) vs. standard dose 75 mg (150 mg loading) Like CURRENT

Death from vascular causes, MI, CVA Ticagrelor 9.0% Clopidogrel 10.7% (P = 0.0025) ARR 1.7%; RRR 16%; NNT 59 CV death, MI, CVA (at 30 days) Double 4.2% Standard 4.4% (P = 0.30)

CV death Ticagrelor 3.4% Clopidogrel 4.3% (P = 0.25) Any cause Ticagrelor 3.9% Clopidogrel 5.0% (P = 0.010) CV death Double 2.1% Standard 2.2% All-cause mortality Double 2.3% Standard 2.4% CV death Double 1.9% Standard 1.9% All-cause mortality Double 1.9% Standard 2.1%

Ticagrelor 5.3% Clopidogrel 6.6% (P = 0.0023)

Ticagrelor 1.2% Clopidogrel 1.1% (P = 0.65)

Ticagrelor 2.2% Clopidogrel 3.0% (P = 0.014)

NonCABG-related major bleedingd: Prasugrel 2.4% Clopidogrel 1.8% (P = 0.03) NNH: 167 CABG-related major bleeding Prasugrel 13.4% Clopidogrel 3.2% (P < 0.001) NNH: 10 (CABG) Major bleedinge Ticagrelor 11.6% Clopidogrel 11.2% (P = 0.43) NNH: NA Non-CABG bleeding Ticagrelor 4.5% Clopidogrel 3.8% (P = 0.03) NNH: 143 (not undergoing CABG) Major bleedinge Ticagrelor 11.6% Clopidogrel 11.5% NNH: NA

Double 1.9% Standard 2.2% (P = 0.09)

Double 0.5% Standard 0.5% (P = 0.95)

Not given

Major bleedingg Double 2.5% Standard 2.0% (P = 0.01) NNH: 200

CV death, MI, CVA (at 30 days) Double 3.9% Standard 4.5% (P = 0.039) ARR 0.6%;RRR 14%; NNT 167

Double 2.0% Standard 2.6% (P = 0.018)

Double 0.4% Standard 0.4% (P = 0.56)

Absolute gures not given (31% RRR with double-dose vs. standard dose)

Major bleedingg Double 1.6% Standard 1.1% (P = 0.009) NNH: 200

ARC probable or denite. CURE denition. c Figures to end of follow-up (not just to day 30 as primary endpoint). d TIMI criteria. e PLATO criteria. f Only double-blind component of trial included (i.e. high vs. low dose clopidogrel). g CURRENT criteria. ARC Academic Research Consortium; ARR absolute risk reduction; b.i.d. twice daily; CABG coronary artery bypass grafting; CV cardiovascular; CVA cerebrovascular accident; MI myocardial infarction; NA not applicable; NNH numbers needed to harm; NNT numbers needed to treat; NS not signicant; NSTE-ACS non-ST-elevation acute coronary syndrome; PCI percutaneous coronary intervention; RRR relative risk reduction; STEMI ST-segment elevation myocardial infarction; TVR target vessel revascularization.
b

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Proton pump inhibitors that inhibit CYP2C19, particularly omeprazole, decrease clopidogrel-induced platelet inhibition ex vivo, but there is currently no conclusive clinical evidence that co-administration of clopidogrel and proton pump inhibitors increases the risk of ischaemic events.125,126 One randomized trial (prematurely interrupted for lack of funding) tested routine omeprazole combined with clopidogrel vs. clopidogrel alone in patients with an indication for dual antiplatelet therapy (DAPT) for 12 months, including post-PCI patients, ACS, or other indications. No increase in ischaemic event rates but a reduced rate of upper gastrointestinal bleeding was observed with omeprazole.127 However, the ischaemic event rate in this study was low and it is uncertain whether omeprazole may reduce the efcacy of clopidogrel in higher risk settings. Strong inhibitors (e.g. ketoconazole) or inducers (e.g. rifampicin) of CYP3A4 can signicantly reduce or increase, respectively, the inhibitory effect of clopidogrel, but are rarely used in NSTE-ACS patients. Adverse effects of clopidogrel. In addition to bleeding, gastrointestinal disturbances (diarrhoea, abdominal discomfort) and rash are occasional adverse effects of clopidogrel. Thrombotic thrombocytopenic purpura and blood dyscrasias occur rarely. Clopidogrel desensitization is an option to treat clopidogrel allergy. 5.2.2.2 Prasugrel Prasugrel requires two metabolic steps for formation of its active metabolite, which is chemically similar to the active metabolite of clopidogrel.119 The rst metabolic step requires only plasma esterases; the second step, in the liver, is mediated by CYP enzymes. Consequently prasugrel produces more rapid and consistent platelet inhibition compared with clopidogrel.128 Response to prasugrel does not appear to be affected signicantly by CYP inhibitors, including proton pump inhibitors, or loss-of-function variants of the CYP2C19 gene; nor is it affected by reduced ABCB1 function.129 In the TRial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet InhibitioN with PrasugrelThrombolysis In Myocardial Infarction (TRITON-TIMI) 38 trial, a prasugrel 60 mg loading dose followed by 10 mg daily was compared with a clopidogrel 300 mg loading dose and then 75 mg daily in clopidogrel-nave patients undergoing PCI, either primary PCI for STEMI or for recent STEMI, or moderate to high risk NSTE-ACS once coronary angiography had been performed.130 Patients with NSTE-ACS treated conservatively were not included in this study. Patients with NSTE-ACS were eligible if they had had ischaemic symptoms within 72 h, a TIMI risk score 3, and either ST-segment deviation 1 mm or elevated levels of a cardiac biomarker. In the NSTE-ACS cohort (10 074 patients), study medication could be administered between identifying coronary anatomy suitable for PCI and 1 h after leaving the catheterization laboratory. The composite primary endpoint (cardiovascular death, non-fatal MI, or stroke) occurred in 11.2% of clopidogrel-treated patients and in 9.3% of prasugrel-treated patients (HR 0.82; 95% CI 0.730.93; P 0.002), mostly driven by a signicant risk reduction for MI (from 9.2% to 7.1%; RRR 23.9%; 95% CI 12.733.7; P ,0.001).130 There was no difference in the rates of either non-fatal stroke or cardiovascular death. In the whole cohort, the rate of denite or probable stent thrombosis (as dened by the ARC) was signicantly

ESC Guidelines

reduced in the prasugrel group compared with the clopidogrel group (1.1% vs. 2.4%, respectively; HR 0.48; 95% CI 0.36 0.64; P , 0.001). The corresponding gures for NSTE-ACS patients are not available. In the whole cohort, there was a signicant increase in the rate of non-CABG-related TIMI major bleeding (2.4% vs. 1.8%; HR 1.32; 95% CI 1.031.68; P 0.03), mostly driven by a signicant increase in spontaneous bleeds (1.6% vs. 1.1%; HR 1.51; 95% CI 1.092.08; P 0.01), but not by bleeding related to arterial access (0.7% vs. 0.6%; HR 1.18; 95% CI 0.77 1.82; P 0.45), which means that long-term exposure to a potent antiplatelet agent is the determinant of bleeding. Life-threatening bleeding was signicantly increased under prasugrel, with 1.4% vs. 0.9% (HR 1.52; 95% CI 1.08 2.13; P 0.01), as well as fatal bleeding, with 0.4% vs. 0.1% (HR 4.19; 95% CI 1.58 11.11; P 0.002) with prasugrel compared with clopidogrel. There was evidence of net harm with prasugrel in patients with a history of cerebrovascular events.130 In addition, there was no apparent net clinical benet in patients .75 years of age and in patients with low body weight (,60 kg). Greater benet without increased risk of bleeding was observed in diabetic patients. There was no difference in efcacy in patients with (CrCl ,60 mL/min) or without (CrCl .60 mL/min) renal impairment. Adverse effects of prasugrel. The rate of other adverse effects in the TRITON study was similar with prasugrel and clopidogrel. Thrombocytopenia occurred at the same frequency in each group (0.3%) while neutropenia was less common with prasugrel (,0.1% vs. 0.2%; P 0.02). 5.2.2.3 Ticagrelor Ticagrelor belongs to a novel chemical class, cyclopentyltriazolopyrimidine, and is an oral, reversibly binding P2Y12 inhibitor with a plasma half-life of 12 h. The level of P2Y12 inhibition is determined by the plasma ticagrelor level and, to a lesser extent, an active metabolite. Like prasugrel, it has a more rapid and consistent onset of action compared with clopidogrel, but additionally it has a quicker offset of action so that recovery of platelet function is faster (Table 8).131 Ticagrelor increases levels of drugs metabolized through CYP3A, such as simvastatin, whilst moderate CYP3A inhibitors such as diltiazem increase the levels and reduce the speed of offset of the effect of ticagrelor. In the PLATelet inhibition and patient Outcomes (PLATO) trial, patients with either moderate to high risk NSTE-ACS (planned for either conservative or invasive management) or STEMI planned for primary PCI were randomized to either clopidogrel 75 mg daily, with a loading dose of 300 mg, or ticagrelor 180 mg loading dose followed by 90 mg twice daily.132 Patients undergoing PCI were allowed to receive an additional blinded 300 mg loading dose of clopidogrel (total loading dose 600 mg) or its placebo, and also were recommended to receive an additional 90 mg of ticagrelor (or its placebo) if .24 h after the initial loading dose. Treatment was continued for up to 12 months, with a minimum intended treatment duration of 6 months, and a median duration of study drug exposure of 9 months.132 In total, 11 067 patients had a nal diagnosis of NSTEMI or unstable angina. NSTE-ACS patients were required to have symptom onset within the previous 24 h and at least two of the following inclusion criteria: elevated

ESC Guidelines

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were seen early,133 most of the benet in terms of reduced MI and death accrued progressively over 12 months, with continued separation of event curves at 12 months.132 Ticagrelor reduced early and late mortality following CABG. In 1261 patients who underwent CABG and were on study drug treatment for ,7 days before surgery, the primary composite endpoint occurred in 10.6% with ticagrelor vs. 13.1% with clopidogrel (HR 0.84; 95% CI 0.601.16; P 0.29). Total mortality was reduced by ticagrelor from 9.7% to 4.7% (HR 0.49; CI 0.32 0.77; P ,0.01), cardiovascular death from 7.9% to 4.1% (HR 0.52; 95% CI 0.320.85; P ,0.01), and non-cardiovascular death from 2.0% to 0.7% (P 0.07). There was no signicant difference in CABG-related major bleeding rates between the two groups. As per protocol, ticagrelor should be restarted when it is considered safe in terms of bleeding (see below).134 Adverse effects of ticagrelor. In addition to increased rates of minor or non-CABG-related major bleeding with ticagrelor, adverse effects include dyspnoea, increased frequency of ventricular pauses, and asymptomatic increases in uric acid.132,135,136 The dyspnoea induced by ticagrelor occurs most frequently (up to 15%) within the rst week of treatment and may be transient or persist until cessation of treatment, but only infrequently is it severe enough to cause discontinuation of treatment.132,137 The dyspnoea does not appear to be associated with any deterioration in cardiac or pulmonary function.137 Ventricular pauses associated with ticagrelor mostly consist of asymptomatic nocturnal sinoatrial pauses; caution is advised in patients with either advanced sinoatrial disease or second- or third-degree atrioventricular block, unless already treated by permanent pacemaker. The mechanism for the dyspnoea and ventricular pauses is uncertain.137 A slightly greater increase in serum creatinine was seen in the PLATO trial with ticagrelor compared with clopidogrel, but the difference was no longer apparent 1 month after cessation of treatment.132 Rates of gastrointestinal disturbance and rash are similar with ticagrelor compared with clopidogrel.136 5.2.2.4 Withholding P2Y12 inhibitors for surgery DAPT should be initiated early in NSTE-ACS patients as the benet outweighs the risk in all patients. It has been argued that thienopyridines should be withheld prior to angiography because of a possible need for CABG. Several older studies suggested an increased risk of major bleeding among patients receiving clopidogrel before CABG. In the CURE trial the median time to CABG was 26 days and was on average 12 days for hospitalized patients.113 The decision to withhold clopidogrel was left to local practice. The benet of clopidogrel over placebo in reducing risk of ischaemic events was predominantly before surgery (RR 0.82, 95% CI 0.58 1.16) compared with after CABG (RR 0.97, 95% CI 0.751.26). Major bleeding rates were higher with clopidogrel (RR 1.27, 95% CI 0.961.69), but appeared to be diminished if clopidogrel was withheld for 5 days prior to CABG. Subsequent observational studies have shown a signicantly higher rate of blood transfusion and reoperation, but not mortality, if clopidogrel was given within 5 days prior to CABG.138 140 In the ACUITY study 1539 patients underwent CABG, 50.9% of whom received clopidogrel before surgery. Clopidogrel-exposed patients had a prolonged hospitalization (12.0 days vs. 8.9 days, P 0.0001) but fewer ischaemic events (death, MI, or unplanned revascularization)

Table 8

P2Y12 inhibitors
Clopidogrel Prasugrel Ticagrelor

Class Reversibility Activation Onset of effect a Duration of effect Withdrawal before major surgery
a

Thienopyridine Thienopyridine Triazolopyrimidine Irreversible Irreversible Reversible Active drug

Prodrug, Prodrug, not limited by limited by metabolization metabolization 24 h 310 days 30 min 510 days

30 min 34 days

5 days

7 days

5 days

50% inhibition of platelet aggregation.

biomarkers of myocardial necrosis; ischaemic ST-segment changes; and a clinical characteristic associated with increased risk (i.e. age 60 years, previous MI or CABG, CAD with lesions 50% in at least two vessels, previously documented cerebrovascular disease, diabetes mellitus, peripheral vascular disease, or chronic renal dysfunction). In the overall cohort, the primary composite efcacy endpoint (death from vascular causes, MI, or stroke) was reduced from 11.7% in the clopidogrel group to 9.8% in the ticagrelor group (HR 0.84; 95% CI 0.770.92; P ,0.001). According to the pre-dened statistical analysis plan, death from vascular causes was signicantly reduced from 5.1% to 4.0%, respectively (HR 0.79; 95% CI 0.690.91; P 0.001), and MI from 6.9% to 5.8% (HR 0.84; 95% CI 0.750.95; P 0.005). There was no signicant difference in the rates of stroke (1.3% vs. 1.5%; P 0.22). The rate of denite stent thrombosis was reduced from 1.9% to 1.3% (P , 0.01) and total mortality from 5.9% to 4.5% (P , 0.001). Overall there was no signicant difference in PLATO-dened major bleeding rates between the clopidogrel and ticagrelor groups (11.2% vs. 11.6%, respectively; P 0.43). Major bleeding unrelated to CABG surgery was increased from 3.8% in the clopidogrel group to 4.5% in the ticagrelor group (HR 1.19; 95% CI 1.021.38; P 0.03). Major bleeding related to CABG surgery was similar with ticagrelor and clopidogrel (7.4% vs. 7.9%, respectively; P 0.32). Minor bleeding was increased with ticagrelor compared with clopidogrel. There was no difference in the overall rates of fatal haemorrhage between the groups (0.3% in both groups) despite a higher rate of fatal intracranial haemorrhage in the ticagrelor group. Those patients with a positive initial troponin had a signicant reduction in the primary endpoint with ticagrelor compared with clopidogrel (10.3% vs. 12.3%, HR 0.85, CI 0.770.94) in contrast to patients with negative initial troponin (7.0% vs. 7.0%), as did those with a nal diagnosis of NSTEMI (11.4% vs. 13.9%; HR 0.83, CI 0.730.94) compared with those with a nal diagnosis of unstable angina (8.6% vs. 9.1% respectively; HR 0.96, CI 0.75 1.22). While reduction in stent thrombosis rates by ticagrelor

Page 20 of 56
at 30 days (12.7% vs. 17.3%, P ,0.01), and no higher rate of non-CABG-related major bleeding (3.4% vs. 3.2%, P 0.87) or post-CABG major bleeding (50.3% vs. 50.9%, P 0.83) compared with patients not administered clopidogrel before CABG. Clopidogrel use before surgery was an independent predictor of a reduced rate of ischaemic events but not of excess bleeding.141 Factors other than the time window of administration or withdrawal of clopidogrel before CABG may play a role in the excess bleeding. In a study of 4794 patients undergoing CABG (elective and non-elective), the factors independently associated with composite bleeding (reoperation for bleeding, red cell transfusion, or haematocrit drop of .15%) were baseline haematocrit (P ,0.0001), on-pump surgery (P ,0.0001), the experience of the surgeon performing the CABG (P 0.02), female sex (P ,0.0001), lower CrCl (P 0.0002), presence of angina (P 0.0003), GP IIb/ IIIa receptor inhibitor treatment before CABG (P 0.0004), and Recommendations for oral antiplatelet agents
Recommendations Aspirin should be given to all patients without contraindications at an initial loading dose of 150300 mg, and at a maintenance dose of 75100 mg daily long-term regardless of treatment strategy. A P2Y12 inhibitor should be added to aspirin as soon as possible and maintained over 12 months, unless there are contraindications such as excessive risk of bleeding. A proton pump inhibitor (preferably not omeprazole) in combination with DAPT is recommended in patients with a history of gastrointestinal haemorrhage or peptic ulcer, and appropriate for patients with multiple other risk factors (H. elicobacter pylori infection, age 65 years, concurrent use of anticoagulants or steroids). Prolonged or permanent withdrawal of P2Y12 inhibitors within 12 months after the index event is discouraged unless clinically indicated. Ticagrelor (180-mg loading dose, 90 mg twice daily) is recommended for all patients at moderate-to-high risk of ischaemic events (e.g. elevated troponins) , regardless of initial treatment strategy and including those pre-treated with clopidogrel (which should be discontinued when ticagrelor is commenced). Prasugrel (60-mg loading dose, 10-mg daily dose) is recommended for P2Y12-inhibitor-nave patients (especially diabetics) in whom coronary anatomy is known and who are proceeding to PCI unless there is a high risk of lifethreatening bleeding or other contraindications.d Clopidogrel (300-mg loading dose, 75-mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel. A 600-mg loading dose of clopidogrel (or a supplementary 300-mg dose at PCI following an initial 300-mg loading dose) is recommended for patients scheduled for an invasive strategy when ticagrelor or prasugrel is not an option. A higher maintenance dose of clopidogrel 150 mg daily should be considered for the rst 7 days in patients managed with PCI and without increased risk of bleeding. Increasing the maintenance dose of clopidogrel based on platelet function testing is not advised as routine, but may be considered in selected cases. Genotyping and/or platelet function testing may be considered in selected cases when clopidogrel is used. In patients pre-treated with P2Y12 inhibitors who need to undergo non-emergent major surgery (including CABG), postponing surgery at least for 5 days after cessation of ticagrelor or clopidogrel, and 7 days for prasugrel, if clinically feasible and unless the patient is at high risk of ischaemic events should be considered. Ticagrelor or clopidogrel should be considered to be (re-) started after CABG surgery as soon as considered safe. The combination of aspirin with an NSAID (selective COX-2 inhibitors and non-selective NSAID) is not recommended.
a

ESC Guidelines

the number of diseased vessels (P 0.002).142 The use of clopidogrel within 5 days was not associated with higher bleeding rates once these other factors were accounted for (OR 1.23; 95% CI 0.522.10; P 0.45). Withdrawal of clopidogrel in high risk cohorts such as those with ongoing ischaemia in the presence of high risk anatomy (e.g. left main or severe proximal multivessel disease) is not recommended, and these patients should undergo CABG in the presence of clopidogrel with special attention to reducing bleeding.143 Only in patients whose risk of bleeding is very high, such as redo-CABG or complex CABG with valve surgery, it may be reasonable to withhold clopidogrel for 35 days before surgery even among patients with active ischaemia and consider bridging strategies (see below). In the PLATO trial, clopidogrel treatment was recommended to be withheld for 5 days and ticagrelor for 1 3 days before CABG

Class a I I

Level b A A

Ref C 107, 108 110, 130, 132 125127

132

130 110, 146, 147 108, 114, 115 108 124 119, 121 134 -

I I IIa IIb IIb IIa IIa III

A B B B B C B C

Class of recommendation. Level of evidence. c References. d Prasugrel is in the Guidelines on Revascularization148 given a IIa recommendation as the overall indication including clopidogrel-pre-treated patients and/or unknown coronary anatomy. The class I recommendation here refers to the specically dened subgroup. CABG coronary artery bypass graft; COX cyclo-oxygenase; DAPT dual (oral) antiplatelet therapy; NSAID non-steroidal anti-inammatory drug; PCI percutaneous coronary intervention.
b

ESC Guidelines

Page 21 of 56
a short half-life and reversible antiplatelet agent, e.g. the GP IIb/ IIIa receptor inhibitors tiroban or eptibatide, but this approach is not yet based on evidence. DAPT should be resumed as soon as considered safe. 5.2.3 Glycoprotein IIb/IIIa receptor inhibitors The three GP IIb/IIIa receptor inhibitors approved for clinical use are i.v. agents belonging to different classes: abciximab is a monoclonal antibody fragment; eptibatide is a cyclic peptide; and tiroban is a peptidomimetic molecule. A meta-analysis of 29 570 patients initially medically managed and planned for PCI showed a 9% RRR in death or non-fatal MI with GP IIb/IIIa receptor inhibitors (10.7% vs. 11.5%; P 0.02).149 No reduction in death or MI was seen in purely medically managed patients receiving GP IIb/ IIIa receptor inhibitors vs. placebo. The only signicant benet was observed when GP IIb/IIIa receptor inhibitors were maintained during PCI (10.5% vs. 13.6%; OR 0.74; 95% CI 0.570.96; P 0.02). The use of GP IIb/IIIa receptor inhibitors was associated with an increase in major bleeding complications, but intracranial bleeding was not signicantly increased. Many of the older trials with these inhibitors were carried out in the absence of clopidogrel or newer P2Y12 inhibitors. Upstream versus procedural initiation of glycoprotein IIb/IIIa receptor inhibitors In the ACUITY Timing trial, deferred selective (only during PCI) vs. routine upstream administration of any GP IIb/IIIa receptor inhibitor was tested among 9207 patients in a 2 2 factorial design.150 GP IIb/IIIa receptor inhibitors were used in 55.7% of patients for 13.1 h in the deferred selective strategy and in 98.3% of patients for 18.3 h (pre-treatment median 4 h) in the routine upstream strategy. Overall, 64% of patients received thienopyridines before angiography or PCI. The deferred selective vs. routine upstream strategy resulted in a lower rate of 30 day major non-CABG-related bleeding (4.9% vs. 6.1%; RR 0.80; 95% CI 0.67 0.95; P 0.009) with no signicant difference in ischaemic event rates (7.9% vs. 7.1%; RR 1.12; 95% CI 0.971.29; P 0.13). The net clinical outcome (incorporating both the ischaemic outcomes and major bleeding) at 30 days was similar (11.7% vs. 11.7%; RR 1.00; 95% CI 0.89 1.11; P 0.93; P-value for non-inferiority ,0.001). The Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndrome (EARLY-ACS) trial randomized 9492 patients assigned to an invasive strategy to early eptibatide or placebo with provisional use of eptibatide after angiography for PCI.151 The primary endpoint was a composite of death, MI, recurrent ischaemia requiring urgent revascularization, or the occurrence of thrombotic bailout (thrombotic complication during PCI that required the use of the bailout kit) at 96 h. Among the 5559 patients who underwent PCI in the delayed provisional eptibatide arm, 38% received active GP IIb/ IIIa receptor inhibitor therapy. There was no signicant reduction in the primary outcome in the early vs. delayed provisional eptibatide groups (9.3% vs. 10.0%; OR 0.92; 95% CI 0.801.06; P 0.23). There were also no signicant interactions among important subgroups and the primary endpoint, such as troponin-positive patients or diabetic patients. The secondary endpoint of death

surgery. In an analysis of patients receiving study medication within 7 days of CABG surgery, the rates of CABG-related major bleeding and transfusions were no different with clopidogrel or ticagrelor.134 Although non-fatal MI and stroke rates in the two groups were not signicantly different in this cohort, there was a halving of mortality in the ticagrelor group (4.7% vs. 9.7%; HR 0.49; 95% CI 0.32 0.77; P ,0.01), with much of this difference occurring early after CABG. In this analysis, 36% of patients in each group restarted ticagrelor or clopidogrel within 7 days of surgery, 26 27% restarted after .7 days, and 37 38% did not restart this medication.134 The optimal timing of restarting medication following CABG surgery remains uncertain. 5.2.2.5 Withdrawal of chronic dual antiplatelet therapy Withdrawal of antiplatelet agents may lead to an increased rate of recurrent events.112,144 Interruption of DAPT soon after stent implantation increases the risk of subacute stent thrombosis, which carries a particularly adverse prognosis, with mortality varying from 15% to 45% at 1 month. Interruption of DAPT in the case of a necessary surgical procedure .1 month after ACS in patients without a drug-eluting stent (DES) may be reasonable. If interruption of DAPT becomes mandatory, such as need for urgent surgery (e.g. neurosurgery), or major bleeding that cannot be controlled by local treatment, no proven efcacious alternative therapy can be proposed as a substitute. Low molecular weight heparins (LMWHs) have been advocated, without proof of efcacy.145 The summary of product characteristics of all three P2Y12 inhibitors stipulates that they have to be discontinued 7 days before surgery. However, management of patients under DAPT who are referred for surgical procedures depends on the degree of emergency as well as the thrombotic and bleeding risks of the individual patient. Most surgical procedures can be performed under DAPT or at least under acetylsalicylic acid alone with acceptable rates of bleeding. A multidisciplinary approach is required (cardiologist, anaesthesiologist, haematologist, and surgeon) to determine the patients risk and choose the best strategy. For NSTE-ACS patients, the risk of bleeding related to surgery must be balanced against the risk of recurrent ischaemic events related to discontinuation of therapy, bearing in mind the nature of the surgery, the ischaemic risk and extent of CAD, the time since the acute episode, andfor patients who have undergone PCIthe time since PCI, whether or not a DES was used, and the risk of stent thrombosis. In surgical procedures with low to moderate bleeding risk, surgeons should be encouraged to operate with the patient on DAPT. When it is considered appropriate to have a modest degree of P2Y12 inhibition at the time of surgery, such as is often the case early after an ACS for patients undergoing CABG surgery, then the drugs may be discontinued closer to the time of surgery. Under these circumstances, it is reasonable to stop clopidogrel 5 days before surgery, or less, if a validated platelet function testing method shows a poor response to clopidogrel, and stop prasugrel 7 days before surgery; ticagrelor may be discontinued 5 days before surgery. In very high risk patients in whom cessation of antiplatelet therapy before surgery seems to carry a high risk (e.g. within the rst weeks after stent implantation), it has been suggested to switch before surgery to

Page 22 of 56
from any cause or MI at 30 days was also similar (11.2% early vs. 12.3% delayed; OR 0.89; 95% CI 0.89 1.01; P 0.08). The same endpoint was also examined during the medical phase of the trial (either up to PCI or CABG, or for all the patients managed medically up to 30 days) and the 30 day estimates were similar (4.3% early eptibatide, vs. 4.2% placebo), suggesting no treatment effect among patients managed medically. Major bleeding rates were higher among patients assigned to early eptibatide compared with delayed provisional therapy using a variety of denitions (TIMI major bleed at 120 h, 2.6% vs. 1.8%; OR 1.42; 95% CI 1.97 1.89; P 0.015). Accordingly, this trial demonstrated no advantage with a routine upstream use of eptibatide in an invasive strategy compared with a delayed provisional strategy in the setting of contemporary antithrombotic therapy, where the minority of patients having PCI received eptibatide in the delayed provisional arm. Consistently among the trials is the signal for higher rates of bleeding with upstream GP IIb/IIIa treatment. Thus it is reasonable to withhold GP IIb/IIIa receptor inhibitors until after angiography. In patients undergoing PCI their use can be based on angiographic results (e.g. presence of thrombus and extent of disease), troponin elevation, previous treatment with a P2Y12 inhibitor, patient age, and other factors inuencing risk of serious bleeding.2,152 Upstream use of GP IIb/IIIa receptor inhibitors may be considered if there is active ongoing ischaemia among high risk patients or where DAPT is not feasible. Patients who receive initial treatment with eptibatide or tiroban before angiography should be maintained on the same drug during and after PCI. Thrombocytopenia Thrombocytopenia is associated to varying extents with the three approved GP IIb/IIIa receptor inhibitors (see Section 5.5.10). Acute thrombocytopenia has been reported to occur at rates ranging from 0.5% to 5.6% in clinical trials of parenteral GP IIb/IIIa receptor inhibitors, rates comparable with those observed with unfractionated (UFH) alone.153,154 Delayed thrombocytopenia may also occur after 511 days, and both acute and delayed types may be due to drug-dependent antibodies.155 Abciximab more than doubles the incidence of severe thrombocytopenia in comparison with placebo. The risk is lower with eptibatide [0.2% severe thrombocytopenia in Platelet Glycoprotein IIb-IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT)]156 or tiroban. In the Do Tiroban and ReoPro Give Similar Efcacy Trial (TARGET) study, thrombocytopenia developed in 2.4% of the patients treated with abciximab and in 0.5% of those treated with tiroban (P ,0.001).157 Comparative efcacy of glycoprotein IIb/IIIa receptor inhibitors Abciximab was tested in the setting of PCI in a head-to-head comparison vs. tiroban in the TARGET trial, in which two-thirds of the patients had NSTE-ACS.158 Abciximab was shown to be superior to tiroban in standard doses in reducing the risk of death, MI, and urgent revascularization at 30 days, but the difference was not signicant at 6 months.159 Further trials explored higher doses of tiroban in various clinical settings, and the results of meta-analyses suggest that high dose bolus tiroban (25 mg/kg followed by infusion) has similar efcacy to abciximab.160,161 There are no comparable data for eptibatide.

ESC Guidelines

Combination of glycoprotein IIb/IIIa receptor inhibitors with aspirin and a P2Y12 inhibitor Limited data are available about the benets of adding a GP IIb/IIIa receptor inhibitor to the combination of aspirin with a P2Y12 inhibitor in the setting of NSTE-ACS. In the Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment-2 (ISAR-REACT-2) trial, 2022 high risk NSTE-ACS patients were randomized following pre-treatment with aspirin and 600 mg of clopidogrel to either abciximab or placebo during PCI. There were similar proportions of diabetic patients in each group (average 26.5%); 52% of patients had elevated troponins and 24.1% had had a previous MI. The 30 day composite endpoint of death, MI, or urgent target vessel revascularization occurred signicantly less frequently in abciximab-treated patients vs. placebo (8.9% vs. 11.9%; RR 0.75; 95% CI 0.580.97; P 0.03). Most of the risk reduction with abciximab resulted from a reduction in death and nonfatal MI. The effect was more pronounced in certain pre-specied subgroups, particularly troponin-positive patients (13.1% vs. 18.3%; HR 0.71; 95% CI 0.540.95; P 0.02). The duration of pre-treatment with clopidogrel had no inuence on outcome, and there was no detectable treatment effect with abciximab in troponin-negative patients or among diabetic patients. However, the number of diabetic patients included in this trial may have been too low to provide robust statistical power to detect any effect. In the TRITON and PLATO trials, the rates of use of GP IIb/IIIa receptor inhibitors were 55% and 27%, respectively. Patients receiving a GP IIb/IIIa receptor inhibitor in the TRITON trial had higher rates of TIMI major and minor non-CABG bleeding, but use of a GP IIb/IIIa receptor inhibitor did not inuence the relative risk of bleeding with prasugrel compared with clopidogrel (P-value for interaction 0.19).162 Prasugrel reduced rates of death, MI, or stroke compared with clopidogrel, both with (6.5% vs. 8.5%; HR 0.76; 95% CI 0.64 0.90) and without (4.8% vs. 6.1%; HR 0.78; 95% CI 0.630.97) GP IIb/IIIa receptor inhibitors. In the PLATO trial, ticagrelor also reduced rates of death, MI, or stroke in patients receiving (10.0% vs. 11.1%; HR 0.90; 95% CI 0.761.07) or not receiving (9.7% vs. 11.9%; HR 0.82; 95% CI 0.740.92) a GP IIb/IIIa receptor inhibitor.132 Overall, it is reasonable to combine a GP IIb/IIIa receptor inhibitor with aspirin and a P2Y12 inhibitor for patients with NSTE-ACS undergoing PCI with a high risk of procedural MI and without a high risk of bleeding. Glycoprotein IIb/IIIa inhibitors and adjunctive anticoagulant therapy Most trials showing benets of GP IIb/IIIa receptor inhibitors used an anticoagulant. Several trials in the eld of NSTE-ACS, as well as observational studies in PCI, have shown that LMWH, predominantly enoxaparin, can be safely used with GP IIb/IIIa receptor inhibitors without compromising efcacy, although subcutaneous enoxaparin alone does not adequately protect against catheter thrombosis during primary PCI, despite this combination.163 In the Fifth Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS-5) trial, GP IIb/IIIa receptor inhibitors were used with aspirin, clopidogrel, and either fondaparinux in 1308 patients or enoxaparin in 1273 patients.164 Overall, bleeding complications were lower with fondaparinux than with enoxaparin (see Section 5.3). Bivalirudin and UFH/LMWH were shown to have equivalent safety and efcacy when used with aspirin, clopidogrel, and a GP

ESC Guidelines

Page 23 of 56
was used. Thus, bleeding event rates observed in clinical trials may be an under-representation of what happens in the real world where patients tend to have more frequent co-morbidities. Glycoprotein IIb/IIIa receptor inhibitors and coronary artery bypass graft surgery Patients undergoing CABG surgery whilst receiving GP IIb/IIIa receptor inhibitors require appropriate measures to ensure adequate haemostasis and discontinuation of GP IIb/IIIa receptor inhibitors before or, if not feasible, at the time of surgery. Eptibatide and tiroban have a short half-life ( 2 h), so platelet function due to reversible receptor binding can recover by the end of CABG surgery. Abciximab has a short plasma half-life (10 min) but dissociates slowly from the platelet, with a half-life of 4 h, so that recovery of platelet aggregation responses to normal or near-normal takes 48 h after the infusion has been terminated (although receptor-bound abciximab can be detected for much longer). If excessive bleeding occurs, fresh platelet transfusions may be administered (see Section 5.5.9). Fibrinogen supplementation with fresh frozen plasma or cryoprecipitate either alone or in combination with platelet transfusion can also be considered for managing major haemorrhagic complications associated with the administration of tiroban and eptibatide.169

IIb/IIIa receptor inhibitor in the ACUITY trial.165 The combination of bivalirudin and a GP IIb/IIIa receptor inhibitor results in a similar rate of ischaemic events compared with bivalirudin alone, but is associated with a higher rate of major bleeding events.166 Thus, this combination cannot be recommended for routine use. Dosing of glycoprotein IIb/IIIa receptor inhibitors The use of GP IIb/IIIa receptor inhibitors in routine practice has been explored in several registries. High rates of major bleeding events have been observed, partly related to excess dosing.167,168 The factors associated with excess dosing included older age, female sex, renal insufciency, low body weight, diabetes mellitus, and congestive heart failure. Patients that had excess dosing of GP IIb/IIIa receptor inhibitors had an adjusted major bleeding rate that was 30% higher compared with those where appropriate dosing

Recommendations for GP IIb/IIIa receptor inhibitors

Recommendations The choice of combination of oral antiplatelet agents, a GP IIb/IIIa receptor inhibitor, and anticoagulants should be made in relation to the risk of ischaemic and bleeding events. Among patients who are already treated with DAPT, the addition of a GP IIb/IIIa receptor inhibitor for high-risk PCI (elevated troponin, visible thrombus) is recommended if the risk of bleeding is low. Eptibatide or tiroban added to aspirin should be considered prior to angiography in high-risk patients not preloaded with P2Y12 inhibitors. In high-risk patients eptibatide or tiroban may be considered prior to early angiography in addition to DAPT, if there is ongoing ischaemia and the risk of bleeding is low. GP IIb/IIIa receptor inhibitors are not recommended routinely before angiography in an invasive treatment strategy. GP IIb/IIIa receptor inhibitors are not recommended for patients on DAPT who are treated conservatively.
a

Class a

Level b

Ref C

5.3 Anticoagulants
Anticoagulants are used in the treatment of NSTE-ACS to inhibit thrombin generation and/or activity, thereby reducing thrombusrelated events. There is evidence that anticoagulation is effective in addition to platelet inhibition and that the combination of the two is more effective than either treatment alone.171,172 Several anticoagulants, which act at different levels of the coagulation cascade, have been investigated or are under investigation in NSTE-ACS: Indirect inhibitors of coagulation (need antithrombin for their full action) Indirect thrombin inhibitors: UFH LMWHs Indirect factor Xa inhibitors: LMWHs fondaparinux
IIb C -

152, 161

IIa

Direct inhibitors of coagulation Direct factor Xa inhibitors: apixaban, rivaroxaban, otamixaban Direct thrombin inhibitors (DTIs): bivalirudin, dabigatran
III A 151, 170

For a review of anticoagulants and their action on the coagulation cascade see Figure 3. More detailed information about anticoagulants can be found elsewhere.171 5.3.1 Indirect inhibitors of the coagulation cascade 5.3.1.1 Fondaparinux The only selective activated factor X (factor Xa) inhibitor available for clinical use is fondaparinux, a synthetic pentasaccharide structurally similar to the antithrombin-binding sequence common to all forms of heparin. It inhibits coagulation factor Xa by binding reversibly and non-covalently to antithrombin, with a high afnity. It catalyses antithrombin-mediated inhibition of factor Xa, thereby preventing thrombin generation. Fondaparinux increases the

III

150, 151

Class of recommendation. Level of evidence. c References. DAPT dual (oral) antiplatelet therapy; GP glycoprotein; PCI percutaneous coronary intervention.
b

Page 24 of 56
ability of antithrombin to inhibit factor Xa 300-fold. The inhibition of 1 U of factor Xa prevents the production of 50 U of thrombin. Fondaparinux has 100% bioavailability after subcutaneous injection, with an elimination half-life of 17 h, and can therefore be given once daily. It is eliminated mainly by the kidneys, and is contraindicated if CrCl is ,20 mL/min. Fondaparinux is insensitive to inactivation by platelet-released heparin neutralization proteins. No denite case of heparin-induced thrombocytopenia (HIT) has been reported with this drug, even after extensive use in the setting of prevention and treatment of venous thrombo-embolism (VTE). Therefore, monitoring of the platelet count is not necessary. No dose adjustment and no monitoring of anti-Xa activity are required. Fondaparinux has no signicant inuence on the usual variables that monitor anticoagulant activity, such as activated partial thromboplastin time (aPTT), activated clotting time (ACT), prothrombin, and thrombin times. In ACS, a 2.5 mg xed daily dose of fondaparinux is recommended. This dose was selected on the basis of the results of Pentasaccharide in Unstable Angina (PENTUA), a dose-ranging study of fondaparinux, and further tested in two large phase III trials (OASIS-5 and OASIS-6).173 175 In the PENTUA study, the

ESC Guidelines

2.5 mg dose was shown to be at least as efcacious and as safe as higher doses. Fondaparinux was also tested in the setting of elective or urgent PCI at doses of 2.5 and 5 mg, given i.v. No signicant difference in efcacy and safety was observed between the 2.5 and 5 mg doses, and between the two fondaparinux doses and the UFH control group176; however, with only 350 patients included, the study lacked statistical power. Abrupt vessel closure and unexpected angiographic thrombus tended to occur more frequently in the two fondaparinux groups compared with the UFH group (2.5% and 5.1%, respectively, for the 2.5 mg fondaparinux dose and 0% and 4.3% for the 5.0 mg fondaparinux dose vs. 0.9% and 0.9% for the UFH control group).176 In the OASIS-5 study, 20 078 patients with NSTE-ACS were randomized to receive 2.5 mg of subcutaneous fondaparinux once daily or subcutaneous enoxaparin 1 mg/kg twice daily for 8 days maximum (average 5.2 vs. 5.4 days, respectively).175 The primary efcacy outcome of death, MI, or refractory ischaemia at 9 days was 5.7% for enoxaparin vs. 5.8% for fondaparinux (HR 1.01; 95% CI 0.901.13), fullling the criteria for non-inferiority. At the same point, major bleeds were halved with fondaparinux: 2.2% compared with 4.1% with enoxaparin (HR 0.52; 95% CI

Targets for antithrombics

Anticoagulation
Tissue Factor Aspirin Fondaparinux Plasma clotting cascade Thromboxane A2 ADP Collagen

Antiplatelet

Prothrombin AT

Clopidogrel Prasugrel Ticagrelor

LMWH Heparin

Factor Xa

Conformational activation of GPIIb/IIIa GPIIb/IIIa inhibitors Thrombin Platelet aggregation

AT

Bivalirudin Fibrinogen Fibrin

Thrombus

Figure 3 Targets for antithrombotic drugs. AT antithrombin; GP glycoprotein; LMWH low molecular weight heparin.

ESC Guidelines

Page 25 of 56
rate of major bleeding was not signicantly different between the two groups (1.2% vs. 1.4% standard vs. low dose groups), and was similar to that observed in patients submitted to PCI in the fondaparinux arm of the OASIS-5 trial (1.5% at 48 h, same bleeding denition). Minor bleeding events were less frequent in the low dose group (0.7% vs. 1.7%, low vs. standard dose; OR 0.40; 95% CI 0.160.97; P 0.04). The net clinical benet (major bleeding at 48 h or target vessel revascularization at 30 days) favoured the standard dose group (5.8% vs. 3.9%, low vs. standard dose; OR 1.51; 95% CI 1.002.28; P 0.05). The secondary endpoint of death, MI, or target vessel revascularization also favoured the standard dose group (4.5% vs. 2.9%, low vs. standard dose group; OR 1.58; 95% CI 0.982.53; P 0.06). Catheter thrombus was rare (0.5% in the low dose group and 0.1% in the standard dose group, P 0.15). The practical implications of these data are that a standard UFH bolus should be recommended at the time of PCI in patients pre-treated with fondaparinux on the basis of a more favourable net clinical benet and lower risk of catheter thrombosis compared with low dose UFH. 5.3.1.2 Low molecular weight heparins LMWHs are a class of heparin-derived compounds with molecular weights ranging from 2000 to 10 000 Da. They have balanced anti-Xa and anti-IIa activity, depending on the molecular weight of the molecule, with greater anti-IIa activity with increasing molecular weight. LMWHs have different pharmacokinetic properties and anticoagulant activities, and are not therefore clinically interchangeable. LMWHs have several advantages over UFH, particularly an almost complete absorption after subcutaneous administration, less protein binding, less platelet activation, and, thereby, a more predictable doseeffect relationship.171 Furthermore, there is a lower risk of HIT with LMWHs compared with UFH. LMWHs are eliminated at least partially by the renal route. The risk of accumulation increases with declining renal function, resulting in an increased bleeding risk. Most LMWHs are contraindicated in the case of renal failure with CrCl ,30 mL/min. However, for enoxaparin, dose adaptation is advocated in patients with a CrCl ,30 mL/min (1 mg/kg once instead of twice daily). The LMWH doses used in NSTE-ACS are body weight adjusted and are commonly administered subcutaneously twice daily, although an initial i.v. bolus in high risk patients is possible.179 182 With the current doses used in clinical practice, monitoring of anti-Xa activity is not necessary, except in special populations of patients such as those with renal failure or obesity. The optimal level of anti-Xa activity to be achieved in the treatment of patients with NSTE-ACS remains poorly dened. In patients treated for VTE, the therapeutic range is 0.6 1.0 IU/mL, without a clear relationship between anti-Xa activity and clinical outcome. However, the bleeding risk increases above 1.0 IU/mL of anti-Xa activity.183 In NSTE-ACS, enoxaparin was tested in a dose-ranging trial at 1.25 and 1.0 mg/kg twice daily. Peak anti-Xa activity was 1.5 IU/mL with the higher dose and 1.0 IU/mL with the lower dose. With the 1.25 mg/kg dose the rate of major bleeding through 14 days was 6.5% (predominantly at instrumented sites). With the 1.0 mg/kg dose the rate of major haemorrhage was reduced to 1.9%. Patients with major haemorrhage had anti-Xa activity in the range of 1.8 2.0 IU/mL.184 In a large unselected cohort of patients with unstable

0.440.61; P ,0.001). Major bleeding was an independent predictor of long-term mortality, which was signicantly reduced with fondaparinux at 30 days (2.9% vs. 3.5%; HR 0.83; 95% CI 0.71 0.97; P 0.02) and at 6 months (5.8% vs. 6.5%; HR 0.89; 95% CI 0.801.00; P 0.05). At 6 months the composite endpoint of death, MI, or stroke was signicantly lower with fondaparinux vs. enoxaparin (11.3% vs. 12.5%; HR 0.89; 95% CI 0.820.97; P 0.007). In the population submitted to PCI, a signicantly lower rate of major bleeding complications (including access site complications) was observed at 9 days in the fondaparinux group vs. enoxaparin (2.4% vs. 5.1%; HR 0.46; 95% CI 0.350.61; P ,0.001). Interestingly, the rate of major bleeding was not inuenced by the timing of the intervention after injection of the last dose of fondaparinux (1.6% vs. 1.3% for ,6 h vs. .6 h, respectively). Catheter thrombus was observed more frequently with fondaparinux (0.9%) than with enoxaparin (0.4%), but was abolished by injection of an empirically determined bolus of UFH at the time of PCI. As the rate of ischaemic events was similar in both the fondaparinux and heparin groups at 9 days, the net clinical benet of death, MI, stroke, and major bleeding favoured fondaparinux vs. enoxaparin (8.2% vs. 10.4%; HR 0.78; 95% CI 0.670.93; P 0.004). A mechanistic explanation for the difference between the fondaparinux and enoxaparin regimens has been proposed.177 Fondaparinux at a dose of 2.5 mg daily leads to an 50% lower anticoagulant effect compared with enoxaparin at the standard dose as assessed by anti-Xa activity. Similarly, inhibition of thrombin generation is also twice as low with fondaparinux, as assessed by thrombin generation potential. This suggests that a low level of anticoagulation is sufcient to prevent further ischaemic events during the acute phase of NSTE-ACS in patients on full antiplatelet therapy including aspirin and clopidogrel, plus GP IIb/IIIa receptor inhibitors in many, because there was no difference in the primary endpoint between the fondaparinux and enoxaparin groups at 9 days in OASIS-5.175 This low level of anticoagulation explains the signicant reduction in the risk of bleeding. However, such a low level of anticoagulation is not sufcient to prevent catheter thrombosis during PCI in a highly thrombogenic environment. This also conrms that an additional bolus of UFH is needed at the time of PCI in patients initially treated with fondaparinux. The optimal dose of UFH to be administered as a bolus during PCI in patients initially treated with fondaparinux was investigated in the Fondaparinux Trial With Unfractionated Heparin During Revascularization in Acute Coronary Syndromes (FUTURA)/ OASIS-8 trial.178 In this study, 2026 patients initially treated with fondaparinux, submitted to PCI within 72 h following initiation of therapy, received either a low dose i.v. bolus of UFH (50 IU/kg), regardless of the dose of GP IIb/IIIa receptor inhibitors (if any), or standard dose UFH, namely 85 IU/kg (reduced to 60 U/kg in the case of the use of GP IIb/IIIa receptor inhibitors), adjusted by blinded ACT. PCI was carried out early after administration of the last dose of fondaparinux (4 h). There was no signicant difference between the two groups in terms of the primary composite endpoint (major bleeding, minor bleeding, or major vascular access site complications) at 48 h after PCI (4.7% vs. 5.8%, low vs. standard dose group; OR 0.80; 95% CI 0.541.19; P 0.27). The

Page 26 of 56
angina/NSTEMI, low anti-Xa activity (,0.5 IU/mL) on enoxaparin was associated with a .3-fold increase in mortality compared with patients with anti-Xa levels in the target range of 0.5 1.2 IU/ mL. Low anti-Xa levels (,0.5 IU/mL) were independently associated with 30 day mortality, which highlights the need to achieve at least the anti-Xa level of 0.5 IU/mL with enoxaparin whenever possible.185 Furthermore, it was shown in observational studies and small trials in a PCI setting that anti-Xa activity .0.5 IU/mL was associated with a low incidence of ischaemic and haemorrhagic events.186,187 Several meta-analyses have been published about the respective efcacy of LMWHs vs. UFH in NSTE-ACS. The rst, which included 12 trials with different drugs totalling 17 157 patients, conrmed that heparins in aspirin-treated NSTE-ACS patients conferred a signicant benet over placebo in terms of death or MI (OR 0.53; 95% CI 0.380.73; P 0.0001). There was no signicant advantage in favour of LMWHs compared with UFH with regard to efcacy or safety endpoints.172 A meta-analysis of all trials testing enoxaparin vs. UFH, totalling 21 946 patients, showed no signicant difference between the two compounds for death at 30 days (3.0% vs. 3.0%; OR 1.00; 95% CI 0.851.17; P not signicant). A signicant reduction in the combined endpoint of death or MI at 30 days was observed in favour of enoxaparin vs. UFH (10.1% vs. 11.0%; OR 0.91; 95% CI 0.830.99). A post-hoc subgroup analysis showed a signicant reduction in death or MI at 30 days in enoxaparin-treated patients who did not receive UFH prior to randomization vs. the UFH group (8.0% vs. 9.4%, respectively; OR 0.81; 95% CI 0.700.94). No signicant differences in blood transfusions (7.2% vs. 7.5%; OR 1.01; 95% CI 0.891.14) or major bleeding (4.7% vs. 4.5%; OR 1.04; 95% CI 0.83 1.30) were observed at 7 days after randomization in the overall population, or in the population of patients who received no anticoagulant therapy before randomization. A further meta-analysis encompassing all trials with enoxaparin in ACS, not only NSTE-ACS, derived similar ndings.188 Lastly, the respective efcacy and safety of LMWHs compared with UFH when prescribed in association with GP IIb/IIIa receptor inhibitors was explored in small sized trials. Overall there was no signicant difference in safety endpoints. None of these trials showed a difference in efcacy in terms of hard endpoints, except in the Integrilin and Enoxaparin Randomized Assessment of Acute Coronary Syndrome Treatment (INTERACT) trial, where a signicant difference in favour of enoxaparin plus eptibatide was observed over UFH plus eptibatide.189 191 However, none of these trials had sufcient statistical power to draw denitive conclusions. Most of these trials were carried out at a time when an invasive strategy was not routine practice, and in some an invasive strategy was not encouraged. As a result only a minority of patients in these trials underwent an invasive strategy, and any conclusions that may be drawn from these studies are now likely to be outdated. The only trial to test enoxaparin vs. UFH using a contemporary approach, with a high rate of PCI, revascularization, stent implantation, and active antiplatelet therapy with aspirin, clopidogrel, and GP IIb/IIIa receptor inhibitors, was the Superior Yield of the New Strategy of Enoxaparin, Revascularization and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial.192 This trial included 10 027 high risk patients undergoing early invasive evaluation plus revascularization, of which 76% received anticoagulants prior to randomization. No

ESC Guidelines

signicant difference was observed in terms of death and MI at 30 days (enoxaparin vs. UFH, 14.0% vs. 14.5%; OR 0.96; 95% CI 0.861.06; P not signicant).193 More bleeding events occurred with enoxaparin, with a statistically signicant increase in TIMI major bleeding (9.1% vs. 7.6%; P 0.008), but a non-signicant excess in Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe bleeding events (2.7% vs. 2.2%; P 0.08) and transfusions (17.0% vs. 16.0%; P 0.16). In retrospect, the excess bleeding was probably due to a high rate of prerandomization use of anticoagulants, and also possibly to frequent post-randomization crossover from one anticoagulant to the other. Nevertheless, LMWHs, primarily enoxaparin, are commonly used in the PCI setting in spite of the fact that anticoagulation cannot be monitored easily. The i.v. use of enoxaparin has a different pharmacokinetic/pharmacodynamic prole from the subcutaneous use. In elective PCI, enoxaparin is used at a dose of 1 mg/kg as an i.v. injection. The i.v. doses tested in clinical trials were lower (usually 0.5 mg/kg) and reached the same peak of anti-Xa activity within 3 min.194 I.v. administration provides an immediate and predictable anticoagulation for 2 h. Lower doses have also been tested in the Safety and Efcacy of Intravenous Enoxaparin in Elective Percutaneous Coronary Intervention: an International Randomized Evaluation (STEEPLE) study.195 Lower bleeding rates were achieved with 0.5 and 0.75 mg/kg doses compared with UFH in these non-ACS patients. However, the trial was not powered to detect a difference in efcacy between enoxaparin groups. In NSTE-ACS patients pre-treated with enoxaparin, no additional enoxaparin is recommended during PCI if the last subcutaneous enoxaparin injection was administered ,8 h before PCI, whereas an additional 0.3 mg/kg i.v. bolus is recommended if the last subcutaneous enoxaparin injection was administered .8 h before PCI. Crossing over to another anticoagulant during PCI is strongly discouraged. 5.3.1.3 Unfractionated heparin UFH is a heterogeneous mixture of polysaccharide molecules, with a molecular weight ranging from 2000 to 30 000 (mostly 15 000 18 000) Da. One-third of the molecules found within a standard UFH preparation contain the pentasaccharide sequence, which binds to antithrombin and accelerates the rate at which antithrombin inhibits factor Xa. Inhibition of factor IIa requires heparin to bind to both thrombin and antithrombin to bridge them. UFH is poorly absorbed by the subcutaneous route, so i.v. infusion is the preferred route of administration. The therapeutic window is narrow, requiring frequent monitoring of aPTT, with an optimal target level of 50 75 s, corresponding to 1.5 2.5 times the upper limit of normal. At higher aPTT values, the risk of bleeding complications is increased, without further antithrombotic benets. At aPTT values ,50 s, the antithrombotic effect is limited. A weight-adjusted dose of UFH is recommended, at an initial bolus of 6070 IU/kg with a maximum of 5000 IU, followed by an initial infusion of 1215 IU/kg/h, to a maximum of 1000 IU/h. This regimen is currently recommended as being the most likely to achieve target aPTT values.171 The anticoagulant effect of UFH is lost rapidly within a few hours after interruption. During the rst 24 h after termination of treatment, there is a risk of reactivation

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Page 27 of 56
with either UFH or LMWH with a GP IIb/IIIa receptor inhibitor (control arm) (n 4603); bivalirudin with a GP IIb/IIIa receptor inhibitor (n 4604); or bivalirudin alone (n 4612). Bivalirudin was started before angiography with an i.v. bolus of 0.1 mg/kg and an infusion of 0.25 mg/kg/h, followed before PCI by an additional i.v. bolus of 0.5 mg/kg and infusion of 1.75 mg/kg/h. The drug was stopped after PCI. There was no signicant difference between standard UFH/LMWHs plus GP IIb/IIIa receptor inhibitors, and the combination of bivalirudin and GP IIb/IIIa receptor inhibitors, for the composite ischaemia endpoint at 30 days (7.3% vs. 7.7%, respectively; RR 1.07; 95% CI 0.92 1.23; P 0.39) or for major bleeding (5.7% vs. 5.3%; RR 0.93; 95% CI 0.78 1.10; P 0.38). Bivalirudin alone was non-inferior to the standard UFH/LMWHs combined with GP IIb/IIIa receptor inhibitors with respect to the composite ischaemia endpoint (7.8% vs. 7.3%; RR 1.08; 95% CI 0.93 1.24; P 0.32), but with a signicantly lower rate of major bleeding (3.0% vs. 5.7%; RR 0.53; 95% CI 0.43 0.65; P ,0.001). Therefore, the 30 day net clinical outcome was signicantly better (10.1% vs. 11.7%; RR 0.86; 95% CI 0.770.94; P 0.02) with bivalirudin alone vs. UFH/LMWHs plus GP IIb/IIIa receptor inhibitors.196 The treatment effects of bivalirudin monotherapy as regards net clinical outcome were consistent among most pre-specied subgroups, except in patients not pre-treated with clopidogrel prior to PCI, in whom a signicant excess of composite ischaemic endpoints was observed (9.1% vs. 7.1%; RR 1.29, 95% CI 1.031.63) for bivalirudin alone vs. UFH/LMWHs plus GP IIb/IIIa receptor inhibitors. Overall, bivalirudin plus a provisional GP IIb/IIIa receptor inhibitor showed similar efcacy to heparin/LMWHs plus systematic GP IIb/IIIa receptor inhibitors, while signicantly lowering the risk of major haemorrhagic complications.197 However, no signicant difference in short- or long-term outcomes was observed in ACUITY between these two anticoagulation strategies.198 Lastly, data suggest that crossover from UFH or LMWH to bivalirudin at the time of PCI does not result in an excess of bleeding, but actually has a protective effect against bleeding.199 5.3.3 Anticoagulants under clinical investigation New anticoagulants are currently under investigation in the setting of ACS. Most of these target secondary prevention rather than the initial phase of the disease. Anti-Xa agents have been tested in phase II trials.200,201 Different doses of the oral direct factor Xa inhibitors apixaban [(Apixaban for Prevention of Acute Ischemic Events (APPRAISE) trial]202 and rivaroxaban [Anti-Xa Therapy to Lower Cardiovascular Events in Addition to Aspirin With or Without Thienopyridine Therapy in Subjects with Acute Coronary Syndrome-46 (ATLAS ACS-TIMI)]201 have been tested in patients with recent ACS on top of either aspirin or DAPT (acetylsalicylic acid plus clopidogrel) for a period of 6 months. In both trials a dose-related increase in the rate of bleeding, with a trend towards a reduction in ischaemic events, particularly apparent in patients treated with aspirin only, was observed. These agents have been taken into phase III clinical trials (APPRAISE-2 and ATLAS-2) on the basis of these ndings. APPRAISE-2 was stopped prematurely due to excessive bleeding with the apixaban regimen.

of the coagulation process and thereby a transiently increased risk of recurrent ischaemic events despite concurrent aspirin treatment. A pooled analysis of six trials testing short-term UFH vs. placebo or untreated controls showed a 33% risk reduction in death and MI (OR 0.67; 95% CI 0.450.99; P 0.04).172 The risk reduction for MI accounted for practically all of the benecial effect. In trials comparing the combination of UFH plus aspirin vs. aspirin alone in NSTE-ACS, a trend towards a benet was observed in favour of the UFH aspirin combination, but at the cost of an increased risk of bleeding. Recurrence of events after interruption of UFH explains why this benet is not maintained over time, unless the patient is revascularized before the interruption of UFH. In the PCI setting, UFH is given as an i.v. bolus either under ACT guidance (ACT in the range of 250 350 s, or 200 250 s if a GP IIb/IIIa receptor inhibitor is given) or in a weight-adjusted manner (usually 70 100 IU/kg, or 5060 IU/kg in combination with a GP IIb/IIIa receptor inhibitors).171 Because of marked variability in UFH bioavailability, ACT-guided dosing is advocated, especially for prolonged procedures when additional dosing may be required. Continued heparinization after completion of the procedure, either preceding or following arterial sheath removal, is not recommended. If the patient is taken to the catheterization laboratory with an ongoing i.v. infusion of heparin, a further i.v. bolus of UFH should be adapted according to the ACT values and use of GP IIb/IIIa receptor inhibitors. 5.3.2 Direct thrombin inhibitors (bivalirudin) Several DTIs have been tested over time, but only bivalirudin reached clinical use in PCI and ACS settings. Bivalirudin binds directly to thrombin (factor IIa) and thereby inhibits the thrombin-induced conversion of brinogen to brin. It inactivates brin-bound as well as uid-phase thrombin. As it does not bind to plasma proteins, the anticoagulant effect is more predictable. Bivalirudin is eliminated by the kidney. Coagulation tests (aPTT and ACT) correlate well with plasma concentrations, so these two tests can be used to monitor the anticoagulant activity of bivalirudin. Bivalirudin has been initially tested in the setting of PCI. In the Randomized Evaluation of PCI Linking Angiomax to reduced Clinical Events (REPLACE-2) trial, bivalirudin plus provisional GP IIb/IIIa receptor inhibitors was shown to be non-inferior to UFH plus GP IIb/IIIa receptor inhibitors regarding the protection against ischaemic events during PCI procedures, but with a signicantly lower rate of major bleeding complications (2.4% vs. 4.1%, P , 0.001) for bivalirudin. No signicant difference was observed in the hard endpoints at 1 month, 6 months, and 1 year. Bivalirudin is currently approved for urgent and elective PCI at a dose of 0.75 mg/kg bolus followed by 1.75 mg/kg/h. In NSTE-ACS patients, bivalirudin is recommended at a dose of 0.1 mg/kg i.v. bolus followed by an infusion of 0.25 mg/kg/h until PCI. ACUITY was the only trial to test bivalirudin specically in the setting of NSTE-ACS.196 It was a randomized, open-label trial in 13 819 moderate to high risk NSTE-ACS patients planned for an invasive strategy. Patients were randomized to one of three unblinded treatment groups: standard combination treatment

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The direct thrombin inhibitor dabigatran was investigated in a phase II dose-nding trial [Randomized Dabigatran Etexilate Dose Finding Study In Patients With Acute Coronary Syndromes (ACS) Post Index Event With Additional Risk Factors For Cardiovascular Complications Also Receiving Aspirin And Clopidogrel (RE-DEEM), unpublished]. Otamixaban, an i.v. direct factor Xa inhibitor, has also been tested in a phase II trial203; a phase III trial with this compound is ongoing.

ESC Guidelines

Recommendations for anticoagulants

Recommendations Anticoagulation is recommended for all patients in addition to antiplatelet therapy. The anticoagulation should be selected according to both ischaemic and bleeding risks, and according to the efcacysafety prole of the chosen agent. Fondaparinux (2.5 mg subcutaneously daily) is recommended as having the most favourable efcacysafety prole with respect to anticoagulation. If the initial anticoagulant is fondaparinux, a single bolus of UFH (85 IU/kg adapted to ACT, or 60 IU in the case of concomitant use of GP IIb/IIIa receptor inhibitors) should be added at the time of PCI. Enoxaparin (1 mg/kg twice daily) is recommended when fondaparinux is not available. If fondaparinux or enoxaparin are not available, UFH with a target aPTT of 5070 s or other LMWHs at the specic recommended doses are indicated. Bivalirudin plus provisional GP IIb/IIIa receptor inhibitors are recommended as an alternative to UFH plus GP IIb/IIIa receptor inhibitors in patients with an intended urgent or early invasive strategy, particularly in patients with a high risk of bleeding. In a purely conservative strategy, anticoagulation should be maintained up to hospital discharge. Discontinuation of anticoagulation should be considered after an invasive procedure unless otherwise indicated. Crossover of heparins (UFH and LMWH) is not recommended.
a

Class a

Level b

Ref C

171, 172

5.3.4 Combination of anticoagulation and antiplatelet treatment Anticoagulation and DAPT with aspirin and a P2Y12 inhibitor are recommended as rst-line treatment during the initial phase of NSTE-ACS. The duration of anticoagulation is limited to the acute phase, whereas DAPT is recommended for 12 months with or without PCI and stent implantation. A sizeable proportion of patients (6 8%) presenting with NSTE-ACS have an indication for long-term oral anticoagulation with a vitamin K antagonist (VKA) due to various conditions such as moderate to high embolic risk AF, mechanical heart valves, or VTE. Dual therapy (i.e. aspirin or clopidogrel plus a VKA) or triple therapy (DAPT plus a VKA) is associated with a three- to fourfold increase in major bleeding complications. The management of such patients is challenging owing to the fact that a good level of anticoagulation should be maintained during the acute and long-term phases of the disease. Interruption of VKA therapy may expose the patient to an increased risk of thrombo-embolic episodes. Interventions such as angiography, PCI, or CABG may be delicate or impossible to perform under full VKA anticoagulation; and long-term exposure of patients to triple therapy is clearly associated with a high risk of bleeding. Accordingly, several precautions have to be considered, as outlined in a recent consensus paper in elective coronary interventions as well as in the acute setting (NSTEMI or STEMI).204 DES should be strictly limited to those clinical and/or anatomical situations, such as long lesions, small vessels, diabetes, etc., where a major benet is expected compared with bare-metal stents (BMSs). If patients under dual or triple therapy need re-angiography, radial access should be the preferred choice in order to reduce the risk of periprocedural bleeding. PCI without interruption of VKAs, to avoid bridging therapy that may lead to more bleeding or ischaemic complications, has also been advocated. In the acute setting, it may be prudent to stop VKA therapy and administer antiplatelet therapy and anticoagulants as recommended if the international normalized ratio (INR) is ,2.0. In the medium to long term, if VKA therapy needs to be given in combination with clopidogrel and/or low dose aspirin, careful monitoring of the INR is warranted, with target values in the range of 2.0 2.5. Triple therapy should be limited in duration depending on the clinical setting, the implantation of a BMS or a DES, and ischaemic or bleeding risks as assessed by risk scores and/or baseline characteristics (Table 6). Since 50% of all spontaneous bleeds are gastrointestinal, gastric protection should be implemented with a proton pump inhibitor.

173, 175

178

175, 193

165, 196, 197

175, 180182

IIa

III

171, 183, 193

Class of recommendation. Level of evidence. c References. ACT activated clotting time; aPTT activated partial thromboplastin time; GP glycoprotein; LMWH low molecular weight heparin; PCI percutaneous coronary intervention; UFH unfractionated heparin.
b

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tended to have a higher event rate with an early invasive strategy, suggesting that early invasive procedures should be avoided in low risk, troponin-negative, female patients. A recent meta-analysis, based on individual patient data from the FRISC-2, Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS), and Randomized Intervention Trial of unstable Angina-3 (RITA-3) studies comparing a routine invasive vs. a selective invasive strategy, revealed a reduction in rates of death and non-fatal MI at 5-year follow-up, with the most pronounced difference in high risk patients.209 Age, diabetes, previous MI, ST-segment depression, hypertension, body mass index (,25 kg/m2 or .35 kg/m2), and treatment strategy were found to be independent predictors of death and non-fatal MI during follow-up.209 There was a 2.0 3.8% absolute reduction in cardiovascular death or MI in the low and intermediate risk groups, and an 11.1% absolute risk reduction in the highest risk patients. These results support a routine invasive strategy, but highlight the role of risk stratication in the management decision process. The subgroups of patients at high risk that benet from an early invasive management (diabetic patients, the elderly, patients with renal insufciency) are discussed in the respective sections. 5.4.2 Timing of angiography and intervention The optimal timing of angiography and revascularization in NSTE-ACS has been studied extensively. However, patients at very high risk, i.e. those with refractory angina, severe heart failure, life-threatening ventricular arrhythmias, or haemodynamic instability, were generally not included in RCTs, in order not to withhold potentially life-saving treatment. Such patients may have evolving MI and should be taken to an immediate (,2 h) invasive evaluation, regardless of ECG or biomarker ndings. Previously, there has been a debate about whether early angiography followed by revascularization is associated with an early hazard.206 A very early invasive strategy (0.5 14 h), as opposed to a delayed invasive strategy (2186 h), was tested in ve prospective RCTs, of which only Timing of Intervention in Patients with Acute Coronary Syndromes (TIMACS) had an adequate size (for an overview, see the ESC revascularization guidelines148). In a meta-analysis of three trialsAngioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD),210 Early or Late Intervention in unStable Angina (ELISA),211 Intracoronary Stenting With Antithrombotic Regimen Cooling Off (ISAR-COOL),170 and TIMACS212early catheterization followed by coronary intervention on the rst day of hospitalization was shown to be safe and superior in terms of lower risk of recurrent ischaemia ( 41%) and shorter hospital stay ( 28%).213 With respect to hard endpoints, only the small Optimal Timing of PCI in Unstable Angina (OPTIMA) trial found an increased rate of procedure-related MI in patients having an immediate (30 min) compared with a deferred (25 h) strategy.214 In contrast, the ABOARD trial did not conrm a difference in MI as dened by troponin release when an immediate intervention (1.2 h) was compared with a strategy of intervention deferred to the next working day (mean 21 h).210 Owing to heterogeneous risk proles, the optimal timing for an invasive approach may vary in different risk cohorts. There is growing evidence to suggest a benet of an invasive strategy

5.4 Coronary revascularization

Revascularization for NSTE-ACS relieves symptoms, shortens hospital stay, and improves prognosis. The indications and timing for myocardial revascularization and choice of preferred approach (PCI or CABG) depend on many factors including the patients condition, the presence of risk features, co-morbidities, and the extent and severity of the lesions as identied by coronary angiography. Risk stratication should be performed as early as possible to identify high risk individuals rapidly and reduce the delay to an early invasive approach. However, patients with NSTE-ACS represent a heterogeneous population in terms of risk and prognosis. This extends from low risk patients who benet from conservative treatment and a selective invasive approach to patients at high risk for death and cardiovascular events, who should be rapidly referred for angiography and revascularization. Therefore, risk stratication is critical for selection of the optimal management strategy. Analysis of the patient risk prole may be performed by assessment of generally accepted high risk criteria and/or applying pre-dened risk scores such as the GRACE risk score (see Section 4.4).205

5.4.1 Invasive versus conservative approach Many randomized controlled trials (RCTs) and meta-analyses have assessed the effects of a routine invasive vs. conservative or selective invasive approach in the short and long term. The benet of revascularization is difcult to compare and tends to be underestimated in these trials due to different proportions of patients crossing over from the conservative arm to revascularization (crossover rates vary from 28% to as high as 58%). In general, the benet is more pronounced when the difference in revascularization rates between invasive and conservative arms is high. Furthermore, the selection of patients may have been biased, as some studies included all consecutive patients while others excluded severely unstable patients. A meta-analysis of seven RCTs comparing routine angiography followed by revascularization with a selective invasive strategy showed reduced rates of combined death and MI, with a nonsignicant trend towards fewer deaths and a signicant reduction in MI alone, with a routine invasive strategy.206 There was, however, an early hazard in terms of a signicantly higher risk of death and of death and MI during initial hospitalization for the routine invasive management. However, four of the seven trials included in this meta-analysis were not contemporary due to marginal use of stents and GP IIb/IIIa receptor inhibitors. Another meta-analysis including seven trials with more contemporary adjunctive medication showed a signicant risk reduction for allcause mortality and non-fatal MI for an early invasive vs. conservative approach at 2 years without an excess of death and non-fatal MI at 1 month.207 A more recent meta-analysis of eight RCTs showed a signicant reduction in death, MI, or rehospitalization with ACS for the invasive strategy at 1 year.208 However, this benet was driven mainly by improved outcomes in biomarkerpositive (high risk) patients. In a sex-specic analysis, a comparable benet was found in biomarker-positive women compared with biomarker-positive men. Importantly, biomarker-negative women

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ESC Guidelines

Table 9 Criteria for high risk with indication for invasive management
Primary Relevant rise or fall in troponina Dynamic ST- or T-wave changes (symptomatic or silent) Secondary Diabetes mellitus Renal insufciency (eGFR <60 mL/min/1.73 m) Reduced LV function (ejection fraction <40%) Early post infarction angina Recent PCI Prior CABG Intermediate to high GRACE risk score (Table 5)

a Rise/fall of troponin relevant according to precision of assay (see Section 3.2.3). CABG coronary artery bypass graft; eGFR estimated glomerular ltration rate; GRACE Global Registry of Acute Coronary Events; LV left ventricular; PCI percutaneous coronary intervention.

within 24 h in patients with a high risk prole. The TIMACS trial revealed a signicant 38% reduction in death, MI, or stroke at 6 months in high risk patients (GRACE score .140), with an early (24 h) compared with a delayed (36 h) strategy. No signicant difference was observed in patients with a low to intermediate risk prole (GRACE score 140).212 Importantly, there were no safety issues regarding an early invasive strategy in this trial. In the ACUITY data analysis, delay to PCI .24 h was an independent predictor of 30-day and 1-year mortality.215 This increased ischaemic event rate was most evident among moderate and high risk patients (according to the TIMI risk score). Optimal adjunctive pharmacotherapy is important in an invasive strategy, but pre-treatment should not delay angiography and the intervention.151 An intentional delayed invasive approach for stabilization including GP IIb/IIIa receptor inhibitors (cooling-off strategy) is of no benet.151,170 In summary, timing of angiography and revascularization should be based on patient risk prole. Patients at very high risk (as dened above) should be considered for urgent coronary angiography (,2 h). In patients at high risk with a GRACE risk score of .140 or with at least one major high risk criterion, an early invasive strategy within 24 h appears to be the reasonable time window. This implies expedited transfer for patients admitted to hospitals without on-site catheterization facilities. In lower risk subsets with a GRACE risk score of ,140 but with at least one high risk criterion (Table 9), the invasive evaluation can be delayed without increased risk but should be performed during the same hospital stay, preferably within 72 h of admission. In such patients, immediate transfer is not mandatory, but should be organized within 72 h (e.g. diabetic patients). In other low risk patients without recurrent symptoms a non-invasive assessment of inducible ischaemia should be performed before hospital discharge. Coronary angiography should be performed if the results are positive for reversible ischaemia.

5.4.3 Percutaneous coronary intervention versus coronary artery bypass surgery There are no specic RCTs comparing PCI with CABG in patients with NSTE-ACS. In all trials comparing an early with a late strategy, or an invasive with a medical management strategy, the decision regarding whether to perform CABG or PCI was left to the discretion of the investigator. In patients stabilized after an episode of ACS, the choice of revascularization modality can be made as in stable CAD.148 In approximately one-third of patients angiography will reveal singlevessel disease, allowing ad hoc PCI in most cases. Multivessel disease will be present in another 50%.181,182 Here the decision is more complex and the choice has to be made between culprit lesion PCI, multivessel PCI, CABG, or a combined (hybrid) revascularization in some cases. The revascularization strategy should be based on the clinical status as well as the severity and distribution of the CAD and the lesion characteristics. Culprit lesion PCI usually is the rst choice in most patients with multivessel disease. The strategy of multivessel stenting for suitable signicant stenoses rather than stenting the culprit lesion only has not been evaluated appropriately in a randomized fashion. However, in a large database including 105 866 multivessel CAD patients with NSTE-ACS, multivessel PCI was compared with single-vessel PCI.216 Multivessel PCI was associated with lower procedural success but similar in-hospital mortality and morbidity, although no long-term results were reported. CABG was compared with PCI in a propensity-matched analysis among patients with multivessel disease from the ACUITY trial.217 PCI-treated patients had lower rates of stroke, MI, bleeding, and renal injury, similar 1-month and 1-year mortality, but signicantly higher rates of unplanned revascularization at both 1 month and 1 year. However, only 43% of CABG patients could be matched and there was a strong trend for a greater major adverse cardiac event rate at 1 year with PCI compared with CABG (25.0% vs. 19.5%; P 0.05). These results are consistent with those of the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) trial, which included 28.5% of patients with a recent ACS, in both PCI and CABG arms.218 However, a subanalysis of these patients has not been reported. Culprit lesion PCI does not necessarily require a case by case review by the Heart Team (a multidisciplinary decision-making team), when on clinical or angiographic grounds the procedure needs to be performed ad hoc after angiography.148 However, protocols based on the SYNTAX score should be designed by the Heart Team at each institution, dening specic anatomical criteria and clinical subsets that can be treated ad hoc or transferred directly to CABG.219 After culprit lesion PCI, patients with scores in the two higher terciles of the SYNTAX score should be discussed within the Heart Team, in light of functional evaluation of the remaining lesions. This also includes the assessment of co-morbidities and individual characteristics. 5.4.4 Coronary artery bypass surgery The proportion of patients with NSTE-ACS undergoing bypass surgery during initial hospitalization is 10%.220 While the benet from PCI in patients with NSTE-ACS is related to its

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early performance, the benet from CABG is greatest when patients can be operated on after several days of medical stabilization depending on individual risk. As there is no randomized study comparing an early with a delayed CABG strategy, the general consensus is to wait for 4872 h in patients who had culprit lesion PCI and have additional severe CAD. In a large database analysis of unselected patients admitted for ACS, performance of early CABG, even in higher risk patients, was associated with very low in-hospital mortality.221 In the CRUSADE and ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry Get With The Guidelines programmes in patients with NSTEMI, unadjusted and adjusted analyses showed no difference in outcomes between patients undergoing early (48 h) or in-hospital late (.48 h) surgery, although CABG was delayed more often in higher risk patients, suggesting that timing might be appropriately determined by multidisciplinary clinical judgement.222 Therefore, in patients selected for CABG, its timing should be individualized according to symptoms, haemodynamic status, coronary anatomy, and inducible ischaemia or ow reserve measurements. When there is ongoing or recurrent ischaemia, ventricular arrhythmias, or haemodynamic instability, CABG should be performed immediately. Surgery should be performed during the same hospital stay in patients with left main or three-vessel disease involving the proximal left anterior descending artery. In this decision process it is important to consider the risk of bleeding complications in patients who undergo bypass surgery, when initially treated with aggressive antiplatelet treatment.142,223,224 However, pre-treatment with a triple or dual antiplatelet regimen should be considered only as a relative contraindication to early bypass surgery, but does require specic surgical measures to minimize bleeding. In patients requiring emergent surgery before the washout period of thienopyridines, off-pump CABG or minimized cardiopulmonary bypass circuits, blood salvaging techniques, and platelet transfusion should be used to minimize risk of bleeding and its consequences. 5.4.5 Percutaneous coronary intervention technique Outcome after PCI in NSTE-ACS has been improved markedly with the use of intracoronary stenting and contemporary antithrombotic and antiplatelet therapies. As for all patients undergoing PCI, stent implantation in this setting helps to reduce the threat of abrupt closure and restenosis. The safety and efcacy of DESs have not been prospectively tested in this specic population, although patients with recent NSTE-ACS comprise up to 50% of patients included in most PCI trials. Owing to platelet activation and the inammatory background of ACS, DES implantation results may be different from those in stable patients. However, HORIZONS AMI, a randomized study of DES vs. BMS in STEMI patients, did not reveal any safety concerns, whereas a consistent reduction of restenosis and unplanned repeat revascularization was found after DES implantation.225 Owing to the lack of randomized trials in NSTE-ACS, the choice between the use of a BMS or a DES should be based on an individual assessment of benet vs. risk.226 DAPT should be maintained for 12 months irrespective of the type of stent. In patients with a compelling indication for long-term anticoagulation, BMS implantation, stand-alone balloon angioplasty, or CABG may be considered in order to restrict the

Recommendations for invasive evaluation and revascularization

Recommendations An invasive strategy (within 72 h after rst presentation) is indicated in patients with: at least one high-risk criterion (Table 9); recurrent symptoms. Urgent coronary angiography (<2 h) is recommended in patients at very high ischaemic risk (refractory angina, with associated heart failure, life-threatening ventricular arrhythmias, or haemodynamic instability). An early invasive strategy (<24 h) is recommended in patients with a GRACE score >140 or with at least one primary high-risk criterion. Non-invasive documentation of inducible ischaemia is recommended in low-risk patients without recurrent symptoms before deciding for invasive evaluation. The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG) should be based on the clinical status as well as the disease severity, i.e. distribution and angiographic lesion characteristics (e.g. SYNTAX score), according to the local Heart Team protocol. As there are no safety concerns related to the use of DESs in ACS, DESs are indicated based on an individual basis taking into account baseline characteristics, coronary anatomy, and bleeding risk. PCI of non-signicant lesions is not recommended. Routine invasive evaluation of low-risk patients is not recommended.
a

Class a

Level b

Ref C

148

148, 209

212, 215

54, 55, 148

225, 226

III

III

148, 208

Class of recommendation. Level of evidence. References. ACS acute coronary syndromes; BMS bare-metal stent; CABG coronary bypass graft; DES drug-eluting stent; GRACE Global Registry of Acute Coronary Events; PCI percutaneous coronary intervention; SYNTAX SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery.
b c

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duration of triple therapy to 1 month. The use of aspiration thrombectomy in the NSTEMI setting is possible; however, its benet was not assessed prospectively in randomized trials in patients with NSTE-ACS.227 It remains undetermined whether other coronary segments with non-signicant stenoses but vulnerable features will merit mechanical intervention and is therefore not supported. For the use of intravascular ultrasound and FFR, see Section 3.2.4.

ESC Guidelines

Recommendations for elderly patients

Recommendations Because of the frequent atypical presentation, elderly patients (>75 years) should be investigated for NSTE-ACS at low level of suspicion Treatment decisions in the elderly (>75 years) should be made in the context of estimated life expectancy, co-morbidities, quality of life, and patient wishes and preferences. Choice and dosage of antithrombotic drugs should be tailored in elderly patients to prevent the occurrence of adverse effects. Elderly patients should be considered for an early invasive strategy with the option of possible revascularization, after careful weighing up of the risks and benets.
a

Class a

Level b

Ref C

15, 230

5.5 Special populations and conditions

5.5.1 The elderly The term elderly is used arbitrarily to describe different age groups. Although 65 years has been the traditional cut-off, with an ageing population a cut-off set at 75 or even 80 years would seem more appropriate. Beyond biological age, co-morbidities and associated conditions such as frailty, cognitive and functional impairment, and physical dependence should be considered. In European registries of NSTE-ACS, 2734% of patients are aged .75 years.228,229 Despite the high proportion of elderly patients in registries, the elderly (.75 years) represent not more than 20% of all patients in recent trials of NSTE-ACS. Even when elderly patients are recruited into clinical trials, those randomized have substantially less co-morbidity than patients encountered in daily clinical practice.230 Thus the applicability of ndings from clinical trials to elderly patients encountered in routine clinical practice may be questionable. Diagnosis and risk stratication in the elderly The clinical presentation of NSTE-ACS in the elderly is often atypical and they are more likely to have mild symptoms.15 Among elderly patients with atypical presentation of NSTE-ACS, dyspnoea is the leading symptom, while syncope, malaise, and confusion are less frequent. The results of an ECG are less likely to demonstrate marked ST-segment deviation. Elderly patients present more frequently with NSTE-ACS than STEMI. Age is one of the most important predictors of risk in NSTE-ACS.50 Patients aged .75 years have at least double the mortality rate of those ,75 years. The prevalence of ACS-related complications such as heart failure, bleeding, stroke, renal failure, and infections markedly increases with age. Therapeutic considerations The elderly are at higher risk of side effects from medical treatment. This is particularly true for the risk of bleeding with antiplatelet agents and anticoagulants, but also for hypotension, bradycardia, and renal failure. In addition to the intrinsic bleeding risk of the elderly, older patients are more frequently exposed to excessive dose of antithrombotic drugs that are excreted by the kidney.231 The risk of major bleeding associated with unfractionated heparin, enoxaparin, GP IIb/IIIa receptor inhibitors, and P2Y12 inhibitors is signicantly increased in older patients. In the SYNERGY trial, no difference in the rates of 30-day death or MI, 30-day death, and 1-year death between UFH and enoxaparin groups was observed among patients .75 years of age. However, the rates of TIMI major bleeding and GUSTO severe bleeding were signicantly higher in the enoxaparin group. As a
b

230

230

IIa

233235

Class of recommendation. Level of evidence. c References. NSTE-ACS non-ST-elevation acute coronary syndrome.

consequence, enoxaparin should be used with caution in the elderly and the dose should be adapted to renal function. Over 75 years of age, the dose should be reduced to 1 mg/kg once daily and anti-Xa activity monitored.232 A signicantly lower risk of bleeding was observed with fondaparinux compared with enoxaparin in patients .65 years of age in the OASIS-5 trial.175 Elderly patients are substantially less likely to undergo an invasive strategy after NSTE-ACS. However, reports from individual trials suggested that the benet from the invasive strategy was mainly observed in patients .65 years of age.233,234 In a subgroup analysis of the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS)TIMI 18 trial, patients .75 years of age with NSTE-ACS derived the largest benet, in terms of both relative and absolute risk reductions, from an invasive strategy at the cost of an increase in risk of major bleeding and need for transfusions.235 This was conrmed by a recent meta-analysis.209 Decisions on how to manage individual elderly patients should be based on ischaemic and bleeding risk, estimated life expectancy, co-morbidities, quality of life, patient wishes, and the estimated risks and benets of revascularization. 5.5.2 Gender issues Women presenting with NSTE-ACS are older than men and have a higher frequency of diabetes, hypertension, heart failure, and other

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Thus, the data suggest that a routine early invasive strategy should be considered in women on the same principles as in men, i.e. after careful risk stratication for both ischaemic and bleeding risks including clinical and ECG evaluation, analysis of biomarkers, co-morbidities, and use of risk scores (see Section 4). 5.5.3 Diabetes mellitus Approximately 20 30% of patients with NSTE-ACS have known diabetes, and at least as many have undiagnosed diabetes or impaired glucose tolerance.247 The Euro Heart Survey revealed that 37% of patients with NSTE-ACS had established or newly discovered diabetes.248 Patients with diabetes are older, are more often female, have more co-morbidities such as hypertension and renal failure, are more likely to present with atypical symptoms, and are more prone to develop complications, particularly heart failure and bleeding.248 Diabetes mellitus is an independent predictor of mortality among patients with NSTE-ACS. Patients with diabetes have a two-fold higher risk of death.249,250 In addition, patients with impaired glucose tolerance or impaired fasting blood glucose have a worse prognosis than patients with normal glucose metabolism, but a better prognosis than patients with conrmed diabetes. Hyperglycaemia on admission or later during the hospital course is a strong independent marker of adverse prognosis in ACS whether or not the patient is diabetic, and may even be a stronger marker of risk than diagnosed diabetes.251 Therapeutic considerations Registries have consistently shown that patients with NSTE-ACS and diabetes are at a higher risk for short- and long-term cardiovascular events, but also that they are suboptimally treated compared with non-diabetic patients. In the European registries, revascularization (any form), thienopyridines, and GP IIb/IIIa receptor inhibitors were prescribed less frequently among diabetic patients than among non-diabetic patients, with a clear impact on in-hospital and long-term mortality (5.9% vs. 3.2% at 1 month, and 15.2% vs. 7.6% at 1 year). In addition, diabetic patients are less likely to receive reperfusion therapies or undergo revascularization compared with non-diabetic patients.248,250 Diabetics are high risk patients, and as such require aggressive pharmacological as well as invasive management. In addition, a comprehensive approach to secondary prevention should include pharmacological therapy and lifestyle changes.252 Data on the value of tight glycaemic control in MI are inconclusive.251 In STEMI patients, tight glycaemic control using i.v. insulin was shown in Diabetes, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) to reduce 1-year mortality by 30%, but this was not conrmed in DIGAMI-2. In predominantly stable patients with diabetes and also in intensive care units, recent studies have not shown improved outcomes with tight glycaemic control, but rather an excess of events related to more frequent hypoglycaemic episodes in patients allocated to tight blood glucose control.253 Until more data become available the treatment target should be to avoid severe hyperglycaemia [glucose concentration .10 11 mmol/L (.180200 mg/dL)] as well as hypoglycaemia [,5 mmol/L (,90 mg/dL)]. There is no evidence

Recommendations for gender

Recommendations Both genders should be evaluated and treated in the same way.
a

Class a I

Level b B

Ref C 246

Class of recommendation. Level of evidence. c Reference. NSTE-ACS non-ST-elevation acute coronary syndrome.
b

co-morbidities.236 238 Atypical presentation, including dyspnoea or symptoms of heart failure, is more common.228,239 Despite the differences in baseline risk, women and men with NSTE-ACS have a similar prognosis except in the elderly when women appear to have a better prognosis than men. This may be partially explained by the higher prevalence of non-obstructive CAD found on angiography in women.238 On the other hand, women with NSTE-ACS have a higher bleeding risk than men.

Therapeutic considerations Although no sex-specic treatment effect has been described for most therapeutic agents, women with NSTE-ACS are less likely than men to receive evidence-based therapies including invasive diagnostic procedures and coronary revascularization.236,237,240 Contradictory results have been published with respect to the inuence of sex on the treatment effect of an invasive strategy in NSTE-ACS. While observational studies suggested better longterm outcomes in unselected women undergoing an early invasive strategy, a meta-analysis showed that the benet of invasive strategies was restricted to male patients, with no benet in women up to 1 year of follow-up.241 Moreover, a number of randomized trials233,242 revealed a higher rate of death and non-fatal MI among women with NSTE-ACS undergoing an early invasive strategy. A signicant sex interaction was also found in the FRISC-2 trial during the 5-year follow-up period, in which an invasive strategy showed a signicant improvement in the reduction of death or MI in men but not in women.234 The meta-analysis by the Cochrane collaboration pointed out that women derive a signicant long-term benet in terms of death or MI (RR 0.73; 95% CI 0.590.91) for an invasive vs. conservative strategy, although with an early hazard.243 Some studies suggest that only in high risk female patients, such as those with troponin elevation244 or with multivessel disease, is an early invasive strategy benecial. Parallel ndings have been described for the use of GP IIb/IIIa receptor inhibitors in women.245 In fact, in a cohort of 35 128 patients with angiographic data, taken from a pooled analysis of 11 trials, 30-day mortality in women was not signicantly different from that in men, regardless of ACS type, after adjustment for angiographic disease severity. Sex-based differences in 30-day mortality observed among ACS patients are markedly attenuated after adjustment for baseline characteristics, angiographic ndings, and treatment strategies.246

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that glucoseinsulinpotassium improves outcome, but may be even deleterious.254 Revascularization in diabetic patients causes specic problems. CAD is typically diffuse and extensive, and restenosis as well as occlusion rates after PCI and CABG are higher. Repeat revascularization procedures are more frequent after PCI, compared with CABG. An early invasive approach has been shown to be benecial in this high risk subgroup, with greater benet in diabetic than in non-diabetic patients.255 In unselected diabetic patients with multivessel disease, CABG appears to offer a better outcome compared with PCI. In a meta-analysis of individual data from 7812 patients in 10 randomized trials, CABG was associated with signicantly lower mortality at 5.9-year follow-up than with PCI in diabetic patients.256 Overall there was no difference in mortality with CABG vs. PCI (15% vs. 16%; HR 0.91; 95% CI 0.821.02; P 0.12), but mortality was signicantly lower for CABG among 1233 patients with diabetes [23% vs. 29%; HR 0.70; 95% 0.560.87; P 0.05; numbers needed to treat (NNT) 17]. In the Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI-2D) trial, diabetic patients with stable angina were randomized to either intensive medical therapy or intensive medical therapy plus revascularization with either CABG or PCI (physicians choice). At 5-year follow-up, in 763 patients in the CABG group, the rates of allcause mortality or MI were signicantly lower in the CABG group vs. intensive medical therapy alone (21.1% vs. 29.2%; P ,0.010), as well as the rate of cardiac death or MI (15.8% vs. 21.9%; P ,0.03) and MI (10% vs. 17.6%; P ,0.003). There was no signicant difference in outcome between intensive medical therapy alone and intensive medical therapy plus PCI.257,258 In SYNTAXa trial comparing CABG with PCI with DESs in main stem and multivessel diseasethe difference in major adverse cardiac and cerebral events at 1-year follow-up between CABG and PCI groups was doubled in the pre-dened diabetes cohort, mostly driven by repeat revascularization.259 However, there was no signicant difference in rates of death or MI. Finally, in the New York Registry, a trend to improved outcomes in diabetic patients treated with CABG compared with DESs (OR for death or MI at 18 months 0.84; 95% CI 0.691.01) was reported.260 All of these studies suggest that CABG offers a better outcome compared with PCI in diabetic patients. However, it has to be pointed out that these trials incorporated mostlyif not only chronic stable patients, and it is unclear whether these data can be extrapolated to patients with NSTE-ACS. With respect to the choice of stent, in a meta-analysis a DES proved to be at least as safe as a BMS provided that DAPT is continued for .6 months, which is indicated in ACS anyway.261 Repeat target vessel revascularization was considerably less frequent with a DES than a BMS (OR 0.29 for sirolimus eluting; 0.38 for paclitaxel eluting). It may be assumed that this is similar in diabetic patients with ACS. Regarding the choice of conduits, observational studies suggest that arterial grafts offer better outcome compared with saphenous vein grafts. The impact of revascularization with bilateral arterial grafting on long-term outcome and risk of mediastinal infections is still debated. Again, no data conned to ACS patients alone are available.

ESC Guidelines

Recommendations for diabetic patients

Recommendations All patients with NSTEACS should be screened for diabetes. Blood glucose levels should be monitored frequently in patients with known diabetes or admission hyperglycaemia. Treatment of elevated blood glucose should avoid both excessive hyperglycaemia [1011 mmol/L (>180200 mg/dL)] and hypoglycaemia [<5 mmol/L (<90 mg/dL)]. Antithrombotic treatment is indicated as in non-diabetic patients. Renal function should be closely monitored following contrast exposure. An early invasive strategy is recommended. DESs are recommended to reduce rates of repeat revascularization. CABG surgery should be favoured over PCI in diabetic patients with main stem lesions and/or advanced multivessel disease.
a

Class a

Level b

Ref C

251, 253

233, 255

148, 261

259

Class of recommendation. Level of evidence. References. CABG, coronary artery bypass graft; DES drug-eluting stent; NSTE-ACS, non-ST-segment elevation acute coronary syndromes; PCI, percutaneous coronary intervention.
b c

There is no indication that the antithrombotic regimen should differ between diabetic and non-diabetic patients. However, in the TRITON-TIMI 38 trial, prasugrel was shown to be superior to clopidogrel in reducing the composite endpoint of cardiovascular death or MI or stroke without excess major bleeding.262 Similarly, ticagrelor, when compared with clopidogrel in the PLATO trial, reduced the rate of ischaemic events in ACS patients irrespective of diabetic status and glycaemic control, without an increase in major bleeding events.263 Ticagrelor reduced all-cause mortality in patients with haemoglobin A1c above the median (.6%). Although GP IIb/IIIa receptor inhibitors were shown in an earlier meta-analysis (without concomitant use of thienopyridines) to have a favourable impact on outcome in diabetic patients,264 routine upstream treatment was not conrmed to be benecial in the more recent EARLY-ACS trial.151 Therefore, with the current use of high dose oral antiplatelet agents, diabetic patients

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do not seem to benet from the routine addition of GP IIb/IIIa receptor inhibitors. Prevention of contrast-induced nephropathy is particularly important in diabetic patients undergoing angiography and/or PCI (see Section 5.5.4). There are no data to support delay of angiography in patients treated with metformin as the risk of lactate acidosis is negligible.265 Renal function should be monitored closely following contrast exposure. 5.5.4 Chronic kidney disease Renal dysfunction is present in 3040% of patients with NSTE-ACS.266,267 Kidney function is best assessed with eGFR according to the MDRD equation, which includes ethnicity and sex in its calculation. It should be calculated in all patients with or at increased risk of chronic kidney disease (CKD). In daily clinical practice, however, CrCl calculated with the Cockroft Gault formula may also be used. For denitions of CKD, see the previous guideline.3 Patients with CKD more frequently present with heart failure and without typical chest pain.268 Patients with NSTE-ACS and CKD often do not receive guideline-recommended therapy. CKD is associated with a very adverse prognosis,266,268 and is an independent predictor of short- and long-term mortality and of major bleeding in patients with NSTE-ACS.267 Therapeutic considerations Despite the fact that patients with NSTE-ACS and CKD are frequently under-represented in clinical trials, there is no particular reason not to treat these patients just like patients devoid of renal dysfunction. However, caution is needed with respect to the antithrombotic treatment in terms of bleeding complications.168,269,270 Registry data show that CKD patients are often overdosed with antithrombotics, particularly anticoagulants and GP IIb/IIIa receptor inhibitors, and are therefore more prone to bleed. Many drugs with exclusive or substantial renal elimination need to be down-titrated or might even be contraindicated in CKD patients, including enoxaparin, fondaparinux, bivalirudin, and small-molecule GP IIb/IIIa receptor inhibitors (Table 10). In the case of severe renal failure, when fondaparinux or enoxaparin are contraindicated, UFH should be used. However, in the GRACE registry UFH did not protect against bleeding complications, and a gradual increase in the risk of bleeding with declining renal function was observed with UFH, similar to that observed with LMWH.269 The advantages of UFH over other anticoagulants in CKD patients are that its anticoagulant activity is easily monitored with aPTT, and it can be quickly neutralized in the event of bleeding. Fondaparinux has a much safer prole than enoxaparin in CKD, as shown by the much lower risk of bleeding complications observed in OASIS-5 with fondaparinux compared with enoxaparin. Ticagrelor compared with clopidogrel in the PLATO trial signicantly reduced ischaemic endpoints and mortality without a signicant increase in major bleeding, but with numerically more non-procedurerelated bleeding.271 Data on the impact of an invasive strategy on clinical endpoints in patients with NSTE-ACS and CKD are not available, as many trials of revascularization in NSTE-ACS excluded patients with CKD. In a large registry as well as in substudies of trials in the

Table 10 Recommendations for the use of antithrombotic drugs in CKD

Drug Clopidogrel Prasugrel Ticagrelor Recommendations No information in patients with renal dysfunction. No dose adjustment necessary, including in patients with end-stage disease. No dose reduction required; no information in dialysis patients. Dose reduction to 1 mg/kg once daily in the case of severe renal failure (CrCl <30 mL/min). Consider monitoring of anti-Xa activity. Contraindicated in severe renal failure (CrCl <20 mL/min). Drug of choice in patients with moderately reduced renal function (CrCl 3060 mL/min). Patients with moderate renal impairment (3059 mL/min) should receive an infusion of 1.75 mg/kg/h. If the creatinine clearance is <30 mL/min, reduction of the infusion rate to 1 mg/kg/h should be considered. No reduction in the bolus dose is needed. If a patient is on haemodialysis, the infusion rate should be reduced to 0.25 mg/kg/h. No specic recommendations for the use of abciximab, or for dose adjustment in the case of renal failure. Careful evaluation of haemorrhagic risk is needed before using the drug in the case of renal failure. The infusion dose should be reduced to 1 g/kg/min in patients with CrCl <50 mL/min. The dose of the bolus remains unchanged at 180 g/kg. Eptibatide is contraindicated in patients with CrCl <30 mL/min. Dose adaptation is required in patients with renal failure; 50% of the bolus dose and infusion if CrCl is <30 mL/min.

Enoxaparin Fondaparinux

Bivalirudin

Abciximab

Eptibatide

Tiroban

Recommendations for the use of drugs listed in this table may vary depending on the exact labelling of each drug in the country where it is used. CrCl creatinine clearance.

setting of NSTE-ACS, the outcome of CKD patients improved with invasive management, not only at end-stage renal failure but also at the stage of moderate CKD. In observational studies an early invasive therapy is associated with better 1-year survival in patients with mild to moderate renal insufciency, but the benet decreases with worse renal function, and is uncertain in those with renal failure or on dialysis. Patients with CKD are at risk of contrast-induced nephropathy. This risk is increased in patients with older age and diabetes. In the case of urgent angiography the risk of contrast-induced nephropathy must be balanced against the ischaemic risk. Hydration before (12 h) and following (24 h) angiography and/or angioplasty is the strategy that has been shown to have the greatest impact in reducing the risk of this nephropathy. The amount of contrast should

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ESC Guidelines

Recommendations for patients with CKD

Recommendations Kidney function should be assessed by CrCl or eGFR in patients with NSTE-ACS, with special attention to elderly people, women, and patients with low body weight, as near normal serum creatinine levels may be associated with lower than expected CrCl and eGFR levels. Patients with NSTE-ACS and CKD should receive the same rst-line antithrombotic treatment as patients devoid of CKD, with appropriate dose adjustments according to the severity of renal dysfunction. Depending on the degree of renal dysfunction, dose adjustment or switch to UFH with fondaparinux, enoxaparin, bivalirudin, as well as dose adjustment with small molecule GP IIb/IIIa receptor inhibitors are indicated. UFH infusion adjusted to aPTT is recommended when CrCl is <30 mL/min or eGFR is <30 mL/min/1.73 m2 with most anticoagulants (fondaparinux <20 mL/min). In patients with NSTE-ACS and CKD considered for invasive strategy, hydration and low- or iso-osmolar contrast medium at low volume (<4 mL/kg) are recommended. CABG or PCI is recommended in patients with CKD amenable to revascularization after careful assessment of the riskbenet ratio in relation to the severity of renal dysfunction.
a

Class a

Level b

Ref C

5.5.5 Left ventricular systolic dysfunction and heart failure Heart failure is one of the most frequent and deadly complications of NSTE-ACS,274 although its incidence may be declining.50 Both LVEF and heart failure are independent predictors of mortality and other major adverse cardiac events in NSTE-ACS. Heart failure is more common in older patients, and is associated with a worse prognosis whether it presents on admission or during hospitalization.274 In patients presenting with heart failure without chest pain, ACS may be difcult to diagnose due to a troponin rise related to acute heart failure. In these patients it might be impossible to distinguish acute heart failure only, from NSTEMI complicated with heart failure. Coronary angiography may be needed to differentiate the two conditions.

269, 270

269, 270

Therapeutic considerations Patients with NSTE-ACS and heart failure less frequently receive evidence-based therapies, including b-blockers and ACE inhibitors or angiotensin receptor blockers (ARBs), coronary angiography, and revascularization.50,274 All recommendations derived from post-MI studies may be extrapolated to NSTE-ACS patients with heart failure and are found in the respective guidelines.275

Recommendations for patients with heart failure

I C Recommendations -Blockers and ACE-inhibitors/ ARBs appropriately titrated are indicated in patients with NSTE-ACS and LV dysfunction with or without signs of heart failure. Aldosterone inhibitors, preferably eplerenone, are indicated in patients with NSTE-ACS, LV dysfunction, and heart failure. I B 273 Patients with NSTE-ACS and LV dysfunction or heart failure are recommended to undergo coronary revascularization, if amenable to it. Patients with NSTE-ACS and severe LV dysfunction should be considered after 1 month for device therapy (CRT and/ or implantable cardioverter debrillator) in addition to optimal medical therapy whenever indicated.
a

Class a

Level b

Ref C

275

148, 272

275277

209

Class of recommendation. Level of evidence. c References. aPTT activated partial thromboplastin time; CABG coronary artery bypass graft; CKD chronic kidney disease; CrCl creatinine clearance; eGFR estimated glomerular ltration rate; GP glycoprotein; NSTE-ACE non-ST-elevation acute coronary syndrome; PCI percutaneous coronary intervention; UFH unfractionated heparin.
b

IIa

275, 278

be maintained at ,4 mL/kg. Further details are given in the ESC revascularization guidelines.148 Owing to a lack of prospective data, the choice of revascularization mode and stent type should be made as in stable CAD, with special consideration of the patients individual risk and life expectancy.

Class of recommendation. Level of evidence. References. ACE angiotensin-converting enzyme; ARB angiotensin receptor blocker; CRT cardiac resynchronization therapy; LV left ventricular; NSTE-ACS non-ST-elevation acute coronary syndrome.
b c

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The term syndrome X is used to describe patients with angina precipitated by exercise, ST-segment depression on stress test, and non-obstructed coronary arteries at angiography. The chest pain may increase in frequency or intensity, or may occur at rest. Patients may present with typical features of unstable angina. The prognosis is usually excellent. The real cause of the syndrome has not been established, but it is most frequently associated with impaired endothelial-dependent arterial vasodilatation, decreased nitric oxide production, and increased sensitivity to sympathetic stimulation. There is growing evidence that such patients often have an increased response to pain. Because the prognosis is excellent, the most important therapy is reassurance and symptom relief, for which nitrates, b-blockers, and calcium antagonists have been found to be effective. Apical ballooning (Tako-Tsubo cardiomyopathy) may present clinically as STEMI or NSTE-ACS, and is characterized by normal coronary arteries at angiography accompanied by apical and sometimes medioventricular or basal akinesia unrelated to the distribution of a coronary artery. It is more frequent in women and occurs typically after major emotional stress. The LV dysfunction is generally reversible within days to weeks. In rare cases, NSTE-ACS with a normal or near-normal coronary arteriogram is linked to coronary embolism, due to AF or atrial utter. As AF is often clinically unrecognized, the frequency of this mechanism of NSTE-ACS may be underestimated. 5.5.8 Anaemia Anaemia is associated with a worse prognosis (cardiovascular death, MI, or recurrent ischaemia) across the spectrum of ACS.69 Beyond the hospital phase, persistent or worsening anaemia is associated with increased mortality or heart failure compared with patients who have no anaemia or resolving anaemia.282 Anaemia is associated with more co-morbidities, such as older age, diabetes, and renal failure, but also noncardiovascular conditions (haemorrhagic diathesis or malignancy), which may account partly for the adverse prognosis. Baseline

5.5.6 Extreme body weights Low body weight is associated with an increased risk of death or MI, and particularly of bleeding, which is frequently due to inappropriate dosing of antithrombotic drugs.279 Normal creatinine levels in patients with low body weight may conceal renal insufciency, particularly in elderly patients, which may increase the risk of toxicity or secondary effects of drugs with renal excretion. Therefore, it is recommended to estimate CrCl in patients with low body weight and adjust i.v. drug doses accordingly. Although obesity is associated with a higher risk of coronary events in the population, obese patients with NSTE-ACS show better in-hospital and 1-year outcomes, including lower bleeding risk, which has been called the obesity paradox.279,280 Obese patients have more risk factors but are younger. In general, these patients are more likely to receive evidence-based therapies, which may explain the better outcome.280

5.5.7 Non-obstructive coronary artery disease A sizeable proportion of patients ( 15%) with NSTE-ACS have normal coronary arteries or non-obstructive lesions. The pathophysiology of NSTE-ACS is not homogeneous and possible mechanisms include: a coronary artery spasm (Prinzmetals angina), an intramural plaque complicated by acute thrombosis with subsequent recanalization, coronary emboli, and syndrome X. In patients admitted with suspected NSTE-ACS, the demonstration of normal or near-normal coronary arteries at angiography challenges the diagnosis. However, ST-segment changes and release of biomarkers in patients with typical chest pain and patent coronary arteries without signicant stenotic lesions may be due to true necrosis rather than false-positive results. This tends to be more common in women. Relevant atherosclerotic burden may be present even in the absence of angiographically signicant stenoses because it may occur in a diffuse manner and lead to arterial wall remodelling in which the wall thickens and expands outwards without encroaching on the lumen. The prognosis of these patients appears to be better than that of patients with NSTE-ACS and signicant coronary atherosclerosis, and they therefore merit optimal antithrombotic therapy and secondary prevention with antiplatelet agents and statins.281 Prinzmetals variant angina refers to a frequently unrecognized syndrome of chest pain secondary to myocardial ischaemia that is not precipitated by physical exertion or emotional stress, and is associated with transient ST-segment elevation. The underlying pathological mechanism is spasm of an epicardial coronary artery that may occur at sites of severe focal stenoses, but typically is seen on angiography at sites of minimal atherosclerotic disease. Patients with variant angina tend to be younger than those with conventional NSTE-ACS and are often heavy smokers. The symptoms are often severe and may be accompanied by syncope. Attacks of Prinzmetals angina tend to be clustered between midnight and 8 am The spasm may be spontaneous or provoked by acetylcholine, a cold pressor test, or hyperventilation. The mainstay therapy for Prinzmetals angina is the administration of calcium antagonists, shown to be effective in preventing coronary spasm, alone or in combination with nitrates. They should be prescribed at maximally tolerated doses.

Recommendations for anaemia

Recommendations Low baseline haemoglobin is an independent marker of the risk of ischaemic and bleeding events and therefore haemoglobin measurement is recommended for risk stratication. Blood transfusion is only recommended in the case of compromised haemodynamic status or haematocrit <25% or haemoglobin level <7 g/dL.
a

Class a

Level b

Ref C

69, 283

287

Class of recommendation. Level of evidence. c References.

b

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haemoglobin was also shown to be an independent predictor of the risk of bleeding: the lower the baseline haemoglobin the higher the risk, for both procedure-related and non-procedure-related bleeding.283 The management of patients with NSTE-ACS and anaemia is empirical. It is important to identify the cause of anaemia, particularly if it is due to occult bleeding. Special attention should be given to the antithrombotic therapy. The use of a DES should be restrictive due to the need for long-term DAPT. The indication for angiography and the access site (radial approach) must be critically considered to avoid further blood loss.284,285 Red blood cell transfusions should be given only with strict indication, as there is evidence that transfusions are associated with an increased mortality in patients with NSTE-ACS. Observational studies suggest that transfusions should be avoided as long as haematocrit is .25% and anaemia is well tolerated.286 5.5.9 Bleeding and transfusion Bleeding is the most frequent non-ischaemic complication observed in the management of NSTE-ACS, as well as in other clinical settings such as STEMI, PCI, and cardiac surgery. In the previous document,3 the importance of bleeding was addressed in detail, which has been conrmed by new studies. Therefore, this document will focus only on novel ndings. Because of the lack of a universally accepted denition for bleeding, its true frequency is still difcult to assess across trials and registries. The Universal Denition of bleeding as proposed by the Bleeding Academic Research Consortium may help to make assessment of bleeding more objective in the future.288 Interestingly, the rate of bleeding observed in registries has reportedly decreased over the past 7 years, despite more frequent use of aggressive pharmacological therapies with dual or triple antiplatelet therapy plus anticoagulants, and greater use of invasive strategies for diagnostic or therapeutic purposes.289 This may indicate that clinicians have become more aware of the risk incurred by bleeding in the management of ACS, and that they may have adapted their management strategies accordingly. Irrespective of the scale used to assess bleeding, many reports conrmed the dose-dependent association between bleeding and risk of death or other ischaemic events. Major bleeding was shown to be associated with a four-fold increase in the risk of death, a ve-fold increase in risk of recurrent MI, and a three-fold increase in risk of stroke at 30 days.290 These data have been conrmed in further analyses of the GRACE registry and in clinical trials such as OASIS-5291 and ACUITY.292 Minor bleeding can also inuence outcome, albeit to a lesser extent. Bleeding has been studied extensively at the initial phase of ACS (i.e. in the rst 30 days), while the risk of bleeding incurred by longterm potent antiplatelet therapy (from 30 days to the end of follow-up or 1 year) has been less well analysed. In the CURE study,111 the risk of any major bleed was 1.54% in the placebo group and 2.01% in the clopidogrel group in the rst 30 days; corresponding data from 30 days to 1 year were 1.18% for placebo and 1.75% for clopidogrel. In TRITON, with an invasive protocol, the rate of major bleeding was 1.23% for clopidogrel vs. 1.71% for prasugrel from 30 to 450 days.293 Corresponding gures are

ESC Guidelines

not available for the PLATO study. There was no difference in the overall rate of major bleeding, but there was a gradual excess of non-CABG major bleedings over time with a HR of 1.19 (95% CI 1.021.38; P ,0.03) at 1 year.132 In a setting of stable vascular disease, the same gradual increase in risk of bleeding with clopidogrel vs. placebo was observed, with a HR of 1.88 (95% CI 1.452.45; P 0.001) at 1-year follow-up.294 Thus, bleeding risk is highest during the rst 30 days, but long-term exposure to potent antiplatelet therapy leads to a persistent increase in the risk of bleeding. The independent predictors of major bleeding, established from trials and registries, are baseline characteristics, particularly age, female sex, history of bleeding, baseline haemoglobin, diabetes, and renal insufciency. Declining renal function, particularly for CrCl levels ,60 mL/min, has a major impact on the risk of bleeding. Treatment modalities also play a major role. Bleeding risk increases with the number of antithrombotic drugs in use, including anticoagulants, aspirin, P2Y12 receptor inhibitors, and particularly GP IIb/IIIa receptor inhibitors, as well as use of the femoral rather than the radial approach.284,285 In addition, excessive dosage of drugs, frequent in those at highest risk of bleeding such as women, the elderly, or patients with renal failure, has a major impact on bleeding risk.168 Furthermore, the combination of DAPT and VKAs, often formally indicated in ACS patients, has the potential to increase bleeding risk.295 For bleeding risk scores see Section 4.4. The mechanisms that mediate the negative impact of bleeding on outcome remain unclear. The main component of the risk is probably the need to discontinue antiplatelet and antithrombotic drugs when bleeding occurs, as this leads to an increased risk of ischaemic events, particularly stent thrombosis after PCI. Furthermore, since the risk factors for bleeding and ischaemic events largely overlap, it is possible that higher risk patients are exposed to both risks and submitted to the most aggressive medical and invasive strategies. In the GRACE registry, the increase in the risk of bleeding with declining renal function parallels the increase in the risk of death. This nding has been conrmed in a post-hoc analysis of the OASIS-5 study, where it was shown that the risk of bleeding mirrored an increasing GRACE risk score.296 Hence, the occurrence of bleeding may simply be a precipitating factor for worse outcome in an already frail population. Other factors may contribute to the higher risk of death in patients who bleed, namely the haemodynamic consequences of the bleed, the potential deleterious effects of blood transfusion, and the prothrombotic or proinammatory state triggered by bleeding.297,298 Management of bleeding complications Prevention of bleeding has become as important a target as is the prevention of ischaemic events. Therefore, risk assessment in patients with NSTE-ACS needs to address the risk of both thrombotic and bleeding complications. Prevention of bleeding encompasses the choice of safer drugs, appropriate dosage (taking into account age, sex, and CrCl), reduced duration of antithrombotic treatment, use of a combination of antithrombotic and antiplatelet agents according to proven indications, and the choice of a radial over a femoral approach if an invasive strategy is used.299 Use of closure devices and bivalirudin rather than conventional

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anticoagulants plus GP IIb/IIIa receptor inhibitors was shown to impact favourably on bleeding risk in a pooled analysis of data from the ACUITY and HORIZONS studies.300 Gastrointestinal bleeds make up 50% of all spontaneous bleeding events during the initial phase of ACS. Thus proton pump inhibitors are indicated during the initial phase of ACS, particularly in patients with a history of gastrointestinal bleed or peptic ulcer. The potential interaction of clopidogrel with omeprazole, but less for other proton pump inhibitors, does not appear to be clinically important (see Section 5.2.2). Minor bleeding, unless persistent, does not require the interruption of active treatments. Major bleeding such as gastrointestinal, retroperitoneal, intracranial, or other severe blood loss requires the interruption and neutralization of both antiplatelet and antithrombotic treatment, if bleeding cannot be controlled by appropriate interventions. It may not be necessary to interrupt treatment with antithrombotic agents if complete control of the haemorrhage can be obtained with local measures. In clinical practice, the risk of interrupting antithrombotic agents must be weighed against the risk of a thrombotic event, particularly if the patient has had a stent implantation. UFH can be inhibited by an equimolar concentration of protamine sulfate. Protamine sulfate has less impact on the neutralization of enoxaparin and has no effect on fondaparinux or bivalirudin. Bivalirudin has a very short half-life, with the result that it may not be necessary to neutralize it. In the case of fondaparinux, recombinant factor VIIa has been recommended, but is associated with an increased risk of thrombotic complications.301 There is no known antidote to irreversible antiplatelet agents such as aspirin, clopidogrel, or prasugrel. Therefore, their action can be neutralized only by transfusion of fresh platelets. This is largely the same for ticagrelor shortly (,3 days) after withdrawal of the drug. GP IIb/IIIa receptor inhibitors have different pharmacological properties that are important to consider when evaluating the modalities for reversal. Small molecules (tiroban and eptibatide) bind reversibly to the receptor and are swiftly eliminated by the renal route, with the result that a return to normal platelet function can be expected within 48 h after interruption of the infusion. With abciximab a return to normal platelet function takes 48 h after drug discontinuation. Antiplatelet and/or anticoagulation agents should not be reintroduced until strict control of the haemorrhage has been obtained for at least 24 h. Impact of blood transfusion Blood transfusion has detrimental effects (excess death and MI, but also lung infections) in many clinical settings, including ACS, PCI, cardiac surgery, and acute critical care.286,298 The mechanisms of the deleterious effects of blood transfusions are multifactorial and mostlybut not onlyrelated to blood storage. The negative impact of blood transfusion on outcome depends largely on the nadir haematocrit or haemoglobin level at which the transfusion is administered. Blood transfusion has a favourable impact if given for haematocrit values ,25%, but not above this value.286,298 In this regard, a restrictive transfusion policy with a trigger set at 7 g/dL, and a target haemoglobin level of 910 g/dL,

Recommendations for bleeding complications

Recommendations Assessment of the individual bleeding risk is recommended on the basis of baseline characteristics (by use of risk scores), type, and duration of pharmacotherapy. Drugs or combinations of drugs and non-pharmacological procedures (vascular access) known to carry a reduced risk of bleeding are indicated in patients at high risk of bleeding. Interruption and/or neutralization of both anticoagulant and antiplatelet therapies is indicated in case of major bleeding, unless it can be adequately controlled by specic haemostatic measures. Co-medication of proton pump inhibitors and antithrombotic agents is recommended in patients at increased risk of gastrointestinal haemorrhage. Minor bleeding should preferably be managed without interruption of active treatments. Interruption of antiplatelet drugs and neutralization of their activity with platelet transfusion is recommended, depending on the drugs under consideration and the severity of bleeding. Blood transfusion may have deleterious effects on outcome, and is therefore indicated only after individual assessment, but withheld in haemodynamically stable patients with haematocrit >25% or haemoglobin level >7 g/dL. Erythropoietin is not indicated as a treatment for anaemia or blood loss.
a

Class a

Level b

Ref C

83

196, 285, 299

125127

287, 298

III

303

Class of recommendation. Level of evidence. c References.

b

was shown to derive better clinical outcome than a liberal transfusion policy in the setting of acute care.287,302 In haemodynamically stable patients it is now increasingly recommended to consider

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transfusion only for baseline haemoglobin levels ,7 g/dL, whereas no restrictions apply to patients in unstable haemodynamic situations. Iron and erythropoietin therapy Iron therapy is required in the presence of anaemia associated with iron deciency or bleeding with massive blood loss. The treatment of iron deciency comprises long-term oral administration of iron supplements. I.v iron administration can be used if oral administration is poorly tolerated. Concomitant administration of erythropoietin or derivatives cannot be given in the setting of ACS because of an increased risk of deep vein thrombosis, stroke, and acute coronary events.303 5.5.10 Thrombocytopenia Thrombocytopenia can occur during treatment of NSTE-ACS. Thrombocytopenia is dened as a decrease in platelet count to ,100 000/mL or a drop of .50% from baseline platelet count. Thrombocytopenia is considered to be moderate if the platelet count is between 20 000 and 50 000/mL, and severe if it is ,20 000/mL. In the ACS setting, there are two main types of drug-induced thrombocytopenia, i.e. HIT and GP IIb/IIIa receptor inhibitorinduced thrombocytopenia, with a different prognosis for each type. Full information on each type of thrombocytopenia can be found in the previous guidelines.3 HIT must be suspected when there is a drop of .50% in platelet count, or a decrease in platelet count to ,100 000/mL. It occurs in up to 15% of patients treated with UFH, is less frequent under LMWH, and is not seen with fondaparinux. Immediate interruption of UFH or LMWH therapy is mandatory, as soon as HIT is suspected. Alternative antithrombotic therapy must be introduced, even in the absence of thrombotic complications. Heparinoids such as danaparoid sodium may be used, although in vitro crossreactions with UFH or LMWH have been observed, but apparently without causing thrombosis. The alternative is to use direct thrombin inhibitors, such as argatroban, hirudin, or derivatives, which do not carry any risk of thrombocytopenia, and make it possible to have sustained and controllable antithrombotic activity that can be monitored by aPTT, but dose response is non-linear and attens out at higher doses. Fondaparinux also has the potential to be used in this type of situation, since it has a potent antithrombotic effect, without any cross-reaction with platelets; however, it is not approved for this indication. GP IIb/IIIa receptor inhibitor-induced thrombocytopenia has been reported to occur at rates ranging from 0.5% to 5.6% in clinical trials, depending on the compound used. Severe and profound thrombocytopenia due to GP IIb/IIIa receptor inhibitors may remain asymptomatic, with only minor bleeding at the access site and minor oozing. Major bleeds are rare, but may be life threatening. It is recommended that all patients treated with GP IIb/IIIa receptor inhibitors undergo a platelet count within 8 h of onset of drug infusion or in the case of bleedings with all GP IIb/IIIa receptor inhibitors. If platelet counts drop below 10 000/mL, discontinuation of GP IIb/IIIa receptor inhibitors as well as UFH or enoxaparin is recommended. Platelet transfusions are indicated in the case of bleeding. Fibrinogen supplementation with fresh

ESC Guidelines

Recommendations for thrombocytopenia

Recommendations Immediate interruption of GP IIb/IIIa receptor inhibitors and/or heparin (UFH or LMWH) is indicated in the case of signicant thrombocytopenia (<100 000/L or >50% drop in platelet count) occurring during treatment. Platelet transfusion with or without brinogen supplementation with fresh frozen plasma or cryoprecipitate in the case of bleeding is indicated in the case of severe thrombocytopenia (<10 000/L) induced by GP IIb/IIIa receptor inhibitors. Interruption of heparin (UFH or LMWH) is indicated in the case of documented or suspected HIT, to be replaced by a DTI in the case of thrombotic complications. Anticoagulants with a low risk of HIT or devoid of risk of HIT (such as fondaparinux or bivalirudin) or brief administration of heparin (UFH or LMWH) in cases where these compounds are chosen as anticoagulantis recommended to prevent the occurrence of HIT.
a

Class a Level b

Class of recommendation. Level of evidence. DTI direct thrombin inhibitor; GP glycoprotein; HIT heparin-induced thrombocytopenia; LMWH low molecular weight heparin; UFH unfractionated heparin.
b

frozen plasma or cryoprecipitate either alone or in combination with platelet transfusion has also been advocated.

5.6 Long-term management

Secondary prevention is of paramount importance since ischaemic events continue to accrue at a high rate after the acute phase. In a database of 16 321 ACS patients, 20% of all patients were rehospitalized and 18% of the men and 23% of the women .40 years of age died during the rst year following the ischaemic index event.304 In this context, secondary prevention has a major impact on long-term outcome. Long-term management after NSTE-ACS was described in detail in the previous version of the guidelines and this remains valid.3 In addition, detailed recommendations on secondary prevention have been extensively described in the ESC guidelines on cardiovascular disease prevention in clinical practice.252 The ESC guidelines address all patients at risk for cardiovascular disease or with overt cardiovascular disease. Established cardiovascular disease places a patient in the high risk group. The American Heart Association/American College of Cardiology (AHA/ACC) guidelines on secondary prevention specically address the patient group after an acute cardiac event (i.e. secondary prevention).305 This section will therefore focus only on new developments in the eld. For more detailed information, refer to the above-mentioned documents. For specic goals in secondary prevention and treatment of cardiovascular risk factors

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release of cardiac biomarkers (unstable angina) are less likely to receive guideline-oriented pharmacological secondary prevention as compared with NSTEMI patients.59 It should be emphasized, therefore, that all ACS patients do benet from comprehensive secondary prevention. Enrolment in a cardiac rehabilitation/secondary prevention programme can enhance patient compliance with the medical regimen and is particularly advised to those with multiple modiable risk factors and to moderate to high risk patients in whom supervised guidance is warranted. The degree of benet associated with secondary prevention measures was documented in a follow-up study of patients from the OASIS-5 trial. In this study, patients with NSTE-ACS were encouraged to adhere to a healthy diet, regular physical activity, and smoking cessation 30 days after onset of symptoms. Patients who adhered to both diet and exercise showed an RRR of 54% for MI, stroke, or death (OR 0.46; 95% CI 0.38 0.57; P ,0.0001), and for those who gave up smoking an RRR of 43% for MI (OR 0.57; 95% CI 0.360.89; P 0.0145).306 Two other studies conrmed that implementation of secondary prevention measures after ACS saves at least the same number of lives as treatment delivered during the acute phase.307,308 ACE inhibitors and ARBs are well established in secondary prevention309,310 and are especially indicated in patients with reduced LV function. In patients with ACE intolerance, an ARB is an established alternative, and telmisartan has proven non-inferior to ramipril in a large study, with fewer side effects than with ACE inhibitors.311 The combination of ACE inhibitors and ARBs is generally not recommended. As with ACE inhibitors, it has to be assumed that the conclusions for ARBs apply to patients with recent NSTE-ACS. Aldosterone antagonists, namely eplerenone, have been shown to reduce cardiovascular mortality after MI in patients with reduced LV function (LVEF 35%) even in only mildly symptomatic patients.277 Therefore, these results may also be extrapolated to NSTE-ACS patients with reduced LV function. Table 11
I B 313

Recommendations for drugs in secondary prevention (see separate recommendations for antithrombotic treatment)
Recommendations -Blockers are recommended in all patients with reduced LV systolic function (LVEF 40%). ACE inhibitors are indicated within 24 h in all patients with LVEF 40% and in patients with heart failure, diabetes, hypertension, or CKD, unless contraindicated ACE inhibitors are recommended for all other patients to prevent recurrence of ischaemic events, with preference given to agents and doses of proven efcacy. ARBs are recommended for patients who are intolerant to ACE inhibitors, with preference given to agents and doses of proven efcacy. Aldosterone blockade with eplerenone is indicated in patients after MI who are already being treated with ACE inhibitors and -blockers and who have an LVEF 35% and either diabetes or heart failure, without signicant renal dysfunction [serum creatinine >221 mol/L (>2.5 mg/dL) for men and >177 mol/L (>2.0 mg/dL) for women] or hyperkalaemia. Statin therapy with target LDL-C levels <1.8 mmol/L (<70 mg/dL) initiated early after admission is recommended.
a

Class a I

Level b A

Ref C 314

315, 316

309, 310

311, 317

276, 277

Performance measures in NSTEMI patients

Use of aspirin Use of clopidogrel/prasugrel/ticagrelor

Class of recommendation. b Level of evidence. c References. ACE angiotensin-converting enzyme; ARB angiotensin receptor blocker; CKD chronic kidney disease; LDL-C low-density lipoprotein cholesterol; LV left ventricular; LVEF left ventricular ejection fraction; MI myocardial infarction.

Use of UFH/enoxaparin/fondaparinux/bivalirudin -Blocker at discharge in patients with LV dysfunction Use of statins Use of ACE-inhibitor or ARB Use of early invasive procedures in intermediate- to high-risk patients.

please refer to the table provided in the online Addenda (www. escardio.org/guidelines). All measures and treatments with proven efcacy in secondary prevention should be implemented: lifestyle changes, control of risk factors, and prescription of the pharmacological classes with proven efcacy, namely aspirin, P2Y12 receptor inhibitors, b-blockers, statins, ACE inhibitors or ARBs, and eplerenone. Recently, it has been shown that NSTE-ACS patients without

Smoking cessation advice/counselling Enrolment in a secondary prevention/ cardiac rehabilitation programme

ACE angiotensin-converting enzyme; ARB angiotensin receptor blocker; LV left ventricular; NSTEMI, non-ST-segment elevation myocardial infarction; UFH unfractionated heparin.

Page 42 of 56
Statins are recommended for all NSTE-ACS patients (in the absence of contraindications), irrespective of cholesterol levels, initiated early (within 1 4 days) after admission, with the aim of achieving low-density lipoprotein cholesterol (LDL-C) levels of ,2.6 mmol/L (,100 mg/dL). This is based on several large-scale trials with atorvastatin and pravastatin. A meta-analysis of early statin therapy did not reveal benet of outcome in the rst 4 months.312 However, on extended follow-up over 2 years, a 19% reduction of deaths and cardiovascular events could be demonstrated. Further event rate reduction was demonstrated by reducing the LDL-C levels to ,1.81 mmol/L (,70 mg/dL).313 The dose to achieve maximal benet appears high (e.g. 80 mg of atorvastatin). The effect seems to be independent of and in addition to the anti-inammatory effect (hsCRP reduction) of statins. It is unknown whether the results observed with atorvastatin and pravastatin represent a class effect.

ESC Guidelines

mortality.318 Thus, priority needs to be given to improving the uptake of evidence-based guidelines. The benet/risk of the recommended treatments in terms of NNT and numbers needed to harm can be assessed as depicted in Figure 4. Continuous monitoring of performance indicators is strongly encouraged to enhance the quality of treatment and minimize unwarranted variations in evidence-based care. Consistent application of therapies based on robust evidence (Figure 4) may have larger effects on real-life cardiovascular health than those seen in selected trial populations, especially with the combined implementation of several effective treatment modalities. Such programmes have been implemented successfully in several countries, including Sweden [Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA) registry], the UK

Recommendations for performance measures

6. Performance measures
Variations in the application of evidence-based strategies are associated with differences in outcome. Several large registries have shown deciencies in the treatment of NSTEMI patients when compared with recommendations from contemporary guidelines. Underutilization of evidence-based treatments is common. Adherence to guidelines has been correlated with improvements in patient outcomes in ACS, including reduced

Recommendations Development of regional and/or national programmes to measure performance indicators systematically and provide feedback to individual hospitals is recommended.
a

Class a Level b

Class of recommendation. Level of evidence.

Size
Aspirin vs. Ctrl Heparin vs. Ctrl 3096 2859

Death or MI at 30 days
0.47 0.55 0.91 0.91 0.93 0.90 0.84
Exp+ Ctrl+ Exp+

Major Bleeds
17 31 111 113 176 154 63
Ctrl+ Exp+ Ctrl+ Exp+ Ctrl+

1.4 2.3 1.6 1.1 1.0 0.62

-303 -158 -160 -258 55

GP IIb/IIIa vs. Ctrl 31 402 LMWH vs. UFH DTI vs. UFH Fonda vs. Enox Invasive vs. Cons 21 946 24 701 20 078 7962

0% Incidence

0.5

1 10 102 103 10 1 0% NNT and 95% CI

15% 0.5 Incidence

1 10 102 103 10 1 NNH and 95% CI

OR and 95% CI

OR and 95% CI

Figure 4 Benet and risk for different treatment modalities. CI condence interval; Cons conservative; Ctrl control; DTI direct
thrombin inhibitor; Enox enoxaparin; Exp + experimental therapy; Fonda fondaparinux; GP glycoprotein; LMWH low molecular weight heparin; MI myocardial infarction; NNH numbers needed to harm; NNT numbers needed to treat; OR odds ratio; UFH unfractionated heparin.

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[Myocardial Infarction National Audit Project (MINAP) registry], Germany, Italy, and Israel on a regional basis, or in intermittent programmes in many other countries. These performance measure programmes are also proposed and developed by the ESC through the continuous ACS Registry within the Euro Heart Survey Programme. The most useful performance indicators for monitoring and improving the standards of care in NSTEMI are listed in Table 11.

Table 12
Oxygen Nitrates Morphine

Initial therapeutic measures

Insufation (48 L/min) if oxygen saturation is <90% Sublingual or intravenous (caution if systolic blood pressure is <90 mmHg) 35 mg intravenous or subcutaneously, if severe pain

7. Management strategy
This section summarizes the diagnostic and therapeutic steps as discussed in detail in the previous sections and translates the key elements into checklists and a workow. This allows standardization of the clinical routine work-up and thereby improves quality of care. However, specic ndings in individual patients may result in appropriate deviations from the proposed strategy since NSTE-ACS encompasses a heterogeneous spectrum of patients with different levels of risk in terms of death, MI, or recurrence of MI. For every patient, the physician must make an individual decision, taking into account the patients history (co-morbid illnesses, age, etc.), his/her clinical condition, ndings during the initial assessment on rst contact, and the available pharmacological and non-pharmacological treatment options.

or I, creatinine, haemoglobin, blood glucose, and blood cell count, in addition to standard biochemistry tests. Assignment of the patient to the NSTE-ACS category will lead on to step twodiagnosis validation and risk assessment.

Step two: diagnosis validation and risk assessment

After the patient is assigned to the group NSTE-ACS, i.v. and oral antithrombotic treatments will be started according to Table 13. Further management of the patient will be based on additional information/data: Responsiveness to antianginal treatment. Routine clinical chemistry, particularly troponins (on presentation and after 6 9 h) and other markers, according to working diagnoses (e.g. D-dimers, BNP, NT-proBNP); if highly sensitive troponin assays are available, a fast track rule-out protocol (3 h) may be implemented (Figure 5). Repeat or continuous ST-segment monitoring (when available). Ischaemic risk score assessment (GRACE score). Echocardiogram;

Step one: initial evaluation

Chest pain or discomfort suggestive of ACS or other symptoms as described in Section 3.1 will lead to the patient seeking medical attention or hospitalization. A patient with suspected NSTE-ACS must be evaluated in a hospital and seen immediately by a qualied physician. Specialized chest pain units or coronary care units provide the best and most expeditious care.47 The initial step is to assign the patient without delay to a working diagnosis on which the treatment strategy will be based. The assessment criteria are the following: Quality of chest pain and a symptom-orientated physical examination Assessment of the likelihood of CAD (e.g. age, risk factors, previous MI, CABG, PCI) ECG (to detect ST-segment deviation or other abnormality). On the basis of these ndings, which should be available within 10 min of rst medical contact, the patient can be assigned to one of the three major working diagnoses: STEMI NSTE-ACS; ACS (highly) unlikely. The treatment of patients with STEMI is covered in the respective guidelines.2 The assignment to the category unlikely must be done with caution and only when another explanation is obvious (e.g. thorax trauma). The initial treatment measures are summarized in Table 12. Blood is drawn on arrival of the patient in hospital and the results should be available within 60 min to be used in the second step. Initial blood tests must at least include: troponin T

Table 13 Checklist of treatments when an ACS diagnosis appears likely

Initial dose of 150300 mg non-enteric formulation followed by 75100 mg/day (i.v. administration is acceptable) Loading dose of ticagrelor or clopidogrela Choice between different options depends on strategy: Fondaparinux 2.5 mg/daily subcutaneously Enoxaparin 1 mg/kg twice daily subcutaneously UFH i.v. bolus 6070 IU/kg (maximum 5000 IU) followed by infusion of 1215 IU/kg/h (maximum 1000 IU/h) titrated to aPTT 1.52.5 control Bivalirudin is indicated only in patients with a planned invasive strategy If tachycardic or hypertensive without signs of heart failure

Aspirin P2Y 12 inhibitor

Anticoagulation

Oral -Blocker

aPTT activated partial thromboplastin time; IU international units; i.v. intravenous; UFH unfractionated heparin. a Prasugrel is not mentioned as it is not approved as medical therapy before invasive strategy, but only after angiography when anatomy is known.

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ESC Guidelines

Acute Chest Pain

hsTn < ULN hsTn > ULN

Pain >6h

Pain <6h

Re-test hsTn: 3h

hsTn no change

changea (1 value > ULN)

+ clinical presentation

Highly abnormal Tn

hsTn no change

Painfree, GRACE <140, differential diagnoses excluded

Work-up differential diagnoses

Discharge/ Stress testing

Invasive management

Figure 5 Rapid rule-out of ACS with high-sensitivity troponin. GRACE, GRACE Global Registry of Acute Coronary Events; hsTn highsensitivity troponin; ULN upper limit of normal, 99th percentile of healthy controls. aD change, dependent on assay (see Sections 3.2.3. and 4.3). At the end of this step, the decision has to be made whether the patient should go on to cardiac catheterization (Figure 6).

Optional: chest X-ray, CT, MRI or nuclear imaging for differential diagnoses (e.g. aortic dissection, pulmonary embolism, etc.). Bleeding risk assessment (CRUSADE score). During step two, other diagnoses may be conrmed or excluded, such as pulmonary embolism and aortic aneurysm (see Table 4 and Section 3.3). Treatment of the individual patient is tailored according to their risk for subsequent events, which should be assessed early at the initial presentation as well as repeatedly thereafter in the light of continuing or repetitive symptoms and additional information from clinical chemistry or imaging modalities. Risk assessment is an important component of the decisionmaking process and is subject to constant re-evaluation. It encompasses assessment of both ischaemic and bleeding risk. The risk factors for bleeding and ischaemic events overlap considerably, with the result that patients at high risk of ischaemic events are also at high risk of bleeding. Therefore, the choice of pharmacological environment (dual or triple antiplatelet therapy, or anticoagulants) is important, as is the dosage of the drugs and the access site in the case of angiography. Particular attention has to be paid to renal dysfunction, shown to be particularly frequent in elderly patients and diabetic patients. The pharmacological options are summarized in Table 13.

Step three: invasive strategy

Cardiac catheterization followed by revascularization has been shown to prevent recurrent ischaemia and/or improve shortand long-term outcomes. Several risk factors (troponin elevation, diabetes, ST-segment depression, renal insufciency, etc.) have been identied to predict the long-term benet of an invasive strategy. Depending on the acuteness of risk, the timing of angiography can be tailored, according to four categories (Figure 6): invasive (,72 h); urgent invasive (,120 min); early invasive (,24 h); primarily conservative. The optimal timing depends on the risk prole of the individual patient and can be assessed by several variables.

Urgent invasive strategy (<120 min after rst medical contact) This should be undertaken for very high risk patients. These patients are characterized by: Refractory angina abnormalities). (indicating evolving MI without ST

ESC Guidelines

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1. Clinical Evaluation STEMI

2. Diagnosis/Risk Assessment reperfusion

3. Coronary angiography urgent <120 min

Evaluation
Quality of chest pain Symptom-orientated physical examination Short history for the likelihood of CAD Electrocardiogram (ST elevation?)

Validation
ACS possible
Response to antianginal treatment Biochemistry/troponin ECG Echocardiogram Calculated risk score (GRACE) Risk criteria (Table 9) Optional: CT, MRI, scintigraphy

early <24 h <72 h

No CAD

no/elective

Figure 6 Decision-making algorithm in ACS. ACS acute coronary syndrome; CAD coronary artery disease; CT computed tomography; ECG, electrocardiogram; GRACE Global Registry of Acute Coronary Events; MRI magnetic resonance imaging; STEMI ST-elevation myocardial infarction.

Table 14 Checklist of antithrombotic treatments prior to PCI

Aspirin Conrm loading dose prior to PCI. Conrm loading dose of ticagrelor or clopidogrel prior to PCI. If P2Y12 nave, consider prasugrel (if <75 years age, >60 kg, no prior stroke or TIA) Fondaparinux pre-treated: add UFH for PCI Enoxaparin pre-treated: add if indicated UFH pre-treated: titrate to ACT >250 s, or switch to bivalirudin (0.1 mg/kg bolus followed by 0.25 mg/kg/h) Consider tiroban or eptibatide in patients with high-risk anatomy or troponin elevation Abciximab only prior to PCI in high-risk patients.

time to catheterization. A checklist of antithrombotic treatments prior to PCI is given in Table 14. Early invasive strategy (<24 h after rst medical contact) Most patients initially respond to the antianginal treatment, but are at increased risk and need angiography followed by revascularization. High risk patients as identied by a GRACE risk score .140 and/or the presence of at least one primary high risk criterion (Table 9) should undergo invasive evaluation within 24 h. Invasive strategy (<72 h after rst medical contact) In patients with less acute risk, according to Table 9, and without recurrence of symptoms, angiography may be performed within a time window of 72 h. Thus, such patients should undergo elective invasive evaluation at the rst opportunity depending on the local circumstances. Conservative strategy (no or elective angiography) Patients that full all of the following criteria may be regarded as low risk and should not routinely be submitted to early invasive evaluation: No recurrence of chest pain. No signs of heart failure. No abnormalities in the initial ECG or a second ECG (at 69 h). No rise in troponin level (at arrival and at 69 h). No inducible ischaemia.

P2Y 12 inhibitor

Anticoagulation

GP IIb/IIIa receptor inhibitor

ACT activated clotting time; GP, glycoprotein; PCI percutaneous coronary intervention; TIA transient ischaemic attack; UFH unfractionated heparin.

Recurrent angina despite intense antianginal treatment, associated with ST depression (2 mm) or deep negative T waves. Clinical symptoms of heart failure or haemodynamic instability (shock). Life-threatening arrhythmias (ventricular brillation or ventricular tachycardia). A GP IIb/IIIa receptor inhibitor (eptibatide or tiroban) may be considered in patients with such features in order to bridge the

Low risk as assessed by a risk score (see Section 4.4) should support the decision-making process for a conservative strategy. The further management of these patients is according to the

Page 46 of 56
evaluation of stable CAD.319 Before discharge from hospital, a stress test for inducible ischaemia is useful for treatment planning and required before elective angiography.

ESC Guidelines

Table 15
Aspirin

Measures checked at discharge

Continue life long Continue for 12 months (unless at high risk of bleeding) If LV function depressed If LV function depressed Consider for patients devoid of depressed LV function If depressed LV function (LVEF 35%) and either diabetes or heart failure, without signicant renal dysfunction Titrate to achieve target LDL-C levels <1.8 mmol/L (<70 mg/dL) Risk-factor counselling, referral to cardiac rehabilitation / secondary prevention programme

Step four: revascularization modalities

If the angiogram shows atheromatous burden but no critical coronary lesions, patients will be referred for medical therapy. The diagnosis of NSTE-ACS may be reconsidered and particular attention paid to other possible reasons for symptoms at presentation, before the patient is discharged. However, the absence of critical coronary lesions does not rule out the diagnosis if the clinical presentation was suggestive of ischaemic chest pain and if biomarkers were positive. In this situation, patients should receive treatment according to the recommendations for NSTE-ACS. Recommendations for the choice of a revascularization modality in NSTE-ACS are similar to those for elective revascularization procedures. In patients with single-vessel disease, PCI with stenting of the culprit lesion is the rst choice. In patients with multivessel disease, the decision for PCI or CABG must be made individually, according to institutional protocols designed by the Heart Team. A sequential approach, consisting of treating the culprit lesion with PCI followed by elective CABG with proof of ischaemia and/or functional assessment (FFR) of the non-culprit lesions, may be advantageous in some patients. The anticoagulant should not be changed during PCI. In patients pre-treated with fondaparinux, UFH must be added before PCI. A GP IIb/IIIa inhibitor should be considered if troponins are elevated or on angiographic presence of thrombus. If CABG is planned, P2Y12 inhibitors should be stopped and surgery deferred only if the clinical condition and the angiographic ndings permit. If angiography shows no options for revascularization, owing to the extent of the lesions and/or poor distal run-off, freedom from angina at rest should be achieved by intensied medical therapy, and secondary preventive measures should be instituted.

P2Y 12 inhibitor -Blocker ACE inhibitor/ ARB Aldosterone antagonist/ eplerenone Statin Lifestyle

ACE angiotensin-converting enzyme; ARB angiotensin receptor blocker; LDL-C low-density lipoprotein cholesterol; LV left ventricular; LVEF left ventricular ejection fraction.

months. Patients treated with early revascularization are at low (2.5%) risk for developing life-threatening arrhythmias, with 80% occurring during the rst 12 h after onset of symptoms.320 Accordingly, routine monitoring of the patients beyond 24 48 h is not warranted. Patients with NSTE-ACS should be hospitalized for at least 24 h after successful stenting of the culprit lesion. Intense risk factor modication and lifestyle change are warranted in all patients following the diagnosis of NSTE-ACS (see Section 5.6). Enrolment in a cardiac rehabilitation programme after discharge can enhance patient adherence to the medical regimen and may be supportive in risk factor modication. A checklist of measures necessary at discharge from hospital is given in Table 15.

Step ve: hospital discharge and post-discharge management

Although in NSTE-ACS most adverse events occur in the early phase, the risk for MI or death remains elevated over several

Acknowledgements
We are indebted to Dr Sebastian Szardien for his invaluable support and editorial assistance during the preparation of the manuscript.

The CME text ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation is accredited by the European Board for Accreditation in Cardiology (EBAC). EBAC works according to the quality standards of the European Accreditation Council for Continuing Medical Education (EACCME), which is an institution of the European Union of Medical Specialists (UEMS). In compliance with EBAC/EACCME guidelines, all authors participating in this programme have disclosed potential conicts of interest that might cause a bias in the article. The Organizing Committee is responsible for ensuring that all potential conicts of interest relevant to the programme are declared to the participants prior to the CME activities. CME questions for this article are available at: European Heart Journal http://cme.oxfordjournals. org/cgi/hierarchy/oupcme_node;ehj and European Society of Cardiology http:// www.escardio.org/guidelines.

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ESC Guidelines

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ESC Guidelines

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ESC Guidelines

127. Bhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, Shook TL, Lapuerta P, Goldsmith MA, Laine L, Scirica BM, Murphy SA, Cannon CP. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med 2010;363:1909 1917. 128. Wiviott SD, Trenk D, Frelinger AL, ODonoghue M, Neumann F-J, Michelson AD, Angiolillo DJ, Hod H, Montalescot G, Miller DL, Jakubowski JA, Cairns R, Murphy SA, McCabe CH, Antman EM, Braunwald E, PRINCIPLE-TIMI 44 Investigators. Prasugrel compared with high loading- and maintenance-dose clopidogrel in patients with planned percutaneous coronary intervention: the Prasugrel in Comparison to Clopidogrel for Inhibition of Platelet Activation and Aggregation Thrombolysis in Myocardial Infarction 44 Trial. Circulation 2007;116:2923 2932. 129. Small DS, Farid NA, Payne CD, Weerakkody GJ, Li YG, Brandt JT, Salazar DE, Winters KJ. 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158. Topol EJ, Moliterno DJ, Herrmann HC, Powers ER, Grines CL, Cohen DJ, Cohen EA, Bertrand M, Neumann F-J, Stone GW, DiBattiste PM, Yakubov SJ, DeLucca PT, Demopoulos L, the TARGET Investigators. Comparison of two platelet glycoprotein IIb/IIIa inhibitors, tiroban and abciximab, for the prevention of ischemic events with percutaneous coronary revascularization. N Engl J Med 2001;344:1888 1894. 159. Moliterno DJ, Yakubov SJ, DiBattiste PM, Herrmann HC, Stone GW, Macaya C, Neumann F-J, Ardissino D, Bassand J-P, Borzi L. Outcomes at 6 months for the direct comparison of tiroban and abciximab during percutaneous coronary revascularisation with stent placement: the TARGET follow-up study. Lancet 2002;360:355 360. 160. De Luca G, Ucci G, Cassetti E, Marino P. Benets from small molecule administration as compared with abciximab among patients with ST-segment elevation myocardial infarction treated with primary angioplasty: a meta-analysis. J Am Coll Cardiol 2009;53:1668 1673. 161. 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ESC Guidelines

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