2023 ESC clinical practice guidelines for the management of acute coronary syndromes

New European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes (ACS) were presented at the ESC Congress by Prof Robert A Byrne, Mater Private Network and RCSI, Dublin; and Prof Borja Ibanez, Spanish National Centre for Cardiovascular Research [CNIC] and Fundación Jiménez Díaz University Hospital-CIBERCV, Madrid, Spain; Chairs of the guidelines taskforce.

“Previous ESC guidelines dealt with ST-elevation myocardial infarction (STEMI) and non-ST elevation ACS (NSTE-ACS) separately, but these have been brought together in the 2023 guidelines to highlight that ACS should be considered as a spectrum that encompasses both,” said Prof Byrne.

Diagnostic tests, invasive procedures, and pharmacological treatments are pretty much the same across the spectrum, and differences in the management between the different forms of presentation of ACS relate to the time of invasive coronary angiography. This should be immediately for STEMI and very high-risk NSTE-ACS, with a less emergent nature for NSTE-ACS. For the latter, it is recommended that invasive strategy is performed during hospitalisation (inpatient), and in some cases (ie, patients with high-risk characteristics), it should be considered to do so within 24 hours of admission (early invasive strategy). After the acute management and stabilisation phase, most aspects of the subsequent management strategy are common to all patients with ACS and can therefore be considered under a similar pathway. Accordingly, “it makes a lot of sense to combine the former two guidelines into a single document, which we hope will be very useful for healthcare providers attending ACS patients,” said Prof Ibanez.

There are 37 new recommendations on topics including the use of antiplatelet and anticoagulation therapy, treating multivessel disease, managing ACS complications, and intensification of lipid-lowering therapy. In addition, new recommendations are given on comorbid conditions, including six that are relevant to ACS patients with cancer. Prof Ibanez explained: “Cancer patients with ACS have been reported to undergo invasive management less frequently; however, invasive management is recommended in cancer patients presenting with high-risk ACS with expected survival of six months or more. A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (ie, with expected survival <six months) and/or very high bleeding risk.” Temporary interruption of cancer therapy is recommended when it is suspected to be a contributing cause of ACS.

Also new is a section on patient perspectives. Prof Byrne drew attention to the opinion of the ESC taskforce that management should not only consider the best available evidence with regard to clinical treatment strategies, but should also be respectful of and responsive to individual patient preferences, needs and values, ensuring that these values are used to inform all clinical decisions. It is recommended to include patients in decision-making where possible and to inform them about the risk of adverse events, radiation exposure, and alternative options.

The new guidelines also advocate preparing for discharge on admission and integrating educationally-appropriate material in both written and verbal formats. The ‘teach back’ technique and/or motivational interviewing, giving information in chunks and checking for understanding, should be considered. Regarding long-term management, it is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, multidisciplinary exercise-based cardiac rehabilitation and prevention programme, and adopt a healthy lifestyle.