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CONFERENCE UPDATE: ESC 2023

The management of acute coronary syndromes: ESC 2023 guidelines

19 Sep 2023

Acute coronary syndromes (ACS) encompass a spectrum of conditions including unstable angina, non-ST-elevation myocardial infarction (NSTEMI), or ST-elevation myocardial infarction (STEMI).¹ Although patients may present differently with ACS, they face many similar diagnostic tests, invasive management strategies, hospital care, and long-term management.¹ As a result, the 2023 ESC guidelines, which were developed by 26 authors and 58 reviewers globally, combine the management of ACS in both STEMI and NSTEMI patients into a single document for the first time.¹

In the ESC Congress 2023, Professor Robert Byrne and Professor Borja Ibanez, the chairpersons of the ESC Guideline Task Force, introduced the 2023 ESC Guidelines for ACS management which details 193 recommendations and 936 references.¹ While most of the guidelines were maintained, the esteemed professors highlighted several revised recommendations which covered early invasive strategies, antithrombotic and lipid-lowering therapies, intravascular imaging and the long-term management of patients with comorbid conditions.¹

In addition, the guidelines contain a new section focused on patient perspectives and recommendations for providing patient-centered care.¹ By considering both the patient’s physical and psychosocial needs throughout various stages of their ACS journey, healthcare professionals can enhance patient engagement and education, ultimately improving their quality of care.¹

Management strategies	Recommendations	Class of recommendation	LOE
NSTE-ACS	An early invasive strategy within 24 hours should be considered in patients with at least one of the following high-risk criteria: Confirmed diagnosis of NSTEMI based on current recommended ESC hs-cTn algorithms Dynamic ST-segment or T-wave changes Transient ST-segment elevation GRACE risk score >140	IIa	A
Out-of-hospital cardiac arrest	Routine immediate angiography after resuscitated cardiac arrest is not recommended in hemodynamically stable patients without persistent ST-segment elevation (or equivalents)	III	A
Out-of-hospital cardiac arrest	Temperature control [i.e., continuous monitoring of core temperature and active prevention of fever (i.e., >37.7°C)] is recommended after either out-of-hospital or in-hospital cardiac arrest for adults who remain unresponsive after the return of spontaneous circulation	I	B
Anti-thrombotic therapy in ACS (no OAC)	Bivalirudin with full-dose post-PCI infusion should be considered as an alternative to UFH in patients with STEMI undergoing PPCI.	IIa	A
	Routine pretreatment with a P2Y12 inhibitor may be considered in patients undergoing a primary PCI strategy.	IIb	B
	In patients who are event-free after 3-6 months of DAPT and who are not at high ischemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered.	IIa	A
	In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered.	IIb	B
	De-escalation of P2Y12 receptor inhibitor treatment (e.g., with a switch from prasugrel/ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk	IIb	A
	De-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended	III	B
Anti-thrombotic therapy in ACS (with OAC)	P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment	IIb	A
Intravascular imaging	Intravascular imaging should be considered to guide PCI	IIa	A
Intravascular imaging	Intravascular imaging (preferably OCT) may be considered in patients with ambiguous culprit lesions	IIb	C
ACS with Multivessel Disease in cardiogenic shock	Staged PCI of non-IRA should be considered*	IIa	C
Multivessel disease in hemodynamically stable STEMI patients undergoing PPCI	Complete revascularization is recommended either during the index PCI procedure or within 45 days	I	A
LLT	It is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values	I	A
	Combination therapy with high-dose statin plus ezetimibe may be considered during index hospitalization	IIb	B
	If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4-6 weeks, the addition of ezetimibe is recommended	I	B
	If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4–6 weeks, the addition of a PCSK9i is recommended	I	A
Comorbid conditions	For frail older patients with comorbidities individualized intervention and pharmacological treatments after careful evaluation of the risks and benefits	I	B
	In older ACS patients, especially if HBR, clopidogrel as the P2Y12 receptor inhibitor may be considered	IIb	B
	An invasive strategy is recommended in cancer patients presenting with high-risk ACS with an expected survival of ≥6 months	I	B
	A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis^ (i.e., with expected survival <6 months) and/or very high bleeding risk	IIa	C
Long-term management	A polypill should be considered as an option to improve adherence and outcomes in secondary prevention after ACS	IIa	B

Table 1: Revised ESC guidelines for managing ACS

ACS: Acute coronary syndrome; DAPT: Dual antiplatelet therapy; ESC: European Society of Cardiology; GRACE: Global Registry of Acute Coronary Events; HBR: High bleeding risk; hs-cTn: High-sensitivity cardiac troponin; IRA: Infarct-related artery; LDL-C: Low-density lipoprotein-cholesterol; LLT: Lipid-lowering therapy; LOE: Levels of evidence; MI: myocardial infarction; NSTE-ACS: Non-ST-elevation acute coronary intervention; OAC: Oral anti-coagulation; OCT: Optical coherence tomography; PCI: Percutaneous coronary intervention; PCKS9i: Proprotein convertase subtilisin/kexin type 9 inhibitor; PPCI: Primary PCI; STEMI: ST-elevation myocardial infarction; UFH: Unfractionated heparin

*Based on ischemia, symptoms, patient comorbidities, and clinical condition

^Related to advanced cancer stage and/or severe irreversible non-CV comorbidities

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