2020ESC Guidelines for the management of acute coronary ...

European Heart Journal (2020) 00, 1?79 doi:10.1093/eurheartj/ehaa575

ESC GUIDELINES

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2020 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 in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)

Authors/Task Force Members: Jean-Philippe Collet * (Chairperson) (France), Holger Thiele * (Chairperson) (Germany), Emanuele Barbato (Italy), Olivier Barthe?le?my (France), Johann Bauersachs (Germany), Deepak L. Bhatt (United States of America), Paul Dendale (Belgium), Maria Dorobantu (Romania), Thor Edvardsen (Norway), Thierry Folliguet (France), Chris P. Gale (United Kingdom), Martine Gilard (France), Alexander Jobs (Germany), Peter Ju? ni (Canada), Ekaterini Lambrinou (Cyprus), Basil S. Lewis (Israel), Julinda Mehilli (Germany), Emanuele Meliga (Italy), Be?la Merkely (Hungary), Christian Mueller (Switzerland), Marco Roffi (Switzerland), Frans H. Rutten (Netherlands), Dirk Sibbing (Germany), George C.M. Siontis (Switzerland)

* Corresponding authors: Jean-Philippe Collet, Sorbonne Universite?, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Ho^ pital Pitie?-Salp^etrie`re (Assistance Publique- Ho^ pitaux de Paris) (AP-HP), 83, boulevard de l'Ho^ pital, 75013 Paris, France. Tel ? 33 01 42 16 29 62, E-mail: jean-philippe.collet@aphp.fr Holger Thiele, Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Stru?mpellstr. 39, 04289 Leipzig, Germany. Tel: ?49 341 865 1428, Fax: ?49 341 865 1461, E-mail: holger.thiele@medizin.uni-leipzig.de ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers, and Author/Task Force Member affiliations: listed in the Appendix. ESC entities having participated in the development of this document: Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (ACNAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure Association (HFA). Councils: Council for Cardiology Practice. Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Thrombosis. 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 (journals.permissions@). Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient's health condition and in consultation with that patient and, where appropriate and/or necessary, the patient's caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authorities, in order to manage each patient's case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional's responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription.

VC The European Society of Cardiology 2020. All rights reserved. For permissions, please email: journals.permissions@.

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ESC Guidelines

Document Reviewers: Adnan Kastrati (CPG Review Coordinator) (Germany), Mamas A. Mamas (CPG Review Coordinator) (United Kingdom), Victor Aboyans (France), Dominick J. Angiolillo (United States of America), Hector Bueno (Spain), Raffaele Bugiardini (Italy), Robert A. Byrne (Ireland), Silvia Castelletti (Italy), Alaide Chieffo (Italy), Veronique Cornelissen (Belgium), Filippo Crea (Italy), Victoria Delgado (Netherlands), Heinz Drexel (Austria), Marek Gierlotka (Poland), Sigrun Halvorsen (Norway), Kristina Hermann Haugaa (Norway), Ewa A. Jankowska (Poland), Hugo A. Katus (Germany), Tim Kinnaird (United Kingdom), Jolanda Kluin (Netherlands), Vijay Kunadian (United Kingdom), Ulf Landmesser (Germany), Christophe Leclercq (France), Maddalena Lettino (Italy), Leena Meinila (Finland), Darren Mylotte (Ireland), Gjin Ndrepepa (Germany), Elmir Omerovic (Sweden), Roberto F. E. Pedretti (Italy), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Gianluca Pontone (Italy), Bogdan A. Popescu (Romania), Tatjana Potpara (Serbia), Kausik K. Ray (United Kingdom), Flavio Luciano Ribichini (Italy), Dimitrios J. Richter (Greece), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (United Kingdom), Miguel Sousa-Uva (Portugal), Robert F. Storey (United Kingdom), Rhian M. Touyz (United Kingdom), Marco Valgimigli (Switzerland), Pascal Vranckx (Belgium), Robert W. Yeh (United States of America)

The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website guidelines

For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online.

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Keywords

Guidelines ? acute cardiac care ? acute coronary syndrome ? angioplasty ? anticoagulation ? antiplatelet

? apixaban ? aspirin ? atherothrombosis ? betablockers ? bleedings ? bivalirudin ? bypass surgery ? can-

grelor ? chest pain unit ? clopidogrel ? dabigatran ? diabetes ? dual antithrombotic therapy ? early inva-

sive strategy ? edoxaban ? enoxaparin ? European Society of Cardiology ? fondaparinux ? glycoprotein IIb/

IIIa inhibitors ? heparin ? high-sensitivity troponin ? minoca ? myocardial ischaemia ? myocardial infarction

? nitrates ? non-ST-elevation myocardial infarction ? platelet inhibition ? prasugrel ? recommendations ?

revascularization ? rhythm monitoring ? rivaroxaban ? stent ? ticagrelor ? triple therapy ? unstable angina

Table of contents

Abbreviations and acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1 Preamble . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 2 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

2.1 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.1.1 Universal definition of myocardial infarction . . . . . . . . . . . . . . . 8 2.1.1.1 Type 1 myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . 8 2.1.1.2 Type 2 myocardial infarction . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.1.1.3 Types 3?5 myocardial infarction . . . . . . . . . . . . . . . . . . . . . 9 2.1.2 Unstable angina in the era of high-sensitivity cardiac troponin assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.2 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.3 What is new? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 2.4 Number and breakdown of classes of recommendations (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . 10 3 Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.1 Clinical presentation (Supplementary Data) . . . . . . . . . . . . . . . . . . 10 3.2 Physical examination (Supplementary Data) . . . . . . . . . . . . . . . . . . 10 3.3 Diagnostic tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

3.3.1 Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 3.3.2 Biomarkers: high-sensitivity cardiac troponin . . . . . . . . . . . . . 11

3.3.2.1 Central laboratory vs. point-of-care . . . . . . . . . . . . . . . . . . 12

.......................................................................

3.3.2.2 Other biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.3.3 Rapid `rule-in' and `rule-out' algorithms . . . . . . . . . . . . . . . . . . . 13 3.3.4 Observe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

3.3.4.1 Caveats of using rapid algorithms . . . . . . . . . . . . . . . . . . . . 15 3.3.4.2 Confounders of cardiac troponin concentration . . . . . . 15 3.3.4.3 Practical guidance on how to implement the European Society of Cardiology 0 h/1 h algorithm . . . . . . . . . . . 16 3.3.4.4 Avoiding misunderstandings: time to decision = time of blood drawrn-around time . . . . . . . . . . . . . . . . . . . . . . . 16 3.3.5 Non-invasive imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3.5.1 Functional evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.3.5.2 Anatomical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 3.4 Differential diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4 Risk assessment and outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.1 Electrocardiogram indicators (Supplementary Data) . . . . . . . . . . 19 4.2 Biomarkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.3 Clinical scores for risk assessment (Supplementary Data) . . . . . . 19 4.4 Bleeding risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 4.5 Integrating ischaemic and bleeding risks . . . . . . . . . . . . . . . . . . . . . . . 21 5 Pharmacological treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5.1 Antithrombotic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5.1.1 Antiplatelet drugs and pre-treatment . . . . . . . . . . . . . . . . . . . . . 23 5.1.1.1 Antiplatelet drugs and dual antiplatelet therapy . . . . . . . 23

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5.1.1.2 Pre-treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 5.1.2 Peri-interventional anticoagulant treatment . . . . . . . . . . . . . . . 26 5.1.3 Peri-interventional antiplatelet treatment . . . . . . . . . . . . . . . . . 27 5.1.4 Post-interventional and maintenance treatment . . . . . . . . . . 27 5.2 Pharmacological treatment of ischaemia (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 5.2.1 Supportive pharmacological treatment (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 5.2.2 Nitrates and beta-blockers (Supplementary Data) . . . . . . . . 30 5.3 Managing oral antiplatelet agents in patients requiring long-termoral anticoagulants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 5.3.1 Patients with atrial fibrillation without mechanical prosthetic heart valves or moderate-to-severe mitral stenosis undergoing percutaneous coronary intervention or managed medically (Supplementary Data) . . . . . . . . . . . . . . . . . . 30 5.3.2 Patients requiring vitamin K antagonists or undergoing coronary artery bypass surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 5.4 Management of acute bleeding events (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.1 General supportivemeasures (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.2 Bleeding events on antiplatelet agents (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.3 Bleeding events on vitamin K antagonists (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.4 Bleeding events on non-vitamin K antagonist oral anticoagulants (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.5 Non-access-related bleeding events (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.6 Bleeding events related to percutaneous coronary intervention (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.7 Bleeding events related to coronary artery bypass surgery (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 5.4.8 Transfusion therapy (Supplementary Data) . . . . . . . . . . . . . . . 34 5.4.9 Recommendations for bleeding management and blood transfusion in non-ST-segment elevation acute coronary syndromes for anticoagulated patients . . . . . . . . . . . . . . . 34 6 Invasive treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 6.1 Invasive coronary angiography and revascularization . . . . . . . . . . 34 6.1.1 Routine invasive vs. selective invasive approach (Supplementary Data) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 6.1.2 Timing of invasive strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

6.1.2.1 Immediate invasive strategy (65 years), drugs and alcohol (1 point each) High bleeding risk Heart-type fatty acid-binding protein

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