European Society of Cardiology

European Society of Cardiology

Source:

Thiele H, et al. 2020 ESC guidelines on non ST-segment elevation acute coronary syndromes. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).

Disclosures: Mueller reports he has financial ties with Abbott, Acon, Amgen, AstraZeneca, Bayer, Beckman Coulter, Boehringer Ingelheim, Daiichi Sankyo, Idorsia, Novartis, OrthoClinical Diagnostics, Quidel, Roche Diagnostics, Siemens, Singulex and Sphingotec. Roffi reports he has financial ties with Biotronik, Boston Scientific, GE Healthcare and Medtronic. Sibbing reports he has financial ties with AstraZeneca, Bayer, Daiichi Sankyo, Pfizer, Roche Diagnostics and Sanofi. Windecker reports he has financial ties with multiple pharmaceutical and device companies.
August 31, 2020
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Antithrombotic therapies, troponin protocols among changes to ESC NSTEACS guideline

Source:

Thiele H, et al. 2020 ESC guidelines on non ST-segment elevation acute coronary syndromes. Presented at: European Society of Cardiology Congress; Aug. 29-Sept. 1, 2020 (virtual meeting).

Disclosures: Mueller reports he has financial ties with Abbott, Acon, Amgen, AstraZeneca, Bayer, Beckman Coulter, Boehringer Ingelheim, Daiichi Sankyo, Idorsia, Novartis, OrthoClinical Diagnostics, Quidel, Roche Diagnostics, Siemens, Singulex and Sphingotec. Roffi reports he has financial ties with Biotronik, Boston Scientific, GE Healthcare and Medtronic. Sibbing reports he has financial ties with AstraZeneca, Bayer, Daiichi Sankyo, Pfizer, Roche Diagnostics and Sanofi. Windecker reports he has financial ties with multiple pharmaceutical and device companies.
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A new European Society of Cardiology guideline on management of non-ST-segment elevation ACS recommends no pretreatment with P2Y12 inhibitors before PCI in this population, among other changes.

The document also endorses use of non-vitamin K-antagonist oral anticoagulants instead of vitamin K antagonists in patients who require anticoagulation and undergo PCI for NSTEACS and proposes, in addition to the 0/1-hour algorithm implemented since the previous version of the guidelines in 2015, a 0/2-hour algorithm using high-sensitivity cardiac troponin essays to diagnose MI.

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Marco Roffi

“The most important change in the guidelines compared with the 2015 [version] is the introduction with a strong class of recommendation of the 0 to 2-hour algorithm [for high-sensitivity cardiac troponin testing],” guideline task force member Marco Roffi, MD, FACC, FESC, vice chairman of cardiology and director of the Interventional Cardiology Unit at University Hospital of Geneva, Switzerland, said during a session at the virtual ESC Congress. “In terms of treatment, for revascularization, the categorization of the risk has been simplified into very high risk, high risk and low risk. The intermediate group has now become low risk because we have high-sensitivity cardiac troponin available. From the antithrombotic perspective, the two important changes are one on dual antithrombotic therapy following the in-hospital phase for patients with a requirement of oral anticoagulation undergoing PCI, and the class III indication for routine pretreatment with P2Y12 inhibitors.”

Dirk Sibbing, MD, FESC, MHBA, professor of cardiology at Privatklinik Lauterbacher Mühle / Ludwig-Maximilians University in Munich and guideline task force member, said in a presentation that the latter recommendation is “due to lack of evidence of benefit from studies such as ACCOAST, the very large SCAAR registry and ISAR-REACT 5. The pretreatment strategy is risky for some patients, including those requiring emergent bypass surgery, as well as for those with aortic dissection or undiscovered bleeding complications."

He also said that because of the results of ISAR-REACT 5, a preference for prasugrel (Effient, Daiichi Sankyo/Eli Lilly) over ticagrelor (Brilinta, AstraZeneca) should be considered for patients with NSTEACS at the time of PCI.

The guideline includes an algorithm for antithrombotic therapy in patients with NSTEACS previously on anticoagulation due to atrial fibrillation or another reason who undergo PCI.

Sibbing said all patients should get triple therapy of a non-vitamin-K-antagonist oral anticoagulant, aspirin and a P2Y12 inhibitor in the hospital, but after that, the default strategy is double therapy with the anticoagulant plus a single antiplatelet for 1 year, while patients at high bleeding risk should have double therapy for 6 months and the anticoagulant alone thereafter, and those at high ischemic risk should have triple therapy for 1 month followed by double therapy until 1 year.

Christian Mueller, MD, head of Cardiovascular Research Institute Basel, University Hospital Basel, Switzerland, and a member of the task force, said the guideline strongly recommends high-sensitivity cardiac troponin assays be used to diagnose MI instead of conventional assays because their results are less likely to be ambiguous. Sibbing noted the ESC first endorsed the idea in 2011.

The ESC’s algorithm for high-sensitivity cardiac troponin assays with blood draws at presentation and at 1 hour remains recommended, but if that is not feasible, then an algorithm with blood draws at presentation and 2 hours can safely be used, Mueller said during the presentation.

Stephan Windecker

During a discussion, Stephan Windecker, MD, FESC, chairman of the department of cardiology at Bern University Hospital, Inselspital, Switzerland, and chairperson of the ESC’s Committee for Practice Guidelines, said the benefits of high-sensitivity cardiac troponin assays outweigh concern that they might cause overdiagnosis of non-STEMI.

“The most important issue is not to miss the diagnosis of myocardial infarction,” he said. “A high negative predictive value is of utmost importance to safely rule out MI. Moreover, the guideline emphasizes that [MI] is not a biomarker-alone diagnosis but an integration of clinical symptomatology, electrocardiographic changes and troponin absolute determination, as well as change [in troponin levels].”

The new guideline also maintains its endorsement of the GRACE risk score for risk assessment, albeit at a lower level of recommendation because the Australian AGRIS cluster randomized trial failed to demonstrate that a GRACE-score-based management strategy improved patient outcomes.

The task force was co-chaired by Jean-Philippe Collet, MD, PhD, FESC, a member of the ACTION Study Group, Unité de Recherche Clinique, Hôpital Lariboisière, APHP, Paris, and Holger Thiele, MD, FESC, interventional cardiologist at Heart Center Leipzig at the University of Leipzig in Germany.

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