Antithrombotic therapies, troponin protocols among changes to ESC NSTEACS guideline
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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.
“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.
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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Elliott M. Antman, MD, MACC, FAHA
For NSTEACS, the previous ESC guideline was published in 2015 and the last American Heart Association/American College of Cardiology guideline was in published in 2014. There is 5 to 6 years’ worth of new information. The new ESC guideline captures the essential updates.
The key findings from this iteration of the ESC guidelines are the prominence of cardiac-specific troponins as the preferred biomarker and specific emphasis on high-sensitivity troponin tests. By using high-sensitivity troponins, clinicians can rule in and rule out non-STEMI in an algorithm that allows for rapid assessment of patients. The next AHA/ACC guidelines should and are likely to emphasize the use of high-sensitivity troponin.
The ESC guideline came out subsequent to the latest Universal Definition of MI. This was important to the writing committee, who referenced it and used it to counsel on how to arrive at a diagnosis of non-STEMI. We should also expect to see this in the next AHA/ACC guidelines.
As in the previous ESC and AHA/ACC guidelines, the importance of healthy lifestyle and secondary prevention is emphasized. What is relatively new is a section on quality indicators. Those are helpful for those caring for patients with ACS. They provide guidance for centers caring for patients with NSTEACS, an ideal invasive strategy, optimum risk stratification, which kinds of antithrombotic therapies should be provided and approaches to secondary prevention. They also provide quality indicators for patient satisfaction. This is a very forward-looking section.
The new information on managing patients with ACS who also have atrial fibrillation is important. There is an excellent section describing the decision-making on therapeutic options with anticoagulant and antiplatelet therapy. There are also some new data suggesting that in certain types of patients, it may be possible to reduce the duration of dual antiplatelet therapy. There is also discussion of some of the newer data on modifying anithrombotic regimens over the long term in patients with NSTEACS.
There are useful updated sections on MI with nonobstructive coronary arteries (MINOCA) and spontaneous coronary artery dissection (SCAD).
The document closes with an excellent section identifying the gaps in the evidence base and suggesting randomized controlled trials that should be undertaken. And as is common with ESC guidelines, this one has figures, tables and algorithms that are easy to translate into clinical practice.
There is not as much attention given to patients with diabetes as there is in the 2014 AHA/ACC guideline. I expect that to remain a major part of the next American guidelines.
Areas that are rapidly changing and are likely to be discussed in the future North American guidelines include duration of antiplatelet therapy, chronic low-level antithrombotic therapy and management of patients with ACS and AF. Just now at the ESC Congress, the EAST-AFNET 4 trial showed the benefit of a rhythm control strategy early in patients with AF. We are seeing more patients with both ACS and AF, so the section on ACS and AF is likely to be expanded in forthcoming AHA/ACC guidelines. I would also expect to see in those more of a call for use of the transradial approach in PCI for NSTEACS, similar to the recommendations in the ESC guideline
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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).
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