2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: comments from the Dutch ACS working group
Neth Heart J
2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: comments from the Dutch ACS working group
P. Damman 0 1 2 3 4 5 6 7 8
A. W. van 't Hof 0 1 2 3 4 5 6 7 8
J. M. ten Berg 0 1 2 3 4 5 6 7 8
J. W. Jukema 0 1 2 3 4 5 6 7 8
Y. Appelman 0 1 2 3 4 5 6 7 8
A. H. Liem 0 1 2 3 4 5 6 7 8
R. J. de Winter 0 1 2 3 4 5 6 7 8
0 Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
1 R. J. de Winter
2 P. Damman , A.W. van 't Hof, J.M. ten Berg, J.W. Jukema, Y. Appelman , A.H. Liem and R.J. de Winter represent the NVVC Acute Coronary Syndrome working group
3 High-sensitive troponin
4 St Franciscus Gasthuis Rotterdam , Rotterdam , The Netherlands
5 VU University Medical Center , Amsterdam , The Netherlands
6 Leiden University Medical Center , Leiden , The Netherlands
7 St Antonius Hospital Nieuwegein , Nieuwegein , The Netherlands
8 Isala Klinieken , Zwolle , The Netherlands
On behalf of the Dutch ACS working group, we discuss multiple recommendations which have been implemented in the 2015 ESC guidelines for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation. have been implemented which we discuss from a Dutch perspective. The introduction of high-sensitive cardiac troponin has led to a better detection and quantification of myocardial injury. Both the absolute value and change in troponin over time provide information on cardiomyocyte injury, and several studies have assessed the sensitivity and specificity of these measurements [2]. In the 2015 guidelines, algorithms are presented for rule-in and rule-out of non-ST-elevation myocardial infarction (NSTEMI) with the use of high-sensitive cardiac troponin (Figs. 1 and 2). We advise to use these high-sensitive troponin assays and incorporate the aforementioned algorithms in daily practice in the Netherlands.
NSTE-ACS guidelines; NVVC ACS working group statement
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Published online: 13 December 2016
© The Author(s) 2016. This article is available at SpringerLink with Open Access.
Introduction
The 2015 ESC guidelines for the management of acute
coronary syndromes (ACS) in patients presenting without
persistent ST-segment elevation were presented at the
European Society of Cardiology (ESC) Conference 2015 in
London and published in the European Heart Journal [
1
].
Compared with the 2011 version, multiple recommendations
When NSTE-ACS is diagnosed, there is an indication for
treatment with dual platelet aggregation inhibitors
(acetylsalicylic acid and a P2Y12 inhibitor). For patients managed
conservatively, the 2015 guidelines advise to use ticagrelor
over clopidogrel. While the 2011 ESC guidelines
recommended starting dual antiplatelet therapy (DAPT) as soon as
possible before coronary angiography [
3
], the most recent
guidelines are less strict suggesting to initiate the P2Y12
inhibitor either before or after coronary angiography. This
change is based on the results of the ACCOAST study,
in which patients with NSTE-ACS, who were scheduled
to undergo catheterisation, were randomised to
pretreatment with prasugrel or placebo [
4
]. Pretreatment with
prasugrel did not reduce the rate of major ischaemic events
up to 30 days but increased the rate of major bleeding
complications. Until more evidence is available, the
current guidelines thus provide the opportunity to individualise
treatment and postpone the initiation of P2Y12 inhibition
in patients with known coronary anatomy or
electrocardiographic changes suggesting three-vessel disease or
leftmain disease and therefore a suspected indication for early
coronary artery bypass surgery (CABG). In patients with
a low to intermediate bleeding risk and a high
probability of subsequent percutaneous coronary intervention (PCI),
pretreatment with clopidogrel or ticagrelor might be useful.
Triple antithrombotic therapy
A subset of patients with NSTE-ACS have indications for
long-term (non-vitamin K) oral anticoagulation ([N]OAC)
such as atrial fibrillation or mechanical heart valves. In
combination with ACS, regardless of the performance of
PCI, there is an indication for triple therapy (DAPT with
[N]OAC). Long-term triple therapy is, however, associated
with increased bleeding outcomes [
5
], and a subsequent
increased mortality. Therefore, individualised treatment is
necessary in which the ischaemic risk is weighed against the
bleeding risk. The current ESC guidelines provide a
useful approach in which both the ischaemic and the bleeding
risk are taken into account (Fig. 3). In medically managed
patients or patients undergoing CABG, a combination of
single antiplatelet aggregation therapy and (N)OAC is
recommended. If the NSTE-ACS patient undergoes PCI, one
or six months of triple therapy is recommended depending
on the bleeding risk. After one or six months, a
combination of single antiplatelet aggregation therapy and (N)OAC
is continued. The Dutch WOEST trial has demonstrated
that dual therapy after PCI might be adequate for the
prevention of ischaemic events, with a reduction of bleeding
events [
6
]. Combinations of (N)OAC with the stronger
platelet aggregation drugs prasugrel or ticagrelor is
discouraged because of the excessive bleeding risk. We
advise to follow the treatment algorithm as shown in Fig. 3,
and emphasise to individualise the treatment based on the
ischaemic and bleeding risk. Furthermore, there is room
for improvement with regards to the communication
between the interventional cardiologist performing PCI and
the treating physician, especially regarding ischaemic and
bleeding risk. Complex coronary interventions, such as
multiple stent constructions and the placement of
bioabsorbable vascular scaffolds, might require more intensive
and longer treatment with DAPT also when combined with
(N)OAC. Otherwise, monotherapy with (N)OAC is
recommended after 1 year.
Same-day transfer in high-risk patients
Comparable with the 2011 ESC guidelines, the current
guidelines mention that the decision for and timing of
invasive coronary angiography is based on risk stratification and
the assessment of the risks related to the procedure (Fig. 4).
Very high-risk patients
Patients at very high risk, including haemodynamic
instability or cardiogenic shock, recurrent or ongoing chest pain
refractory to medical treatment, life-threatening arrhythmias,
mechanical complications of MI, acute heart failure, or
recurrent dynamic ECG changes, should be referred for
urgent PCI. Urgent PCI is defined as within 2 h of admission,
analogous to primary PCI in ST-segment elevation MI.
High-risk patients
It is recommended that high-risk patients are transferred
from a non-PCI centre to a PCI centre for coronary
angiography within 24 h. High-risk patients are defined as patients
with a rise and fall in cardiac troponin comparable with MI,
dynamic ST- or T-wave changes, or a GRACE score >140.
The ACS working group does not consider referral
within 24 h to be a necessity for the Dutch situation, based
on the following considerations. First, the scientific basis
for the recommendation is weak as it is only based on
two meta-analyses of randomised trials and a retrospective
analysis of the ACUITY trial [
7, 8
]. Both
meta-analyses showed no benefit for the hard endpoints mortality,
nonfatal MI or major bleeding, but only a reduction in
refractory ischaemia. Although the TIMACS trial
demonstrated a beneficial effect of early intervention in a
highrisk subgroup (GRACE >140), this was only a
hypothesisgenerating result in a trial which did not show a significant
reduction of the primary endpoint death or myocardial
infarction [9]. Second, the Dutch situation is markedly
different from that in many other European countries since
the majority of Dutch cardiology departments are equipped
with a catheterisation laboratory where diagnostic coronary
angiography is routinely performed in ACS patients. After
diagnostic angiography, patients are discussed in a heart
team and only those patients suitable for PCI and CABG
are referred to an interventional centre. We do not know
whether referring all NSTEMI-ACS patients for undergoing
catheterisation leads to over-treatment by performing
adhoc PCI. Third, the current experience of non-PCI centres
in the Netherlands as well as the results of the ICTUS
trial show us that a more conservative (selective invasive)
treatment of NSTE-ACS patients is also a good option [
10
].
Fourth, same-day transfer of patients based on a rise and
fall in cardiac troponin might result in unnecessarily
transferring patients with other pathology such as myocarditis
or a type II MI (demand ischaemia) associated with heart
failure of arrhythmias.
Other issues for implementing the 2015 ESC guidelines
are that the Dutch hospitals and ambulance services do not
have sufficient capacity for same-day transfer and that not
performing the diagnostic angiogram in non-PCI centres
could endanger the viability of the catheterisation
laboratory in these hospitals. Subsequently, this might have
important consequences for the role of the acute cardiac care
and coronary care units and supply of patients. The ACS
working group considers reducing catheterisation capacity
in non-PCI centres not applicable if this is not based on
proven-health benefits.
In this regard, from 2017, the ACS working group will
inventorise and evaluate the current NSTE-ACS treatment
in the Netherlands in collaboration with the Netherlands
Society of Cardiology (NVVC), general practitioners,
ambulance service, the NVVC ACS Connect project and the
NCDR (national cardiovascular data registry). First results
are expected in 2018.
Conflict of interest P. Damman, A.W. van ’t Hof, J.M. ten Berg,
J.W. Jukema, Y. Appelman, A.H. Liem and R.J. de Winter declare that
they have no competing interests.
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