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DECLARATION OF CONFLICT OF INTEREST
New NSTE ACS Guidelines 2011
Non-ST-elevation-acute coronary syndrome
Invasive management
Dariusz Dudek
Institute of Cardiology, Jagiellonian University
Krakow, Poland
The European Association of Percutaneous Cardiovascular Interventions (EAPCI)
The Chair of the Scientific Programme Committee
New NSTEACS ESC Guidelines – Invasive management
- Invasive versus conservative approach
Recommendations
Class
Level
An invasive strategy (<72 h after first presentation) is indicated in patients with:
• at least one high-risk criterion;
• recurrent symptoms.
I
A
Non-invasive documentation of inducible ischaemia is recommended in low-risk
patients without recurrent symptoms before deciding for invasive evaluation.
I
A
Routine invasive evaluation of low-risk patients is not recommended.
III
A
 A recent meta-analysis, based on individual patient data from the FRISC-2, ICTUS, RITA-3
studies comparing a routine invasive vs. a selective invasive strategy, revealed a reduction in
rates of death and non-fatal MI at 5-year follow-up, with the most pronounced difference in
high risk patients.
 There was a 2.0–3.8% absolute reduction in cardiovascular death or MI in the low and
intermediate risk groups, and an 11.1% absolute risk reduction in the highest risk patients.
These results support a routine invasive strategy, but highlight the role of risk stratification
in the management decision process.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- Invasive versus conservative approach
Criteria for high risk with indication for invasive management
Primary:
 Relevant rise or fall in troponin
 Dynamic ST- or T-wave changes (symptomatic or silent)
Secondary:
 Diabetes mellitus
 Renal insufficiency (eGFR <60 mL/min/1.73 m²)
 Reduced LV function (ejection fraction <40%)
 Early post infarction angina
 Recent PCI
 Prior CABG
 Intermediate to high GRACE risk score
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- Timing of angiography and intervention
Recommendations
Class
Level
An invasive strategy (<72 h after first presentation) is indicated in patients with:
• at least one high-risk criterion;
• recurrent symptoms.
I
A
Urgent coronary angiography (<2 h) is recommended in patients at very high
ischaemic risk (refractory angina, with associated heart failure, life-threatening
ventricular arrhythmias, or haemodynamic instability).
I
C
An early invasive strategy (<24 h) is recommended in patients with a GRACE
score >140 or with at least one primary high-risk criterion.
I
A
 Optimal adjunctive pharmacotherapy is important in an invasive strategy, but pretreatment should not delay angiography and the intervention. An intentional delayed
invasive approach for stabilization including GP IIb/IIIa receptor inhibitors (‘cooling-off’
strategy) is of no benefit.
 Timing of angiography and revascularization should be based on patient risk profile.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- PCI vs CABG (1/3)
Recommendations
Class
Level
I
C
The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG)
should be based on the clinical status as well as the disease severity, i.e.
distribution and angiographic lesion characteristics (e.g. SYNTAX score), according
to the local ‘Heart Team’ protocol.
 In patients stabilized after an episode of ACS, the choice of revascularization
modality can be made as in stable CAD.
 In multivessel disease the decision is more complex and the choice has to be
made between culprit lesion PCI, multivessel PCI, CABG, or a combined (hybrid)
revascularization in some cases.
 The revascularization strategy should be based on the clinical status as well as
the severity and distribution of the CAD and the lesion characteristics
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- PCI vs CABG (2/3)
Recommendations
The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG)
should be based on the clinical status as well as the disease severity, i.e.
distribution and angiographic lesion characteristics (e.g. SYNTAX score), according
to the local ‘Heart Team’ protocol.
Class
Level
I
C
 Culprit lesion PCI usually is the first choice in most patients with multivessel
disease. The strategy of multivessel stenting for suitable significant stenoses
rather than stenting the culprit lesion only has not been evaluated appropriately
in a randomized fashion.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- PCI vs CABG (3/3)
Recommendations
The revascularization strategy (ad-hoc culprit lesion PCI/ multivessel PCI/CABG)
should be based on the clinical status as well as the disease severity, i.e.
distribution and angiographic lesion characteristics (e.g. SYNTAX score), according
to the local ‘Heart Team’ protocol.
Class
Level
I
C
 Culprit lesion PCI does not necessarily require a case by case review by the ‘Heart Team’ (a
multidisciplinary decision-making team), when on clinical or angiographic grounds the
procedure needs to be performed ad hoc after angiography.
 However, protocols based on the SYNTAX score should be designed by the Heart Team at
each institution, defining specific anatomical criteria and clinical subsets that can be treated
ad hoc or transferred directly to CABG.
 After culprit lesion PCI, patients with scores in the two higher terciles of the SYNTAX score
should be discussed within the Heart Team, in light of functional evaluation of the
remaining lesions. This also includes the assessment of co-morbidities and individual
characteristics.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines 2011
- Coronary artery bypass surgery
 The proportion of patients with NSTE-ACS undergoing bypass
surgery during initial hospitalization is 10%.
The general consensus is to wait for 48–72 h in patients who had
culprit lesion PCI and have additional severe CAD.
 Surgery should be performed during the same hospital stay in
patients with LMCA or three-vessel disease involving the proximal
LAD.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation,
ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- Coronary artery bypass surgery
 In this decision process it is important to consider the risk of bleeding complications in
patients who undergo bypass surgery, when initially treated with aggressive antiplatelet
treatment.
 However, pre-treatment with a triple or dual antiplatelet regimen should be considered
only as a relative contraindication to early bypass surgery, but does require specific surgical
measures to minimize bleeding.
 In patients requiring emergent surgery before the washout period of thienopyridines, offpump CABG or minimized cardiopulmonary bypass circuits, blood salvaging techniques, and
platelet transfusion should be used to minimize risk of bleeding and its consequences.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
New NSTEACS ESC Guidelines – Invasive management
- Percutaneous coronary intervention technique
Recommendations
As there are no safety concerns related to the use of DESs in ACS, DESs are
indicated based on an individual basis taking into account baseline characteristics,
coronary anatomy, and bleeding risk.
Class
Level
I
A
 Owing to the lack of randomized trials in NSTE-ACS, the choice between the use of a BMS
or a DES should be based on an individual assessment of benefit vs. risk.
 DAPT should be maintained for 12 months irrespective of the type of stent. In patients
with a compelling indication for long-term anticoagulation, BMS implantation, stand-alone
balloon angioplasty, or CABG may be considered in order to restrict the duration of triple
therapy to 1 month.
 The use of aspiration thrombectomy in the NSTEMI setting is possible; however, its
benefit was not assessed prospectively in randomized trials in patients with NSTE-ACS.
 It remains undetermined whether other coronary segments with non-significant stenoses
but vulnerable features will merit mechanical intervention and is therefore not supported.
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011
Conclusions
 Key recommendations consistent with ESC/EACTS Guidelines on
myocardial revascularization
 Stronger recommendation for urgent (<2 h) and early (<24 h)
invasive strategy
 In comparison to ESC NSTEACS Guidelines 2007 time window for
early invasive diagnostics & treatment shortened from <72 h to <24
hours
ESC Guidelines for the management of ACS in patients presenting without persistent ST-segment elevation, ESC Congress 2011