European Heart Journal Advance Access originally published online on June 14, 2007
European Heart Journal 2007 28(13):1598-1660; doi:10.1093/eurheartj/ehm161
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© The European Society of Cardiology 2007. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes,
The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology
Authors/Task Force Members,
(France)
(Germany)
(Italy)
(The Netherlands)
(Poland)
(Spain)
(UK)
(Israel)
(USA)
(Sweden)
(Belgium)
ESC Committee for Practice Guidelines (CPG),
France
(UK)
(Italy)
(France)
(Norway)
(Greece)
(Denmark)
(Czech Republic)
(France)
(Germany)
(Poland)
(The Netherlands)
(Spain)
(Germany)
(France)
Document Reviewers,
(CPG Review Coordinator) ( Denmark)
(Italy)
(Austria)
(France)
(Spain)
(Italy)
(Belgium)
(Germany)
(Spain)
(Germany)
(Israel)
(Austria)
(Israel)
(Spain)
(Portugal)
(Norway)
(Germany)
(France)
(Denmark)
(Italy)
(Canada)
(The Netherlands)
(Switzerland)
* Corresponding authors. Chair: Jean-Pierre Bassand, Department of Cardiology, University Hospital Jean Minjoz, Boulevard Fleming, 25000 Besançon, France. Tel: +33 381 668 539; fax: +33 381 668 582. E-mail address: jean-pierre.bassand@ufc-chu.univ-fcomte.fr Co-chair: Christian W. Hamm Kerckhoff Heart Center, Benekestr. 2-8, 61231 Bad Nauheim, Germany. Tel: +49 6032 996 2202; fax: +49 6032 996 2298. E-mail address: c.hamm@kerckhoff-klinik.de
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.
Disclaimer. The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Health professionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where
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Preamble |
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1. Introduction and definitions |
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2. Epidemiology and natural history |
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3. Pathophysiology |
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3.1 The vulnerable plaque
3.2 Coronary thrombosis
3.3 The vulnerable patient
3.4 Endothelial vasodilatory dysfunction
3.5 Accelerated atherosclerosis
3.6 Secondary mechanisms
3.7 Myocardial injury
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4. Diagnosis and risk assessment |
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4.1 Clinical presentation and history
4.2 Diagnostic tools
4.2.1 Physical examination
4.2.2 Electrocardiogram
Continuous ST-segment monitoring
Exercise or other stress testing
4.2.3 Biochemical markers
Markers of myocardial injury
Markers of inflammatory activity
Markers of neurohumoral activation
Markers of renal function
Novel biomarkers
Multimarker approach
Point-of-care (bedside) biomarker testing
4.2.4 Echocardiography and non-invasive myocardial imaging
4.2.5 Imaging of the coronary anatomy
4.3 Differential diagnoses
4.4 Risk scores
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5. Treatment |
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5.1 Anti-ischaemic agents
5.1.1 Beta-blockers
5.1.2 Nitrates
5.1.3 Calcium channel blockers
5.1.4 New drugs
5.2 Anticoagulants
5.2.1 Unfractionated heparin
Pharmacology
Treatment effects
5.2.2 Low molecular weight heparin
Pharmacology
Treatment effects
5.2.3 Factor-Xa inhibitors
Pharmacology
Treatment effects
5.2.4 Direct thrombin inhibitors
Pharmacology
Treatment effects
5.2.5 Vitamin K antagonists
5.2.6 Anticoagulants during percutaneous coronary intervention procedures in non-ST-segment elevation acute coronary syndromes
5.3 Antiplatelet agents
5.3.1 Acetylsalicylic acid (aspirin)
5.3.2 Thienopyridines
Risk of bleeding
Dose and timing of clopidogrel
5.3.3 Glycoprotein IIb/IIIa receptor inhibitors
Glycoprotein IIb/IIIa inhibitors in a conservative strategy
Glycoprotein IIb/IIIa inhibitors in an invasive strategy
Use of glycoprotein IIb/IIIa inhibitors prior to revascularization
Adjunctive therapy
5.3.4 Resistance to antiplatelet agents/drug interactions
Aspirin resistance/drug interactions
Clopidogrel resistance/drug interactions
5.3.5 Withdrawal of antiplatelet agents
5.4 Coronary revascularization
5.4.1 Coronary angiography
5.4.2 Invasive vs. conservative strategy
Choice of strategy
Timing of invasiveness
5.4.3 Percutaneous coronary intervention
5.4.4 Coronary artery bypass graft
5.4.5 Respective indications for percutaneous coronary intervention or coronary artery bypass graft
5.5 Long-term management
5.5.1 Lifestyle
5.5.2 Weight reduction
5.5.3 Blood pressure control
5.5.4 Management of diabetes
5.5.5 Interventions on lipid profile
Statins
Other lipid-lowering agents
5.5.6 Antiplatelet agents and anticoagulants
5.5.7 Beta-blockers
5.5.8 Angiotensin-converting enzyme inhibitors
5.5.9 Angiotensin-2 receptor blockers
5.5.10 Aldosterone receptor antagonists
5.6 Rehabilitation and return to physical activity
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6. Complications and their management |
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6.1 Bleeding complications
6.1.1 Predictors of bleeding risk
6.1.2 Impact of bleeding on prognosis
6.1.3 Management of bleeding complications
6.1.4 Impact of blood transfusion
6.2 Thrombocytopenia
6.2.1 Heparin-induced thrombocytopenia
6.2.2 Glycoprotein IIb/inhibitor-induced thrombocytopenia
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7. Special populations and conditions |
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7.1 The elderly
7.1.1 Early diagnostic evaluation in the elderly
7.1.2 Therapeutic considerations
7.2 Gender
7.2.1 Glycoprotein IIb/IIIa inhibitors in women
7.2.2 Revascularization and early invasive strategy among women
7.3 Diabetes mellitus
7.4 Chronic kidney disease
7.4.1 Chronic kidney disease as a marker of risk of coronary artery disease
7.4.2 Contrast-induced nephropathy
7.4.3 Management of chronic kidney disease in patients with coronary artery disease
7.4.4 Biomarkers in chronic kidney disease
7.5 Anaemia
7.6 Normal coronary arteries
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8. Management strategies |
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8.1 First step: initial evaluation
8.2 Second step: diagnosis validation and risk assessment
8.2.1 Diagnosis validation
8.2.2 Risk assessment
8.3 Third step: invasive strategy
8.3.1 Conservative strategy
8.3.2 Urgent invasive strategy
8.3.3 Early invasive strategy
8.4 Fourth step: revascularization modalities
8.5 Fifth step: discharge and post-discharge management
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9. Performance measures |
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10. Abbreviations |
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11. Trial acronyms |
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Acknowledgements |
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Footnotes |
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References |
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R. Ferrari Treatment with angiotensin-converting enzyme inhibitors: insight into perindopril cardiovascular protection Eur. Heart J. Suppl., September 1, 2008; 10(suppl_G): G13 - G20. [Abstract] [Full Text] [PDF]
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M. O'Donoghue, W. E. Boden, E. Braunwald, C. P. Cannon, T. C. Clayton, R. J. de Winter, K. A. A. Fox, B. Lagerqvist, P. A. McCullough, S. A. Murphy, et al. Early Invasive vs Conservative Treatment Strategies in Women and Men With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: A Meta-analysis JAMA, July 2, 2008; 300(1): 71 - 80. [Abstract] [Full Text] [PDF]
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H. D. White, D. P. Chew, J. W. Hoekstra, C. D. Miller, C. V. Pollack Jr, F. Feit, A. M. Lincoff, M. Bertrand, S. Pocock, J. Ware, et al. Safety and Efficacy of Switching From Either Unfractionated Heparin or Enoxaparin to Bivalirudin in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Managed With an Invasive Strategy: Results From the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) Trial J. Am. Coll. Cardiol., May 6, 2008; 51(18): 1734 - 1741. [Abstract] [Full Text] [PDF]
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