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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APPRAISE Steering Committee and Investigators Apixaban, an Oral, Direct, Selective Factor Xa Inhibitor, in Combination With Antiplatelet Therapy After Acute Coronary Syndrome: Results of the Apixaban for Prevention of Acute Ischemic and Safety Events (APPRAISE) Trial Circulation, June 9, 2009; 119(22): 2877 - 2885. [Abstract] [Full Text] [PDF]
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S. R. Mehta, C. B. Granger, W. E. Boden, P. G. Steg, J.-P. Bassand, D. P. Faxon, R. Afzal, S. Chrolavicius, S. S. Jolly, P. Widimsky, et al. Early versus Delayed Invasive Intervention in Acute Coronary Syndromes N. Engl. J. Med., May 21, 2009; 360(21): 2165 - 2175. [Abstract] [Full Text] [PDF]
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L. D. Hillis and R. A. Lange Optimal Management of Acute Coronary Syndromes N. Engl. J. Med., May 21, 2009; 360(21): 2237 - 2240. [Full Text] [PDF]
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R. P. Giugliano, J. A. White, C. Bode, P. W. Armstrong, G. Montalescot, B. S. Lewis, A. van `t Hof, L. G. Berdan, K. L. Lee, J. T. Strony, et al. Early versus Delayed, Provisional Eptifibatide in Acute Coronary Syndromes N. Engl. J. Med., May 21, 2009; 360(21): 2176 - 2190. [Abstract] [Full Text] [PDF]
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R K Riezebos and G J Laarman The authors' reply: Heart, May 1, 2009; 95(9): 761 - 761. [Full Text] [PDF]
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K. A A Fox COURAGE to change practice? Revascularisation in patients with stable coronary artery disease Heart, May 1, 2009; 95(9): 689 - 692. [Full Text] [PDF]
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R K Riezebos, E Ronner, E ter Bals, T Slagboom, P C Smits, J M ten Berg, F Kiemeneij, G Amoroso, M S Patterson, M J Suttorp, et al. Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes Heart, May 1, 2009; 95(10): 807 - 812. [Abstract] [Full Text] [PDF]
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B. M. Scirica, D. A. Morrow, A. Budaj, A. J. Dalby, S. Mohanavelu, J. Qin, J. Aroesty, C. M. Hedgepeth, P. H. Stone, and E. Braunwald Ischemia Detected on Continuous Electrocardiography After Acute Coronary Syndrome: Observations From the MERLIN-TIMI 36 (Metabolic Efficiency With Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndrome-Thrombolysis In Myocardial Infarction 36) Trial J. Am. Coll. Cardiol., April 21, 2009; 53(16): 1411 - 1421. [Abstract] [Full Text] [PDF]
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J. L. Anderson Stopping the Hemorrhage: A New Baseline Bleeding Score Brings Us a Step Closer for Patients With Non-ST-Elevation Myocardial Infarction Circulation, April 14, 2009; 119(14): 1846 - 1849. [Full Text] [PDF]
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S. Subherwal, R. G. Bach, A. Y. Chen, B. F. Gage, S. V. Rao, L. K. Newby, T. Y. Wang, W. B. Gibler, E. M. Ohman, M. T. Roe, et al. Baseline Risk of Major Bleeding in Non-ST-Segment-Elevation Myocardial Infarction: The CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Bleeding Score Circulation, April 14, 2009; 119(14): 1873 - 1882. [Abstract] [Full Text] [PDF]
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F. Schiele, N. Meneveau, M. F. Seronde, V. Descotes-Genon, J. Oettinger, F. Ecarnot, J.-P. Bassand, and on behalf of the 'Reseau de Cardiologie de Franche Changes in management of elderly patients with myocardial infarction Eur. Heart J., April 2, 2009; 30(8): 987 - 994. [Abstract] [Full Text] [PDF]
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D J Kurz, A Bernstein, K Hunt, D Radovanovic, P Erne, Z Siudak, and O Bertel Simple point-of-care risk stratification in acute coronary syndromes: the AMIS model Heart, April 1, 2009; 95(8): 662 - 668. [Abstract] [Full Text] [PDF]
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A. Hirsch, F. Windhausen, J. G.P. Tijssen, A. J.M. Oude Ophuis, W. J. van der Giessen, P. M. van der Zee, J. H. Cornel, F. W.A. Verheugt, R. J. de Winter, and for the Invasive versus Conservative Treatment in Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias Eur. Heart J., March 2, 2009; 30(6): 645 - 654. [Abstract] [Full Text] [PDF]
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P. Tricoci, J. M. Allen, J. M. Kramer, R. M. Califf, and S. C. Smith Jr Scientific Evidence Underlying the ACC/AHA Clinical Practice Guidelines JAMA, February 25, 2009; 301(8): 831 - 841. [Abstract] [Full Text] [PDF]
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J. M. van Werkhoven, J. D. Schuijf, O. Gaemperli, J. W. Jukema, E. Boersma, W. Wijns, P. Stolzmann, H. Alkadhi, I. Valenta, M. P.M. Stokkel, et al. Prognostic value of multislice computed tomography and gated single-photon emission computed tomography in patients with suspected coronary artery disease. J. Am. Coll. Cardiol., February 17, 2009; 53(7): 623 - 632. [Abstract] [Full Text] [PDF]
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J. Aoki, A. J. Lansky, R. Mehran, J. Moses, M. E. Bertrand, B. T. McLaurin, D. A. Cox, A. M. Lincoff, E. M. Ohman, H. D. White, et al. Early Stent Thrombosis in Patients With Acute Coronary Syndromes Treated With Drug-Eluting and Bare Metal Stents: The Acute Catheterization and Urgent Intervention Triage Strategy Trial Circulation, February 10, 2009; 119(5): 687 - 698. [Abstract] [Full Text] [PDF]
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N Swanson, G Montalescot, K A Eagle, S G Goodman, W Huang, D Brieger, G Devlin, and for the GRACE Investigators Delay to angiography and outcomes following presentation with high-risk, non-ST-elevation acute coronary syndromes: results from the Global Registry of Acute Coronary Events Heart, February 1, 2009; 95(3): 211 - 215. [Abstract] [Full Text] [PDF]
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H.A. Katus, E. Giannitsis, A.S. Jaffe, and K. Thygesen Higher sensitivity troponin assays: Quo vadis? Eur. Heart J., January 2, 2009; 30(2): 127 - 128. [Full Text] [PDF]
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A. M. Jansson, H. Rosjo, T. Omland, T. Karlsson, M. Hartford, A. Flyvbjerg, and K. Caidahl Prognostic value of circulating chromogranin A levels in acute coronary syndromes Eur. Heart J., January 1, 2009; 30(1): 25 - 32. [Abstract] [Full Text] [PDF]
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K. M. Eggers, A. S. Jaffe, L. Lind, P. Venge, and B. Lindahl Value of Cardiac Troponin I Cutoff Concentrations below the 99th Percentile for Clinical Decision-Making Clin. Chem., January 1, 2009; 55(1): 85 - 92. [Abstract] [Full Text] [PDF]
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 C. W. Hamm, H. Möllmann, J.-P. Bassand, and F. van de Werf CHAPTER 16 Acute Coronary Syndromes ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
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S. Hoeks and D. Poldermans CHAPTER 34 Non-cardiac Surgery in Cardiac Patients ESC Textbook of Cardiovascular Medicine, January 1, 2009; 2(1): med-9780199566990-chapter - med-9780199566990-chapter. [Abstract] [Full Text] [PDF]
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M. Lordkipanidze, C. Pharand, T. A. Nguyen, E. Schampaert, D. A. Palisaitis, and J. G. Diodati Comparison of four tests to assess inhibition of platelet function by clopidogrel in stable coronary artery disease patients Eur. Heart J., December 1, 2008; 29(23): 2877 - 2885. [Abstract] [Full Text] [PDF]
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Authors/Task Force Members, F. Van de Werf, J. Bax, A. Betriu, C. Blomstrom-Lundqvist, F. Crea, V. Falk, G. Filippatos, K. Fox, K. Huber, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology: Eur. Heart J., December 1, 2008; 29(23): 2909 - 2945. [Full Text] [PDF]
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