European Heart Journal Advance Access published online on June 14, 2007
European Heart Journal, 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,
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
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Preamble |
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Guidelines and Expert Consensus Documents summarize and evaluate all currently available evidence on a particular issue with the aim to assist physicians in selecting the best management strategies for a typical patient, suffering from a given condition, taking into account the impact on outcome, as well as the risk–benefit ratio of particular diagnostic or therapeutic means. Guidelines are no substitutes for textbooks. The legal implications of medical guidelines have been discussed previously.
A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) as well as by other societies and organizations. Because of the impact on clinical practice, quality criteria for development of guidelines have been established in order to make all decisions transparent to the user. The recommendations for formulating and issuing ESC Guidelines and Expert Consensus Documents can be found on the ESC website (http://www.escardio.org/knowledge/guidelines/rules).
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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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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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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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S. R. Mehta, W. E. Boden, J. W. Eikelboom, M. Flather, P. G. Steg, A. Avezum, R. Afzal, L. S. Piegas, D. P. Faxon, P. Widimsky, et al. Antithrombotic Therapy With Fondaparinux in Relation to Interventional Management Strategy in Patients With ST- and Non-ST-Segment Elevation Acute Coronary Syndromes: An Individual Patient-Level Combined Analysis of the Fifth and Sixth Organization to Assess Strategies in Ischemic Syndromes (OASIS 5 and 6) Randomized Trials Circulation, November 11, 2008; 118(20): 2038 - 2046. [Abstract] [Full Text] [PDF]
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 R. V. Jeger, D. Radovanovic, P. R. Hunziker, M. E. Pfisterer, J.-C. Stauffer, P. Erne, P. Urban, and for the AMIS Plus Registry Investigators Ten-Year Trends in the Incidence and Treatment of Cardiogenic Shock Ann Intern Med, November 4, 2008; 149(9): 618 - 626. [Abstract] [Full Text] [PDF]
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D. N. Tziakas, G. K. Chalikias, I. K. Tentes, D. Stakos, S. V. Chatzikyriakou, K. Mitrousi, A. X. Kortsaris, J. C. Kaski, and H. Boudoulas Interleukin-8 is increased in the membrane of circulating erythrocytes in patients with acute coronary syndrome Eur. Heart J., November 2, 2008; 29(22): 2713 - 2722. [Abstract] [Full Text] [PDF]
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K. P. Goran Suggestion to list acute aortic dissection as a possible cause of type 2 myocardial infarction (according to the universal definition) Eur. Heart J., November 2, 2008; 29(22): 2819 - 2820. [Full Text] [PDF]
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M. Zimarino and R. De Caterina Long-term treatment strategies for atherothrombotic disease: do platelets define the course? Eur. Heart J. Suppl., November 1, 2008; 10(suppl_I): I8 - I13. [Abstract] [Full Text] [PDF]
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R. Sanz-Ruiz and F. Fernandez-Aviles European perspective on the use of antiplatelet agents in atherothrombotic disease Eur. Heart J. Suppl., November 1, 2008; 10(suppl_I): I14 - I18. [Abstract] [Full Text] [PDF]
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A. Betriu Clinical implications of the results of recent atherothrombotic trials on patient management Eur. Heart J. Suppl., November 1, 2008; 10(suppl_I): I30 - I32. [Abstract] [Full Text] [PDF]
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K. M. Eggers, T. Kempf, T. Allhoff, B. Lindahl, L. Wallentin, and K. C. Wollert Growth-differentiation factor-15 for early risk stratification in patients with acute chest pain Eur. Heart J., October 1, 2008; 29(19): 2327 - 2335. [Abstract] [Full Text] [PDF]
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G. Pundziute, J. D. Schuijf, J. W. Jukema, I. Decramer, G. Sarno, P. K. Vanhoenacker, E. Boersma, J. H.C. Reiber, M. J. Schalij, W. Wijns, et al. Evaluation of plaque characteristics in acute coronary syndromes: non-invasive assessment with multi-slice computed tomography and invasive evaluation with intravascular ultrasound radiofrequency data analysis Eur. Heart J., October 1, 2008; 29(19): 2373 - 2381. [Abstract] [Full Text] [PDF]
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Authors/Task Force Members, K. Dickstein, A. Cohen-Solal, G. Filippatos, J. J.V. McMurray, P. Ponikowski, P. A. Poole-Wilson, A. Stromberg, D. J. van Veldhuisen, D. Atar, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM) Eur. Heart J., October 1, 2008; 29(19): 2388 - 2442. [Full Text] [PDF]
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 K. Dickstein, A. Cohen-Solal, G. Filippatos, J. J.V. McMurray, P. Ponikowski, P. A. Poole-Wilson, A. Stromberg, D. J. van Veldhuisen, D. Atar, A. W. Hoes, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM) Eur J Heart Fail, October 1, 2008; 10(10): 933 - 989. [Full Text] [PDF]
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R. P. Giugliano and E. Braunwald The Year in Non-ST-Segment Elevation Acute Coronary Syndrome J. Am. Coll. Cardiol., September 23, 2008; 52(13): 1095 - 1103. [Full Text] [PDF]
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G. Y H Lip Managing the anticoagulated patient with atrial fibrillation at high risk of stroke who needs coronary intervention BMJ, September 12, 2008; 337(sep12_1): a840 - a840. [Full Text]
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P. G. Steg, A. Kerner, F. Van de Werf, J. Lopez-Sendon, J. M. Gore, G. FitzGerald, L. J. Feldman, F. A. Anderson, A. Avezum, and for the Global Registry of Acute Coronary Events ( Impact of In-Hospital Revascularization on Survival in Patients With Non-ST-Elevation Acute Coronary Syndrome and Congestive Heart Failure Circulation, September 9, 2008; 118(11): 1163 - 1171. [Abstract] [Full Text] [PDF]
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