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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