Abstract
In this review, we would like to summarize the latest guidelines on Coronary artery disease (CAD) released in August 2023. The European Society of Cardiology (ESC) Guidelines on Acute Coronary Syndrome (ACS) and the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines on Chronic Coronary Disease (CCD). Both the guidelines emphasize the patient-centered approach, the inclusion of patients in decision-making regarding the management, the teach-back technique during risk explanation, and consent. Relevant changes and new recommendations in guidelines on ACS and important points of guidelines on CCS have been mentioned below.
Robert A Byrne, Xavier Rossello, J J Coughlan, Emanuele Barbato, Colin Berry, Alaide Chieffo, et al. ESC Scientific Document Group.
Eur Heart J. 2023;ehad191
Abstract
The guidelines have been released in the recent ESC congress held in Amsterdam, Netherlands. The summary is in two headings, new recommendations and change of recommendations compared to the previous guidelines. The wording to use classes of recommendations—is recommended – Class I, should be considered – Class IIa, may be considered – Class IIb, not recommended – Class III. In this guidelines of ACS, both ST segment elevation myocardial infarction and non ST segment elevation acute coronary syndrome diagnosis, management are addressed combinedly rather than separately as done in previous guidelines.Figures emphasizing the importance of evaluation of symptoms, diagnosis, and management are the highlights of the guidelines. Example: At initial assessment think ACS − Abnormal ECG, Clinical context, Stable patient?
New Recommendations
Antiplatelet and Anticoagulant Therapy in ACS
a. If Dual antiplatelet therapy (DAPT) is being stopped in ACS patients to undergo coronary artery bypass grafting (CABG), the DAPT must be resumed after surgery. It must be continued for at least 12 months post-surgery.
b. In elderly ACS patients with high bleeding risk, clopidogrel may be considered as a P2Y12 inhibitor.
Alternative Antithrombotic Therapy Regimens
c. In patients at low ischemic risk and event-free after 3−6 months of DAPT, a single antiplatelet agent (a P2Y12 inhibitor) should be considered.
d. P2Y12 inhibitor monotherapy may be considered in place of aspirin monotherapy for long-term treatment.
e. In HBR patients, aspirin or P2Y12 inhibitor monotherapy may be considered after one month of DAPT.
f. In patients having an indication for oral anticoagulants (OAC), withdrawing DAPT after six months and continuing OAC may be considered.
g. De-escalation of antiplatelet therapy within 30 days after an ACS event is not recommended.
Cardiac Arrest or Out of Hospital Cardiac Arrest
h. Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest.
i. Transport of patients with out-of-hospital arrest to a cardiac arrest center should be considered as per local protocol.
Technical Aspects of Invasive Strategies
j. Percutaneous coronary intervention (PCI) is recommended in Spontaneous coronary artery dissection (SCAD) patients only with symptoms and signs of ongoing myocardial ischemia, a large area of myocardium in jeopardy, and reduced antegrade flow.
k. Intravascular imaging should be considered to guide PCI.
l. Optical coherence tomography (OCT) may be considered in ambiguous culprit lesions.
Multivessel Disease in ACS
m. In cardiogenic shock, staged PCI of a non-infarcted artery should be considered.
n. In hemodynamically stable primary PCI patients, PCI of the non-infarct related arteries (IRA) is based on angiographic severity.
o. Invasive epicardial assessment of non-culprit segments of the IRA is not recommended in the index procedure.
Complications of ACS
p. Permanent pacemaker implantation is recommended in case of high-grade atrioventricular (AV) block not resolving within five days of myocardial infarction (MI).
q. Cardiac Magnetic resonance imaging (MRI) should be considered in cases of equivocal echocardiographic images or cases of high clinical suspicion of thrombus.
r. A contrast echocardiogram may be considered for the detection of left ventricular (LV) thrombus if the apex is not visualized well on echocardiography in patients with acute anterior wall MI (AWMI).
s. Early device implantation (cardiac resynchronization therapy -defibrillator/ pacemaker) may be considered in selected patients with high-grade AV block in the context of AWMI and acute heart failure.
t. Sedation or general anesthesia may be considered in patients with life-threatening arrhythmias to reduce the sympathetic drive.
ACS and Comorbid Conditions
u. The choice of long-term glucose-lowering treatment should be based on the presence of comorbidities including heart failure, chronic kidney disease, and obesity.
a. For frail older patients with comorbidities, a holistic approach is recommended to individualize interventional and pharmacological treatments after careful evaluation of the risks and benefits.
b. An Invasive strategy is recommended in cancer patients presenting with high-risk ACS and with survival of ≥6 months.
c. Temporary interruption of cancer therapy is recommended if it is suspected to be a contributing cause of ACS.
d. Conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (expected life survival is <6 months) and/or very high bleeding risk.
e. In cancer patients with a platelet count of <50,000 cells/µl (ticagrelor and prasugrel), <30,000 cells/µl (clopidogrel) and <10,000 cells/µl (aspirin) are not recommended.
Long-Term Therapy
v. Intensified lipid-lowering therapy is recommended during index hospitalization in patients already on lipid-lowering therapy before admission.
w. Low-dose colchicine (0.5 mg once a day) may be considered, particularly if other risk factors are insufficiently controlled or there is a recurrence of ischemic events under optimal therapy.
x. High-dose statin + ezetimibe may be considered during the index hospitalization.
Patient Perspectives in ACS Care
Patient-centered care is recommended by assessing and adhering to individual patient preferences, needs, and beliefs, ensuring that patient values are used to inform all clinical decisions.
It is recommended to include ACS patients in decision-making (as much as their condition allows) and to inform them about the risk of adverse events, radiation exposure, and alternative options. Decision aids should be used to facilitate the discussion.
It is recommended to assess symptoms using methods that help patients to describe their experience.
The use of the ‘teach back’ technique for decision support during the securing of informed consent should be considered.
Patient discharge information should be provided in both written and verbal formats before discharge. Adequate preparation and education for patient discharge using the teach-back technique and/or motivational interviewing, giving information in chunks, and checking for understanding, should be considered.
Assessment of mental well-being using a validated tool and onward psychological referral when appropriate should be considered.
Revised Recommendations
Imaging for Patients with Suspected NSTE-ACS
1. In patients with suspected ACS, non-elevated (or uncertain) hs-cTn, no ECG changes, and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered (changed from Class I B − IIa A).
Timing of Invasive Strategy in NSTE-ACS
2. An early invasive strategy within 24 h should be considered in patients with at least one of the following high-risk criteria: Confirmed diagnosis of NSTEMI based on current recommended ESC hs-cTn algorithms, Dynamic ST-segment or T wave changes, Transient ST-segment elevation and GRACE risk score >140 (from Class I A – IIa
Antiplatelet and Anticoagulant Therapy in STEMI
3. Pre-treatment with a P2Y12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy (Class I A – IIb B).
Cardiac Arrest and Out-of-hospital Cardiac Arrest
4. Routine immediate angiography after resuscitated cardiac arrest is not recommended in hemodynamically stable patients without persistent ST-segment elevation (or equivalents) (Class IIa A – IIIB).
5. Temperature control (i.e. continuous monitoring of core temperature and active prevention of fever [i.e., >37.7°C]) is recommended after either out-of-hospital or in-hospital cardiac arrest for adults who remain unresponsive after the return of spontaneous circulation (previously temperature between 32°C and 36°C was recommended).
In-hospital Management
6. When echocardiography is suboptimal/inconclusive, CMR imaging may be considered (Class IIa C – IIb C).
Management of Multivessel Disease in Hemodynamically Stable STEMI Patients Undergoing Primary PCI
1. Complete revascularization is recommended either during the index PCI procedure or within 45 days (Class IIa A – Class I A).
American Heart Association/American College of Cardiology Guidelines on Chronic Coronary Disease
Salim S. Virani, L. Kristin Newby, Suzanne V. Arnold, Vera Bittner, LaPrincess C. Brewer, et al.
Circulation. 2023;148:e9–e119.
Term stable ischemic heart disease changed to CCD.
The term CCD includes
Patients discharged after admission for an ACS event or after coronary revascularization procedure and after stabilization of all acute cardiovascular issues. Patients with LV systolic dysfunction and known or suspected CAD or those with established cardiomyopathy are deemed to be of ischemic origin. Patients with stable angina symptoms (or ischemic equivalents such as dyspnoea or arm pain with exertion) are medically managed with or without positive results of an imaging test. Patients with angina symptoms and evidence of coronary vasospasm or microvascular angina. Patients diagnosed with CCD are based solely on the results of a screening study (stress test, coronary computed tomography angiography [CTA]), and the treating clinician concludes that the patient has coronary disease.
Important Points
Healthy dietary habits and exercise are recommended for all patients.
Habitual physical activity reduces sitting time, and aerobic and resistance exercises are encouraged in patients with CCD and have no contraindications.
The benefit of cardiac rehabilitation is evident both in mortality and morbidity.
Sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists are recommended in selected patients [Left ventricular ejection fraction (LVEF) ≤40% and >40%], even without diabetes.
SGLT2 inhibitors and GLP1 agonists are recommended in patients with diabetes and CCD to reduce the risk of MACE.
Beta-blockers are not recommended in the absence of myocardial infarction in the past year, LVEF <50%, or any other primary indication for beta-blocker therapy.
Either a calcium channel blocker or beta blocker is recommended as first-line anginal therapy.
Statins remain the first-line therapy for lipid lowering in patients with CCD.
When the risk of bleeding is high and the ischemic risk is low to moderate, a short duration of DAPT is safe and effective.
The use of fish oil, omega-3 fatty acids, or vitamins is not recommended as there was no benefit found in reducing cardiac events.
Routine periodic anatomic or ischemic testing is not recommended to risk stratify or to guide therapeutic decision-making if there is no change in clinical or functional status.
As long-term safety is lacking regarding the use of e-cigarettes, they are not recommended as first-line therapy for smoking cessation.
About a 10% reduction in mortality and cardiovascular disease when individuals increase their daily step count by 1000 according to the evidence published in the guidelines.
Comparison with ESC Guidelines (2019) (Given in brackets for each)
The use of an SGLT2 inhibitor or a GLP1 agonist in patients with CCD and Heart Failure (LVEF < 40% or >40%) is recommended irrespective of the status of diabetes, apart from diabetes alone.
In patients with CCD who were initiated on beta-blocker therapy for previous MI without a history of or current LVEF #50%, angina, arrhythmias, or uncontrolled hypertension, it may be reasonable to reassess the indication for long-term (>1 year) use of beta-blocker therapy for reducing MACE.
In patients with CCD without previous MI or LVEF <50%, the use of beta-blocker therapy is not beneficial in reducing MACE, in the absence of another primary indication for beta-blocker therapy.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding
The authors received no financial support for the research, authorship and/or publication of this article.
