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DOI 10.1007/s12265-015-9639-z
elevation acute coronary syndromes^ [1]. The title itself reveals an evolution from the 2007 ACC/AHA guidelines on the
Bmanagement of patients with unstable angina/non-ST elevation myocardial infarction^ [2]. In parallel with the AHA/
ACCs release, the European Society of Cardiology (ESC)
and European Association of Cardio-Thoracic Surgery
(EACTS) released new 2014 guidelines on Bmyocardial revascularization,^ [3] updating the 2011 ESC guidelines on the
Bmanagement of acute coronary syndromes in patients presenting without persistent ST -segment elevation^ [4]. There
are some distinct and some subtle differences between the new
and former guidelines, as well as between the AHA/ACC and
the ESC recommendations.
American Guidelines
* Nanette K. Wenger
nwenger@emory.edu
Introduction
Utilize a conservative strategy in low-risk patients, especially women with negative troponin (class I).
An urgent invasive strategy (<2 h) for very high-risk patients, i.e., those with refractory angina, heart failure,
shock, hemodynamic instability, and electrical instability
(class I).
Early invasive strategy (<24 h) for intermediate to highrisk patients. ESC guidelines utilize a GRACE score
>140 to identify such patients and also mention positive
troponin with typical rise and fall and dynamic ST/T
changes (class I).
Delayed invasive strategy (2472 h) for lowintermediate-risk patients, with a GRACE score <140
but at least one other risk factor such as diabetes, reduced
ejection fraction, recurrent angina, recent PCI, prior coronary artery bypass grafting (CABG), or renal dysfunction (class I).
PCI vs CABG in patients with multivessel disease
or complex lesions should be discussed by a heart
team approach, taking into account clinical status,
comorbidities, lesion characteristics, and SYNTAX
score (class I).
If PCI with stenting is done, use of a newer generation
drug eluting stent (DES) is recommended, with at least
12 months of dual antiplatelet therapy (DAPT) for all
stents (class I).
Although not given a strength of classification, it is stated
that if CABG is done, timing depends on clinical status
and also that patient exposure to DAPT is only a relative
contraindication to early CABG.
European Guidelines
The September 2014 guidelines from the ESC/EACTS on
myocardial revascularization include a short section on
Bnon-ST segment elevation acute coronary syndrome.^ The
focus is primarily on myocardial revascularization, and details
of management are primarily unchanged from the 2011 ESC
guidelines on NSTE-ACS. As with the AHA/ACC guideline,
the ESC/EACTS 2014 guidelines compare timing strategies
For all NSTE-ACS, load aspirin 150300 mg and maintain 75100 mg daily (class I).
The ESC gives a strong recommendation for ticagrelor or
prasugrel over clopidogrel:
Ticagrelor is favored for all patients at increased risk (e.g.,
positive troponin likely from ACS), even if this means
changing from clopidogrel (class I).
Prasugrel is favored after anatomy is known and
only if patient going for PCI with stent, in a select
group without high risk of bleeding and no prior
stroke, who are P2Y12 inhibitor nave, especially
if diabetic (class I).
Clopidogrel should be used if patient cannot take
ticagrelor or prasugrel (class I).
Conclusion
The similarities far outweigh the differences between the 2014
AHA/ACC and 2011 ESC guidelines on the treatment of
NSTE-ACS. The three figures recommended from the guidelines (Figs. 1, 2, and 3) provide excellent summaries of the
treatment strategies outlined in each. The strength with which
the clinician chooses ticagrelor over clopidogrel (one of the
only major differences between the two guidelines based on
required level of evidence for the AHA/ACC version) will
likely increase over time in the USA, but at present, is hindered by the frequent cost difference to the patient, given that
clopidogrel but not ticagrelor is now available in generic form
in the USA. The 2014 AHA/ACC writing group joined their
Fig. 1 Algorithm for the management of patients with definite or likely NSTE-ACS, reproduced directly from the original 2014 AHA/ACC Guideline [1]
Fig. 2 Chest pain evaluation algorithms reproduced directly from the original 2011 ESC Guidelines [4]
European colleagues in emphasizing the similar pathophysiology between unstable angina and NSTEMI, by combining
both into the entity of NSTE-ACS. The AHA/ACC guidelines
Fig. 3 Chest pain evaluation algorithms reproduced directly from the original 2011 ESC Guidelines [4]
References
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