ESC 2023 2023 ESC Guidelines for the management of acute coronary syndromes
European Society of Cardiology｜循環器 / 冠動脈疾患｜107 ページ｜チャンク 1093｜推奨 363 件｜current
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| 頁 | クラス | レベル | 推奨文 | 表 |
|---|---|---|---|---|
| p.14 | I | C | If patients presenting with ACS stop DAPT to undergo coronary artery bypass grafting, it is recommended they resume DAPT after surgery for at least 12 months. | Table 4 New recommendations |
| p.14 | IIb | B | In older ACS patients, especially if HBR, clopidogrel as the P2Y12 receptor inhibitor may be considered. | Table 4 New recommendations |
| p.14 | IIa | A | P2Y12 receptor inhibitor) should be considered. | Table 4 New recommendations |
| p.14 | IIb | A | P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment. | Table 4 New recommendations |
| p.14 | IIb | B | In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered. | Table 4 New recommendations |
| p.14 | IIb | B | In patients requiring OAC, withdrawing antiplatelet therapy at 6 months while continuing OAC may be considered. | Table 4 New recommendations |
| p.14 | III | B | De-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended. | Table 4 New recommendations |
| p.14 | I | C | Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest. | Table 4 New recommendations |
| p.14 | IIa | C | Transport of patients with out-of-hospital cardiac arrest to a cardiac arrest centre according to local protocol should be considered. | Table 4 New recommendations |
| p.14 | I | C | myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. | Table 4 New recommendations |
| p.14 | IIa | A | Intravascular imaging should be considered to guide PCI. | Table 4 New recommendations |
| p.14 | IIb | C | Intravascular imaging (preferably optical coherence tomography) may be considered in patients with ambiguous culprit lesions. | Table 4 New recommendations |
| p.14 | IIa | C | Staged PCI of non-IRA should be considered. | Table 4 New recommendations |
| p.14 | I | B | It is recommended that PCI of the non-IRA is based on angiographic severity. | Table 4 New recommendations |
| p.14 | III | C | Invasive epicardial functional assessment of non-culprit segments of the IRA is not recommended during the index procedure. | Table 4 New recommendations |
| p.14 | I | C | Implantation of a permanent pacemaker is recommended when high-degree AV block does not resolve within a waiting period of at least 5 days after MI. | Table 4 New recommendations |
| p.14 | IIa | C | suspicion of LV thrombus. | Table 4 New recommendations |
| p.14 | IIb | C | visualized on echocardiography. | Table 4 New recommendations |
| p.14 | IIb | C | resynchronization therapy—defibrillator/pacemaker) may be considered. | Table 4 New recommendations |
| p.14 | I | A | It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, chronic kidney disease, and obesity. | Table 4 New recommendations |
| p.14 | I | B | 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. | Table 4 New recommendations |
| p.14 | I | B | An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months. | Table 4 New recommendations |
| p.14 | I | C | A temporary interruption of cancer therapy is recommended in patients in whom the cancer therapy is suspected to be a contributing cause of ACS. | Table 4 New recommendations |
| p.14 | IIa | C | A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (i.e. with expected life survival <6 months) and/or very high bleeding risk. | Table 4 New recommendations |
| p.14 | III | C | Aspirin is not recommended in cancer patients with a platelet count <10 000/μL. | Table 4 New recommendations |
| p.15 | III | C | Clopidogrel is not recommended in cancer patients with a platelet count <30 000/μL. | |
| p.15 | III | C | In ACS patients with cancer and <50 000/μL platelet count, prasugrel or ticagrelor are not recommended. | |
| p.15 | I | C | before admission. | |
| p.15 | IIb | A | cardiovascular disease events occur under optimal therapy. | |
| p.15 | IIb | B | Combination therapy with a high-dose statin plus ezetimibe may be considered during index hospitalization. | |
| p.15 | I | B | Patient-centred 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. | |
| p.15 | I | B | 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. | |
| p.15 | I | C | It is recommended to assess symptoms using methods that help patients to describe their experience. | |
| p.15 | IIa | B | Use of the ‘teach back’ technique for decision support during the securing of informed consent should be considered. | |
| p.15 | IIa | B | Assessment of mental well-being using a validated tool and onward psychological referral when appropriate should be considered. | |
| p.15 | IIa | A | and who are not high ischaemic risk, SAPT (preferably with a P2Y12 receptor inhibitor) should be considered. | Table 5 Revised recommendations |
| p.15 | I | B | In patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with suspected ACS, a non-invasive stress test (preferably with imaging) for inducible ischaemia or CCTA is recommended before deciding on an invasive approach. | Table 5 Revised recommendations |
| p.15 | I | A | An early invasive strategy within 24 h is recommended in patients with any of the following high-risk criteria: • Diagnosis of NSTEMI suggested by the diagnostic algorithm recommended in Section 3 • Dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischaemia • Transient ST-segment elevation • GRACE risk score >140. | Table 5 Revised recommendations |
| p.15 | I | A | A potent P2Y12 inhibitor (prasugrel or ticagrelor), or clopidogrel if these are not available or are contraindicated, is recommended before (or at latest at the time of) PCI, and maintained over 12 months, unless there are contraindications such as excessive risk of bleeding. | Table 5 Revised recommendations |
| p.15 | IIa | A | After stent implantation in patients undergoing a strategy of DAPT, stopping aspirin after 3–6 months should be considered, depending on the balance between the ischaemic and bleeding risks. | Table 5 Revised recommendations |
| p.15 | IIa | A | 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. | Table 5 Revised recommendations |
| p.15 | IIa | A | 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 • GRACE risk score >140. | Table 5 Revised recommendations |
| p.15 | IIb | B | Pre-treatment with a P2Y12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy. In patients who are event-free after 3–6 months of DAPT | Table 5 Revised recommendations |
| p.16 | IIb | C | When echocardiography is suboptimal/inconclusive, CMR imaging may be considered. | |
| p.16 | I | A | Complete revascularization is recommended either during the index PCI procedure or within 45 days. | |
| p.16 | IIa | C | episodes of hypoglycaemia should be avoided. | |
| p.16 | IIa | B | Delayed as opposed to immediate angiography should be considered among haemodynamically stable patients without ST-segment elevation successfully resuscitated after out-of-hospital cardiac arrest. | |
| p.16 | I | B | Targeted temperature management (also called therapeutic hypothermia), aiming for a constant temperature between 32 and 36 C for at least 24 h, is indicated in patients who remain unconscious after resuscitation from cardiac arrest (of presumed cardiac cause). | |
| p.16 | IIa | C | Recommendations for in-hospital management When echocardiography is suboptimal/inconclusive, an alternative imaging method (CMR preferably) should be considered. | |
| p.16 | IIa | A | Routine revascularization of non-IRA lesions should be considered in STEMI patients with multivessel disease before hospital discharge. | |
| p.16 | IIa | B | Glucose-lowering therapy should be considered in ACS patients with blood glucose >10 mmol/L (>180 mg/dL), with the target adapted to comorbidities, while episodes of hypoglycaemia should be avoided. New/revised concepts | |
| p.16 | III | A | Routine immediate angiography after resuscitated cardiac arrest is not recommended in haemodynamically stable patients without persistent ST-segment elevation (or equivalents). | |
| p.16 | I | B | 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 return of spontaneous circulation. | |
| p.19 | I | C | with recurrent symptoms or diagnostic uncertainty. | Recommendation Table 1 — Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome |
| p.19 | I | B | It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs-cTn.1,17,18 | Recommendation Table 1 — Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome |
| p.19 | I | B | ECG Twelve-lead ECG recording and interpretation is recommended as soon as possible at the point of FMC, with a target of <10 min.5,19 | Recommendation Table 1 — Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome |
| p.19 | I | B | Continuous ECG monitoring and the availability of defibrillator capacity is recommended as soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made.20,21 | Recommendation Table 1 — Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome |
| p.19 | I | B | The use of additional ECG leads (V3R, V4R, and V7– V9) is recommended in cases of inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive.22–24 An additional 12-lead ECG is recommended in cases | Recommendation Table 1 — Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome |
| p.20 | I | B | Blood sampling It is recommended to measure cardiac troponins with high-sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling.15,25–27 | |
| p.20 | I | B | It is recommended to use an ESC algorithmic approach with serial hs-cTn measurements (0 h/1 h or 0 h/2 h) to rule in and rule out NSTEMI.28–44 | |
| p.20 | I | B | Additional testing after 3 h is recommended if the first two hs-cTn measurements of the 0 h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made.45,46 | |
| p.20 | IIa | B | The use of established risk scores (e.g. GRACE risk score) for prognosis estimation should be considered.47–49 | |
| p.20 | I | A | Triage for emergency reperfusion strategy It is recommended that patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy.50–52 | |
| p.23 | III | B | is not recommended.117 | Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome |
| p.23 | I | C | Emergency TTE is recommended in patients with suspected ACS presenting with cardiogenic shock or suspected mechanical complications. | Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome |
| p.23 | IIa | A | In patients with suspected ACS, non-elevated (or uncertain) hs-cTn levels, 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.116,122–127 | Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome |
| p.23 | IIa | C | Emergency TTE should be considered at triage in cases of diagnostic uncertainty but this should not result in delays in transfer to the cardiac catheterization laboratory if there is suspicion of an acute coronary artery occlusion. Routine, early CCTA in patients with suspected ACS | Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome |
| p.26 | I | C | Oxygen is recommended in patients with hypoxaemia (SaO2 <90%). | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | III | A | without hypoxaemia (SaO2 >90%).148,172 | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | IIa | C | Intravenous opioids should be considered to relieve pain. | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | IIa | C | A mild tranquilizer should be considered in very anxious patients. | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | IIa | A | Routine oxygen is not recommended in patients Symptoms Intravenous beta-blockers Intravenous beta-blockers (preferably metoprolol) should be considered at the time of presentation in patients undergoing PPCI with no signs of acute heart failure, an SBP >120 mmHg, and no other contraindications.163–167,169 Pre-hospital logistics of care | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | I | B | It is recommended that the pre-hospital management of patients with a working diagnosis of STEMI is based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make PPCI available to as many patients as possible.145 | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | I | B | It is recommended that PPCI-capable centres deliver a 24/7 service and are able to perform PPCI without delay.173,174 | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | I | B | It is recommended that patients transferred for PPCI bypass the emergency department and CCU/ICU and are transferred directly to the catheterization laboratory.137,175–178 | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | I | C | It is recommended that EMS transfer patients with suspected STEMI to a PCI-capable centre, bypassing non-PCI centres. | Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome |
| p.26 | I | C | It is recommended that ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation, and fibrinolysis when applicable.142 | |
| p.26 | I | C | It is recommended that all hospitals and EMS participating in the care of patients with suspected STEMI record and audit delay times and work together to achieve and maintain quality targets. | |
| p.31 | I | A | 186,212,213,222–224 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalentsc) and symptoms of ischaemia of ≤12 h duration.51,182 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min.52,218,219 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications.176,183 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | Rescue PCI is recommended for failed fibrinolysis (i.e. ST-segment resolution <50% within 60–90 min of fibrinolytic administration) or in the presence of haemodynamic or electrical instability, worsening ischaemia, or persistent chest pain.184,185 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | C | In patients with a working diagnosis of STEMI and a time from symptom onset >12 h, a PPCI strategy is recommended in the presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias.220 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | IIa | B | A routine PPCI strategy should be considered in STEMI patients presenting late (12–48 h) after symptom onset.189–191,221 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | III | A | Routine PCI of an occluded IRA is not recommended in STEMI patients presenting >48 h after symptom onset and without persistent symptoms.189,192,193 Transfer/interventions after fibrinolysis Transfer to a PCI-capable centre is recommended in | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | all patients immediately after fibrinolysis.184– Emergency angiography and PCI of the IRA, if indicated are recommended in patients with new-onset or persistent heart failure/shock after fibrinolysis.185,225 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | Angiography and PCI of the IRA, if indicated, is recommended between 2 and 24 h after successful fibrinolysis.186,212,213,217,224 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | An invasive strategy during hospital admission is recommended in NSTE-ACS patients with high-risk criteria or a high index of suspicion for unstable angina.196–200 | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | A | A selective invasive approach is recommended in patients without very high- or high-risk NSTE-ACS criteria and with a low index of suspicion for NSTE-ACS.196–200 An immediate invasive strategy is recommended in patients with a working diagnosis of NSTE-ACS and | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | I | C | with at least one of the following very high-risk criteria: • Haemodynamic instability or cardiogenic shock • Recurrent or refractory chest pain despite medical treatment • In-hospital life-threatening arrhythmias • Mechanical complications of MI • Acute heart failure presumed secondary to ongoing myocardial ischaemia | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.31 | IIa | A | • Recurrent dynamic ST-segment or T wave changes, particularly intermittent ST-segment elevation. 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 • GRACE risk score >140202,226–230 6 Antithrombotic therapy | Recommendation Table 4 — Recommendations for reperfusion therapy and timing of invasive strategy |
| p.39 | IIb | A | In P2Y12 receptor inhibitor-naïve patients undergoing PCI, cangrelor may be considered.251–254 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | III | A | is not recommended.292 | |
| p.39 | I | A | Parenteral anticoagulation is recommended for all patients with ACS at the time of diagnosis.255,296 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | A | Enoxaparin should be considered as an alternative to UFH in patients with STEMI undergoing PPCI.258,261,298 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | III | B | STEMI undergoing PPCI.260 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | A | Antiplatelet therapy Aspirin is recommended for all patients without contraindications at an initial oral LD of 150–300 mg (or 75–250 mg i.v.) and an MD of 75–100 mg o.d. for long-term treatment.284,285 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | A | In all ACS patients, a P2Y12 receptor inhibitor is recommended in addition to aspirin, given as an initial oral LD followed by an MD for 12 months unless there is HBRc.238,239,263,286 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | A | A proton pump inhibitor in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding.287,288 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | B | Prasugrel is recommended in P2Y12 receptor inhibitor-naïve patients proceeding to PCI (60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged ≥75 years or with a body weight <60 kg).239 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | B | Ticagrelor is recommended irrespective of the treatment strategy (invasive or conservative) (180 mg LD, 90 mg b.i.d. MD).238 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | C | Clopidogrel (300–600 mg LD, 75 mg o.d. MD) is recommended when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated.263,289 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | C | If patients presenting with ACS stop DAPT to undergo CABG, it is recommended they resume DAPT after surgery for at least 12 months. | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | B | Prasugrel should be considered in preference to ticagrelor for ACS patients who proceed to PCI.244,290 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | C | GP IIb/IIIa receptor antagonists should be considered if there is evidence of no-reflow or a thrombotic complication during PCI. | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIb | B | In older ACS patients,d especially if HBR,c clopidogrel as the P2Y12 receptor inhibitor may be considered.242,243,291 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIb | B | Pre-treatment with a P2Y12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy.244,245 | |
| p.39 | IIb | C | Pre-treatment with a P2Y12 receptor inhibitor may be considered in NSTE-ACS patients who are not expected to undergo an early invasive strategy (<24 h) and do not have HBRc.263 Pre-treatment with a GP IIb/IIIa receptor antagonist | |
| p.39 | III | A | Routine pre-treatment with a P2Y12 receptor inhibitor in NSTE-ACS patients in whom coronary anatomy is not known and early invasive management (<24 h) is planned is not recommended.244,247,248,293–295 Anticoagulant therapy | |
| p.39 | I | C | Routine use of a UFH bolus (weight-adjusted i.v. bolus during PCI of 70–100 IU/kg) is recommended in patients undergoing PCI. | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | B | Intravenous enoxaparin at the time of PCI should be considered in patients pre-treated with subcutaneous enoxaparin.256,261,297 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | C | Discontinuation of parenteral anticoagulation should be considered immediately after an invasive procedure. Patients with STEMI | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | A | Bivalirudin with a full-dose post PCI infusion should be considered as an alternative to UFH in patients with STEMI undergoing PPCI.259,299,300–303 Fondaparinux is not recommended in patients with | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | B | Patients with NSTE-ACS For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is not anticipated, fondaparinux is recommended.262,304 | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | IIa | B | For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is anticipated, enoxaparin should be considered as an alternative to UFH.256 Combining antiplatelets and OAC As the default strategy for patients with atrial | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | A | fibrillation and CHA2DS2-VASc score ≥1 in men and ≥2 in women, after up to 1 week of triple antithrombotic therapy following the ACS event, dual antithrombotic therapy using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel) | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.39 | I | C | for up to 12 months is recommended.305–310 During PCI, a UFH bolus is recommended in any of the following circumstances: • if the patient is on a NOAC • if the INR is <2.5 in VKA-treated patients. Continued | Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome |
| p.40 | III | C | The use of ticagrelor or prasugrel as part of triple antithrombotic therapy is not recommended. | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | III | B | De-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended.238,323 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIa | B | In patients with an indication for OAC with VKA in combination with aspirin and/or clopidogrel, careful regulation of the dose intensity of VKA with a target INR of 2.0–2.5 and a time in the therapeutic range >70% should be considered.305–308,311 | |
| p.40 | IIa | B | When rivaroxaban is used and concerns about HBR prevail over ischaemic stroke, rivaroxaban 15 mg o.d. should be considered in preference to rivaroxaban 20 mg o.d. for the duration of concomitant SAPT or DAPT.307 | |
| p.40 | IIa | B | be considered in preference to dabigatran 150 mg b.i.d. for the duration of concomitant SAPT or DAPT, to mitigate bleeding risk.305 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIa | B | In patients requiring anticoagulation and treated medically, a single antiplatelet agent in addition to an OAC should be considered for up to 1 year.308,312 In patients treated with an OAC, aspirin plus | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIa | C | clopidogrel for longer than 1 week and up to 1 month should be considered in those with high ischaemic risk or with other anatomical/procedural characteristics that are judged to outweigh the | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIb | B | bleeding risk.e In patients requiring OAC, withdrawing antiplatelet therapy at 6 months while continuing OAC may be considered.313 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIa | A | In patients who are event-free after 3–6 months of DAPT and who are not high ischaemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered.264,268– 271,273,274,276,313,320 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIb | A | De-escalation of P2Y12 receptor inhibitor treatment (e.g. with a switch from prasugrel/ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk.279–282,321,322 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIb | B | In HBR patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered.276,313 © ESC 2023 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | I | B | Prolonging antithrombotic therapy Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months.324,325 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIa | A | Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered in patients with high ischaemic risk and without HBRc.314–318 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIb | A | Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention may be considered in patients with moderate ischaemic risk and without HBRc.314–318 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.40 | IIb | A | P2Y12 inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment.326,327 | Recommendation Table 6 — Recommendations for alternative antithrombotic therapy regimens |
| p.43 | I | B | A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended.356,357 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | IIa | B | A half-dose of tenecteplase should be considered in patients >75 years of age.184 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | I | A | Aspirin and clopidogrel are recommended.340–342 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | I | A | Enoxaparin i.v. followed by s.c. is recommended as the preferred anticoagulant.347,348,357–360 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | I | A | Fibrinolytic therapy When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after diagnosis in the pre-hospital setting (aim for target of <10 min to lytic bolus).206,353–355 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | I | A | Antiplatelet co-therapy with fibrinolysis Anticoagulation co-therapy with fibrinolysis Anticoagulation is recommended in patients treated with fibrinolysis until revascularization (if performed) or for the duration of hospital stay (up to 8 days).260,347,348,350,357–360 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | I | B | When enoxaparin is not available, UFH is recommended as a weight-adjusted i.v. bolus, followed by infusion.357 | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.43 | IIa | B | In patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an s.c. dose 24 h later should be considered.260 i.v., intravenous; s.c, subcutaneous; UFH, unfractionated heparin. aClass of recommendation. bLevel of evidence. | Recommendation Table 7 — Recommendations for fibrinolytic therapy |
| p.44 | I | B | Cardiac arrest and OHCA A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents).368,387,388 | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.44 | III | A | Routine immediate angiography after resuscitated cardiac arrest is not recommended in haemodynamically stable patients without persistent ST-segment elevation (or equivalents).373–377 Temperature control | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.44 | I | B | 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 return of spontaneous circulation.378–385,389 | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.44 | I | C | Systems of care It is recommended that healthcare systems implement strategies to facilitate transfer of all patients in whom ACS is suspected after resuscitated cardiac arrest directly to a hospital offering 24/7 PPCI via one specialized EMS.390–392 | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.44 | IIa | C | Transport of patients with OHCA to a cardiac arrest centre according to local protocols should be considered.391,393 | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.44 | I | C | Evaluation of neurological prognosis Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest.386 | Recommendation Table 8 — Recommendations for cardiac arrest and out-of-hospital cardiac arrest |
| p.45 | I | B | CS if PCI of the IRA is not feasible/unsuccessful.394,395 | Recommendation Table 9 — Recommendations for cardiogenic shock |
| p.45 | I | B | Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS.394,396,404 Emergency CABG is recommended for ACS-related | Recommendation Table 9 — Recommendations for cardiogenic shock |
| p.45 | I | C | In cases of haemodynamic instability, emergency surgical/catheter-based repair of mechanical complications of ACS is recommended, based on Heart Team discussion. | Recommendation Table 9 — Recommendations for cardiogenic shock |
| p.45 | IIa | C | Fibrinolysis should be considered in STEMI patients presenting with CS if a PPCI strategy is not available within 120 min from the time of STEMI diagnosis and mechanical complications have been ruled out.184,354 | Recommendation Table 9 — Recommendations for cardiogenic shock |
| p.45 | IIb | C | In patients with ACS and severe/refractory CS, short-term mechanical circulatory support may be considered.402 | |
| p.45 | III | B | The routine use of an IABP in ACS patients with CS and without mechanical complications is not recommended.399,405–407 | |
| p.47 | IIb | C | CMR imaging may be considered. | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | I | C | Logistical issues for hospital stay It is recommended that all hospitals participating in the care of high-risk patients have an ICCU/CCU equipped to provide all required aspects of care, including treatment of ischaemia, severe heart failure, arrhythmias, and common comorbidities. | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | I | C | It is recommended that high-risk patients (including all STEMI patients and very high-risk NSTE-ACS patients) have ECG monitoring for a minimum of 24 h. It is recommended that high-risk patients with | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | I | C | successful reperfusion therapy and an uncomplicated clinical course (including all STEMI patients and very high-risk NSTE-ACS patients) are kept in the CCU/ ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | IIa | A | bed for an additional 24–48 h. Discharge of selected high-risk patients within 48– 72 h should be considered if early rehabilitation and adequate follow-up are arranged.411,413,415,447 | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | IIa | C | Same-day transfer in selected stable patients after successful and uneventful PCI should be considered.419 Imaging | Recommendation Table 10 — Recommendations for in-hospital management |
| p.47 | I | C | Routine echocardiography is recommended during hospitalization to assess regional and global LV function, detect mechanical complications, and exclude LV thrombus. When echocardiography is suboptimal/inconclusive, | Recommendation Table 10 — Recommendations for in-hospital management |
| p.50 | I | A | to bare metal stents in all cases.463,466,468 | |
| p.50 | III | A | recommended.472–474 | |
| p.50 | I | A | Radial access is recommended as the standard approach, unless there are overriding procedural considerations.451,452 | Recommendation Table 11 — Recommendations for technical aspects of invasive strategies |
| p.50 | I | A | PCI with stent deployment in the IRA during the index procedure is recommended in patients undergoing PPCI.490–494 | Recommendation Table 11 — Recommendations for technical aspects of invasive strategies |
| p.50 | I | C | Drug-eluting stents are recommended in preference In patients with spontaneous coronary artery dissection, PCI is recommended only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. Intravascular imaging should be considered to guide | |
| p.50 | IIa | C | Coronary artery bypass grafting should be considered in patients with an occluded IRA when PPCI is not feasible/unsuccessful and there is a large area of myocardium in jeopardy. | |
| p.50 | IIb | C | Intravascular imaging (preferably optical coherence tomography) may be considered in patients with ambiguous culprit lesions. The routine use of thrombus aspiration is not | |
| p.53 | I | B | IRA-only PCI during the index procedure is recommended.404,505 | Recommendation Table 12 — Recommendations for management of patients with multivessel disease |
| p.53 | IIa | C | Staged PCI of non-IRA should be considered.c | Recommendation Table 12 — Recommendations for management of patients with multivessel disease |
| p.53 | I | B | on angiographic severity.511,524 | |
| p.53 | I | B | It is recommended to base the revascularization strategy (IRA PCI, multivessel PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease complexity, according to the principles of management of myocardial revascularization.480,481 shock | Recommendation Table 12 — Recommendations for management of patients with multivessel disease |
| p.53 | I | A | undergoing PPCI Complete revascularization is recommended either during the index PCI procedure or within 45 days.508–511,531 It is recommended that PCI of the non-IRA is based | |
| p.53 | III | C | Invasive epicardial functional assessment of non-culprit segments of the IRA is not recommended during the index procedure. | |
| p.53 | IIa | C | patients undergoing PCI In patients presenting with NSTE-ACS and MVD, complete revascularization should be considered, preferably during the index procedure.513,514 | |
| p.53 | IIb | B | Functional invasive evaluation of non-IRA severity during the index procedure may be considered.518,527,528,532 | |
| p.56 | I | B | In patients with a working diagnosis of MINOCA, CMR imaging is recommended after invasive angiography if the final diagnosis is not clear.544,545 | Recommendation Table 13 — Recommendations for myocardial infarction with non-obstructive coronary arteries |
| p.56 | I | B | Management of MINOCA according to the final established underlying diagnosis is recommended, consistent with the appropriate disease-specific guidelines.546,550,552 | Recommendation Table 13 — Recommendations for myocardial infarction with non-obstructive coronary arteries |
| p.56 | I | C | In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to determine the underlying final diagnosis. 12 Special situations | Recommendation Table 13 — Recommendations for myocardial infarction with non-obstructive coronary arteries |
| p.58 | IIa | C | Heart failure IABP should be considered in patients with haemodynamic instability/cardiogenic shock due to ACS-related mechanical complications. | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | IIa | C | LV thrombus CMR imaging should be considered in patients with equivocal echocardiographic images or in cases of high clinical suspicion of LV thrombus.577,578 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | IIa | C | Oral anticoagulant therapy (VKA or NOAC) should be considered for 3–6 months in patients with confirmed LV thrombus.603 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | IIb | C | Following an acute anterior MI, a contrast echocardiogram may be considered for the detection of LV thrombus if the apex is not well visualized on echocardiography.604 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | I | C | Atrial fibrillation Intravenous beta-blockers are recommended when rate control is needed in the absence of acute HF or hypotension.605 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | I | C | Intravenous amiodarone is recommended when rate control is needed in the presence of acute HF and no hypotension.606 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | I | C | Immediate electrical cardioversion is recommended in patients with ACS and haemodynamic instability and when adequate rate control cannot be achieved promptly with pharmacological agents. | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | I | C | Intravenous amiodarone is recommended to facilitate electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion in unstable patients with recent-onset AF.607,608 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | IIa | C | In patients with documented de novo AF during the acute phase of ACS, long-term oral anticoagulation should be considered depending on the CHA2DS2- VASc score, after taking the HAS-BLED score and the need for concomitant antiplatelet therapy into consideration. NOACs are the preferred drugs.583,584,587 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.58 | I | A | Ventricular arrythmias ICD therapy is recommended to reduce sudden cardiac death in patients with symptomatic HF (NYHA Class II–III) and LVEF ≤35% despite optimal medical therapy for >3 months and at least 6 weeks after MI who are expected to survive for at least 1 year with good functional status.434,609,610 | Recommendation Table 14 — Recommendations for acute coronary syndrome complications |
| p.59 | I | C | • temporary pacing is recommended in cases of failure to respond to atropine. | |
| p.59 | III | B | Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously.620–622 | |
| p.59 | I | B | Intravenous beta-blocker and/or amiodarone treatment is recommended for patients with polymorphic VT and/or VF unless contraindicated.611–614 | |
| p.59 | I | C | Prompt and complete revascularization is recommended to treat myocardial ischaemia that may be present in patients with recurrent VT and/or VF.368,388 | |
| p.59 | IIa | C | Transvenous catheter pacing termination and/or overdrive pacing should be considered if VT cannot be controlled by repeated electrical cardioversion. | |
| p.59 | IIa | C | Radiofrequency catheter ablation at a specialized ablation centre followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy. | |
| p.59 | IIb | C | Treatment of recurrent VT with haemodynamic relevance (despite repeated electrical cardioversion) with lidocaine may be considered if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable.615 | |
| p.59 | IIb | C | In patients with recurrent life-threatening ventricular arrhythmias, sedation or general anaesthesia to reduce sympathetic drive may be considered.616 | |
| p.59 | IIb | C | ICD implantation or the temporary use of a wearable cardioverter defibrillator may be considered <40 days after MI in selected patients (incomplete revascularization, pre-existing LVEF dysfunction, occurrence of arrhythmias >48 h after STEMI onset, polymorphic VT or VF). | |
| p.59 | III | C | Treatment of asymptomatic and haemodynamically irrelevant ventricular arrhythmias with anti-arrhythmic drugs is not recommended. Bradyarrhythmias In cases of sinus bradycardia with haemodynamic | |
| p.59 | I | C | intolerance or high-degree AV block without stable escape rhythm: • i.v. positive chronotropic medication (adrenaline, vasopressin, and/or atropine) is recommended.617,618 | |
| p.59 | I | C | • urgent angiography with a view to revascularization is recommended if the patient has not received previous reperfusion therapy. | |
| p.59 | I | C | Implantation of a permanent pacemaker is recommended when high-degree AV block does not resolve within a waiting period of at least 5 days after MI. | |
| p.59 | IIb | C | In selected patients with high-degree AV block in the context of an anterior wall MI and acute HF, early device implantation (CRT-D/CRT-P) may be considered.619,620 | |
| p.62 | I | C | eGFR in all patients with ACS. | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | B | It is recommended to assess glycaemic status at initial evaluation in all patients with ACS.705–707 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | III | C | platelet count <10 000/μL.715 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | III | C | with a platelet count <30 000/μL. | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | III | C | count, prasugrel or ticagrelor are not recommended. | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | A | Chronic kidney disease The use of low- or iso-osmolar contrast media (at the lowest possible volume) is recommended for invasive strategies.691–693 It is recommended to assess kidney function using | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | C | It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as in patients with normal kidney function. | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | IIa | B | Hydration during and after angiography should be considered in patients at risk of contrast-induced nephropathy, especially in patients with acute kidney injury and/or CKD with eGFR <30 mL/min/ 1.73 m2.694–697 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | A | Diabetes It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, CKD, and obesity.698–704 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | C | It is recommended to frequently monitor blood glucose levels in patients with known diabetes mellitus or hyperglycaemia (defined as glucose levels ≥11.1 mmol/L or ≥200 mg/dL). | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | IIa | C | Glucose-lowering therapy should be considered in patients with ACS with persistent hyperglycaemia, while episodes of hypoglycaemia should be avoided.708,709 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | B | Older adults It is recommended to apply the same diagnostic and treatment strategies in older patients as in younger patients.662,664,665,710,711 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | B | It is recommended to adapt the choice and dosage of antithrombotic agent, as well as of secondary prevention medications, to renal function, co-medications, comorbidities, frailty, cognitive function, and specific contraindications.363,712 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | B | 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.668,673,676 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | B | An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months.682,689,690 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | I | C | A temporary interruption of cancer therapy is recommended in patients in whom the cancer therapy is suspected to be a contributing cause of ACSc.713,714 | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.62 | IIa | C | A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosisd (i.e. with expected survival <6 months) and/or very high bleeding risk.690 Aspirin is not recommended in cancer patients with a Clopidogrel is not recommended in cancer patients In ACS patients with cancer and <50 000/μL platelet | Recommendation Table 15 — Recommendations for acute coronary syndrome comorbid conditions |
| p.68 | I | A | Cardiac rehabilitation It is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, multidisciplinary exercise-based cardiac rehabilitation and prevention programme.721–724,853,854 Lifestyle management It is recommended that ACS patients adopt a healthy lifestyle, including: • stopping all smoking of tobacco | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | IIa | A | • healthy diet (Mediterranean style) • alcohol restriction • regular aerobic physical activity and resistance exercise • reduced sedentary time724,761,763,772,773,776,777,855– In smokers, offering follow-up support, nicotine replacement therapy, varenicline or bupropion, individually or in combination, should be considered.859–864 Pharmacological treatment | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | I | A | Lipid-lowering therapy It is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values.787,865–867 | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | I | A | It is recommended to aim to achieve an LDL-C level of <1.4 mmol/L (<55 mg/dL) and to reduce LDL-C by ≥50% from baseline.868,869 | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | I | B | If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4–6 weeks, the addition of ezetimibe is recommended.788 | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | I | A | If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4–6 weeks, the addition of a PCSK9 inhibitor is recommended.785,786,795,796 | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | I | C | It is recommended to intensify lipid-lowering therapyc during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission. | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | IIb | B | For patients with a recurrent atherothrombotic event (recurrence within 2 years of first ACS episode) while taking maximally tolerated statin-based therapy, an LDL-C goal of <1.0 mmol/L (<40 mg/dL) may be considered.785,786 | Recommendation Table 16 — Recommendations for long-term management |
| p.68 | IIb | B | Combination therapy with high-dose statin plus ezetimibe may be considered during index hospitalization.788 | Recommendation Table 16 — Recommendations for long-term management |
| p.69 | IIa | B | of LVEF should be considered.798,873–878 | |
| p.69 | IIa | A | regardless of LVEF should be considered.816,817 | |
| p.69 | I | A | Influenza vaccination is recommended for all ACS patients.843,845–847 | |
| p.69 | I | A | Beta-blockers Beta-blockers are recommended in ACS patients with LVEF ≤40% regardless of HF symptoms.801,870– Routine beta-blockers for all ACS patients regardless RAAS system inhibitors Angiotensin-converting enzyme (ACE) inhibitorsd are recommended in ACS patients with HF symptoms, LVEF ≤40%, diabetes, hypertension, and/ or CKD.195,813–817,879 | |
| p.69 | I | A | Mineralocorticoid receptor antagonists are recommended in ACS patients with an LVEF ≤40% and HF or diabetes.826,880 Routine ACE inhibitors for all ACS patients | |
| p.69 | IIa | B | Adherence to medication A polypill should be considered as an option to improve adherence and outcomes in secondary prevention after ACS.753 Imaging | |
| p.69 | I | C | In patients with pre-discharge LVEF ≤40%, repeat evaluation of the LVEF 6–12 weeks after an ACS (and after complete revascularization and the institution of optimal medical therapy) is recommended to assess the potential need for sudden cardiac death primary prevention ICD implantation. | |
| p.69 | IIa | C | Cardiac magnetic resonance imaging should be considered as an adjunctive imaging modality in order to assess the potential need for primary prevention ICD implantation. Vaccination | |
| p.69 | IIb | A | Anti-inflammatory drugs Low-dose colchicine (0.5 mg once daily) may be considered, particularly if other risk factors are insufficiently controlled or if recurrent cardiovascular disease events occur under optimal therapy.850,851 14 Patient perspectives | |
| p.72 | I | B | Patient-centred 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.744,881,906,907 | Recommendation Table 17 — Recommendations for patient perspectives in acute coronary syndrome care |
| p.72 | I | B | 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 can be used to facilitate the discussion.908,909 | Recommendation Table 17 — Recommendations for patient perspectives in acute coronary syndrome care |
| p.72 | I | C | It is recommended to assess symptoms using methods that help patients to describe their experience.910 | Recommendation Table 17 — Recommendations for patient perspectives in acute coronary syndrome care |
| p.72 | IIa | B | Use of the ‘teach back’ technique for decision support during the securing of informed consent should be considered.885,889–891 | Recommendation Table 17 — Recommendations for patient perspectives in acute coronary syndrome care |
| p.72 | IIa | B | Patient discharge information should be provided in both written and verbal formats prior to 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.885,896,911 | |
| p.72 | IIa | B | Assessment of mental well-being using a validated tool and onward psychological referral when appropriate should be considered.903,904,912,913 ACS, acute coronary syndrome. aClass of recommendation. bLevel of evidence. 15 Key messages | |
| p.77 | I | C | hypoxaemia (SaO2 <90%). | |
| p.77 | III | A | Routine oxygen is not recommended in patients with oxygen saturation >90%. | |
| p.77 | I | A | Recommendations for clinical and diagnostic tools for patients with suspected acute coronary syndrome It is recommended that patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy. | |
| p.77 | I | B | It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs-cTn. | |
| p.77 | I | B | Twelve-lead ECG recording and interpretation is recommended as soon as possible at the point of first medical contact, with a target of <10 min. | |
| p.77 | I | B | Continuous ECG monitoring and the availability of defibrillator capacity is recommended as soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made. | |
| p.77 | I | B | The use of additional ECG leads (V3R, V4R, and V7– V9) is recommended in cases of inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive. | |
| p.77 | I | C | An additional 12-lead ECG is recommended in cases with recurrent symptoms or diagnostic uncertainty. | |
| p.77 | I | B | It is recommended to measure cardiac troponins with high-sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling. | |
| p.77 | I | B | It is recommended to use an ESC algorithmic approach with serial hs-cTn measurements (0 h/1 h or 0 h/2 h) to rule in and rule out NSTEMI. | |
| p.77 | I | B | Additional testing after 3 h is recommended if the first two hs-cTn measurements of the 0 h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made. | |
| p.77 | I | C | Emergency TTE is recommended in patients with suspected ACS presenting with cardiogenic shock or suspected mechanical complications. | |
| p.77 | III | B | Routine, early coronary computed tomography angiography in patients with suspected ACS is not recommended. | |
| p.77 | I | B | acute coronary syndrome It is recommended that the pre-hospital management of patients with a working diagnosis of STEMI is based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make PPCI available Classa Levelb | |
| p.77 | I | B | to as many patients as possible. It is recommended that PPCI-capable centres deliver a 24/7 service and are able to perform PPCI without delay. | |
| p.77 | I | B | It is recommended that patients transferred for PPCI bypass the emergency department and CCU/ICU and are transferred directly to the catheterization laboratory. Oxygen is recommended in patients with | |
| p.77 | I | C | It is recommended that EMS transfer patients with suspected STEMI to a PCI-capable centre, bypassing non-PCI centres. | |
| p.77 | I | C | It is recommended that ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation, and fibrinolysis when applicable. | |
| p.77 | I | C | It is recommended that all hospitals and EMS participating in the care of patients with suspected STEMI record and audit delay times and work together to achieve and maintain quality targets. | |
| p.77 | I | A | invasive strategy Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalents) and symptoms of ischaemia of ≤12 h duration. | |
| p.77 | I | A | A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min. | |
| p.77 | I | A | If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications. | |
| p.77 | I | A | Rescue PCI is recommended for failed fibrinolysis (i.e. ST-segment resolution <50% within 60–90 min of fibrinolytic administration) or in the presence of haemodynamic or electrical instability, worsening ischaemia, or persistent chest pain. Continued | |
| p.78 | I | A | all patients immediately after fibrinolysis. | |
| p.78 | III | A | Pre-treatment with a glycoprotein IIb/IIIa antagonist is not recommended. | |
| p.78 | I | A | patients with ACS at the time of diagnosis. | |
| p.78 | III | B | Fondaparinux is not recommended in patients with STEMI undergoing PPCI. | |
| p.78 | III | C | antithrombotic therapy is not recommended. | |
| p.78 | I | C | In patients with a working diagnosis of STEMI and a time from symptom onset >12 h, a PPCI strategy is recommended in the presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias. | |
| p.78 | III | A | Routine PCI of an occluded IRA is not recommended in STEMI patients presenting >48 h after symptom onset and without persistent symptoms. Transfer/interventions after fibrinolysis Transfer to a PCI-capable centre is recommended in | |
| p.78 | I | A | Emergency angiography and PCI of the IRA, if indicated is recommended in patients with new-onset or persistent heart failure/shock after fibrinolysis. | |
| p.78 | I | A | Angiography and PCI of the IRA, if indicated, is recommended between 2 and 24 h after successful fibrinolysis. Invasive strategy in NSTE-ACS | |
| p.78 | I | A | An invasive strategy during hospital admission is recommended in NSTE-ACS patients with high-risk criteria or with a high index of suspicion for unstable angina. | |
| p.78 | I | A | A selective invasive approach is recommended in patients without very high- or high-risk features and a low index of suspicion for NSTE-ACS. An immediate invasive strategy is recommended in patients with a working diagnosis of NSTE-ACS and | |
| p.78 | I | C | with at least one of the following very high-risk criteria: • Haemodynamic instability or cardiogenic shock • Recurrent or refractory chest pain despite medical treatment • In-hospital life-threatening arrhythmias • Mechanical complications of MI • Acute heart failure presumed secondary to ongoing myocardial ischaemia Recurrent dynamic ST-segment or T wave changes, particularly intermittent ST-segment elevation. | |
| p.78 | I | A | acute coronary syndrome Antiplatelet therapy Aspirin is recommended for all patients without contraindications at an initial oral LD of 150–300 mg (or 75–250 mg i.v.) and an MD of 75–100 mg o.d. for long-term treatment. | |
| p.78 | I | A | In all ACS patients, a P2Y12 receptor inhibitor is recommended in addition to aspirin, given as an initial oral LD followed by an MD for 12 months unless there is high bleeding risk. | |
| p.78 | I | A | A proton pump inhibitor in combination with dual antiplatelet therapy is recommended in patients at high risk of gastrointestinal bleeding. | |
| p.78 | I | B | Prasugrel is recommended in P2Y12 receptor inhibitor-naïve patients proceeding to PCI (60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged ≥75 years or with a body weight <60 kg). | |
| p.78 | I | B | Ticagrelor is recommended irrespective of the treatment strategy (invasive or conservative) (180 mg LD, 90 mg twice a day MD). | |
| p.78 | I | C | Clopidogrel (300–600 mg LD, 75 mg o.d. MD) is recommended when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated. | |
| p.78 | I | C | If patients presenting with ACS stop DAPT to undergo CABG, it is recommended they resume DAPT after surgery for at least 12 months. | |
| p.78 | III | A | Routine pre-treatment with a P2Y12 receptor inhibitor in NSTE-ACS patients in whom coronary anatomy is not known and early invasive management (<24 h) is planned is not recommended. Anticoagulant therapy | |
| p.78 | I | C | Parenteral anticoagulation is recommended for all Routine use of a UFH bolus (weight-adjusted i.v. bolus during PCI of 70–100 IU/kg) is recommended in patients undergoing PCI. Patients with STEMI | |
| p.78 | I | B | Patients with NSTE-ACS For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is not anticipated, fondaparinux is recommended. Combining antiplatelets and OAC As the default strategy for patients with atrial | |
| p.78 | I | A | fibrillation and CHA2DS2-VASc score ≥1 in men and ≥2 in women, after up to 1 week of triple antithrombotic therapy following the ACS event, dual antithrombotic therapy using a non-vitamin K antagonist oral anticoagulant at the recommended dose for stroke prevention and a single oral | |
| p.78 | I | C | antiplatelet agent (preferably clopidogrel) for up to 12 months is recommended. During PCI, a UFH bolus is recommended in any of the following circumstances: • if the patient is on a NOAC • if the INR is <2.5 in VKA-treated patients. The use of ticagrelor or prasugrel as part of triple Continued | |
| p.79 | III | B | days after ACS is not recommended. | |
| p.79 | I | B | reteplase) is recommended. | |
| p.79 | I | A | Aspirin and clopidogrel are recommended. | |
| p.79 | I | A | recommended as the preferred anticoagulant. | |
| p.79 | I | A | to bare metal stents in all cases. | |
| p.79 | III | A | recommended. | |
| p.79 | I | B | regimens Discontinuation of antiplatelet treatment in patients treated with an oral anticoagulant is recommended after 12 months. De-escalation of antiplatelet therapy in the first 30 | |
| p.79 | I | A | Recommendations for fibrinolytic therapy When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after diagnosis in the pre-hospital setting (aim for target of <10 min to lytic bolus). A fibrin-specific agent (i.e. tenecteplase, alteplase, or | |
| p.79 | I | A | Antiplatelet co-therapy with fibrinolysis Anticoagulation co-therapy with fibrinolysis Anticoagulation is recommended in patients treated with fibrinolysis until revascularization (if performed) or for the duration of hospital stay (up to 8 days). Enoxaparin i.v. followed by subcutaneous is | |
| p.79 | I | B | When enoxaparin is not available, unfractionated heparin is recommended as a weight-adjusted i.v. bolus, followed by infusion. | |
| p.79 | I | B | cardiac arrest A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents). Temperature control (i.e. continuous monitoring of | |
| p.79 | I | B | 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 return of spontaneous circulation. | |
| p.79 | III | A | Routine immediate angiography after resuscitated cardiac arrest is not recommended in haemodynamically stable patients without persistent ST-segment elevation (or equivalents). Systems of care | |
| p.79 | I | C | It is recommended that healthcare systems implement strategies to facilitate transfer of all patients in whom ACS is suspected after resuscitated cardiac arrest directly to a hospital offering 24/7 PPCI via one specialized EMS. | |
| p.79 | I | C | Evaluation of neurological prognosis Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest. | |
| p.79 | I | B | Recommendations for cardiogenic shock Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS. | |
| p.79 | I | B | Emergency CABG is recommended for ACS-related CS if PCI of the IRA is not feasible/ unsuccessful. | |
| p.79 | I | C | In cases of haemodynamic instability, emergency surgical/catheter-based repair of mechanical complications of ACS is recommended, based on Heart Team discussion. | |
| p.79 | III | B | The routine use of an intra-aortic balloon pump in ACS patients with CS and without mechanical complications is not recommended. Recommendations for in-hospital management | |
| p.79 | I | C | It is recommended that all hospitals participating in the care of high-risk patients have an ICCU/CCU equipped to provide all required aspects of care, including treatment of ischaemia, severe heart failure, arrhythmias, and common comorbidities. | |
| p.79 | I | C | It is recommended that high-risk patients (including all STEMI patients and very high-risk NSTE-ACS patients) have ECG monitoring for a minimum of 24 h. | |
| p.79 | I | C | It is recommended that high-risk patients with successful reperfusion therapy and an uncomplicated clinical course (including all STEMI patients and very high-risk NSTE-ACS patients) are kept in the CCU/ ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored bed for an additional 24–48 h. | |
| p.79 | I | A | Radial access is recommended as the standard approach, unless there are over-riding procedural considerations. | |
| p.79 | I | A | PCI with stent deployment in the IRA during the index procedure is recommended for patients undergoing PPCI. Drug-eluting stents are recommended in preference | |
| p.79 | I | C | In patients with spontaneous coronary artery dissection, PCI is recommended only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. The routine use of thrombus aspiration is not | |
| p.79 | I | B | multivessel disease It is recommended to base the revascularization strategy (IRA PCI, multivessel PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease complexity, according to the principles Continued of management of myocardial revascularization. | |
| p.80 | I | B | recommended. | |
| p.80 | I | A | during the index PCI procedure or within 45 days. | |
| p.80 | I | B | on angiographic severity. | |
| p.80 | III | B | Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously. | |
| p.80 | I | C | eGFR in all patients with ACS. | |
| p.80 | I | B | evaluation in all patients with ACS. | |
| p.80 | III | C | shock IRA-only PCI during the index procedure is undergoing PPCI Complete revascularization is recommended either It is recommended that PCI of the non-IRA is based Invasive epicardial functional assessment of non-culprit segments of the IRA is not recommended during the index procedure. Recommendations for myocardial infarction with | |
| p.80 | I | B | non-obstructive coronary arteries In patients with a working diagnosis of MINOCA CMR imaging is recommended after invasive angiography if the final diagnosis is not clear | |
| p.80 | I | B | Management of MINOCA according to the final established underlying diagnosis is recommended, consistent with the appropriate disease-specific guidelines. | |
| p.80 | I | C | In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to determine the underlying final diagnosis. | |
| p.80 | I | C | Atrial fibrillation Intravenous beta-blockers are recommended when rate control is needed in the absence of acute HF or hypotension. | |
| p.80 | I | C | Intravenous amiodarone is recommended when rate control is needed in the presence of acute HF and no hypotension. | |
| p.80 | I | C | Immediate electrical cardioversion is recommended in patients with ACS and haemodynamic instability and when adequate rate control cannot be achieved promptly with pharmacological agents. | |
| p.80 | I | C | Intravenous amiodarone is recommended to facilitate electrical cardioversion and/or decrease risk of early recurrence of AF after electrical cardioversion in unstable patients with recent-onset AF. Ventricular arrythmias | |
| p.80 | I | A | Implantable cardioverter defibrillator use is recommended to reduce sudden cardiac death in patients with symptomatic HF (NYHA Class II–III) and LVEF ≤35% despite optimal medical therapy for >3 months and at least 6 weeks after MI who are expected to survive for at least 1 year with good | |
| p.80 | I | B | functional status. Intravenous beta-blocker and/or amiodarone treatment is recommended for patients with polymorphic VT and/or VF unless contraindicated. | |
| p.80 | I | C | Prompt and complete revascularization is recommended to treat myocardial ischaemia that may be present in patients with recurrent VT and/or VF. Bradyarrhythmias In cases of sinus bradycardia with haemodynamic intolerance or high-degree AV block without stable | |
| p.80 | I | C | escape rhythm: • i.v. positive chronotropic medication (adrenaline, vasopressin, and/or atropine) is recommended. • temporary pacing is recommended in cases of failure to respond to atropine. • urgent angiography with a view to revascularization is recommended if the patient | |
| p.80 | I | C | has not received previous reperfusion therapy. Implantation of a permanent pacemaker is recommended when high-degree AV block does not resolve within a waiting period of at least 5 days after MI. | |
| p.80 | III | C | Treatment of asymptomatic and haemodynamically irrelevant ventricular arrhythmias with anti-arrhythmic drugs is not recommended. | |
| p.80 | I | A | Chronic kidney disease The use of low- or iso-osmolar contrast media (at the lowest possible volume) is recommended for invasive strategies. It is recommended to assess kidney function using | |
| p.80 | I | C | It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as in patients with normal kidney function. | |
| p.80 | I | A | Diabetes It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, CKD, and obesity. It is recommended to assess glycaemic status at initial | |
| p.80 | I | C | It is recommended to frequently monitor blood glucose levels in patients with known diabetes mellitus or hyperglycaemia (defined as glucose levels ≥11.1 mmol/L or ≥200 mg/dL). | |
| p.80 | I | B | Older adults It is recommended to apply the same diagnostic and treatment strategies in older patients as in younger patients. Continued | |
| p.81 | III | C | Aspirin is not recommended in cancer patients with a platelet count <10 000/μL. | |
| p.81 | III | C | Clopidogrel is not recommended in cancer patients with a platelet count <30 000/μL. | |
| p.81 | III | C | In ACS patients with cancer and <50 000/μL platelet count, prasugrel or ticagrelor are not recommended. | |
| p.81 | I | A | Beta-blockers are recommended in ACS patients with LVEF ≤40% regardless of HF symptoms. | |
| p.81 | I | A | Influenza vaccination is recommended for all ACS patients. | |
| p.81 | I | B | It is recommended to adapt the choice and dosage of antithrombotic agent, as well as of secondary prevention medications, to renal function, co-medications, comorbidities, frailty, cognitive function, and specific contraindications. | |
| p.81 | I | B | 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. | |
| p.81 | I | B | An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected life survival ≥6 months. | |
| p.81 | I | C | A temporary interruption of cancer therapy is recommended in patients in whom the cancer therapy is suspected to be a contributing cause of ACS. | |
| p.81 | I | A | Recommendations for long-term management It is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, multidisciplinary exercise-based cardiac rehabilitation and prevention programme. It is recommended that ACS patients adopt a healthy | |
| p.81 | I | B | lifestyle, including: • stopping all smoking of tobacco • healthy diet (Mediterranean style) • alcohol restriction • regular aerobic physical activity and resistance exercise • reduced sedentary time | |
| p.81 | I | A | Pharmacological treatment Lipid-lowering therapy It is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values. | |
| p.81 | I | A | It is recommended to aim to achieve an LDL-C level of <1.4 mmol/L (<55 mg/dL) and to reduce LDL-C by ≥50% from baseline. | |
| p.81 | I | A | If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4–6 weeks, the addition of a PCSK9 inhibitor is recommended | |
| p.81 | I | B | If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4–6 weeks, the addition of ezetimibe is recommended. | |
| p.81 | I | C | It is recommended to intensify lipid-lowering therapy during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission. | |
| p.81 | I | A | Beta-blockers RAAS system inhibitors Angiotensin-converting enzyme inhibitors are recommended in ACS patients with HF symptoms, LVEF ≤40%, diabetes, hypertension, and/or CKD. | |
| p.81 | I | A | Mineralocorticoid receptor antagonists are recommended in ACS patients with an LVEF ≤40% and HF or diabetes. Imaging | |
| p.81 | I | C | In patients with pre-discharge LVEF ≤40%, repeat evaluation of the LVEF 6–12 weeks after an ACS (and after complete revascularization and the institution of optimal medical therapy) is recommended to assess the potential need for sudden cardiac death primary prevention ICD implantation. Vaccination | |
| p.81 | I | B | syndrome care Patient-centred 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. | |
| p.81 | I | B | 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. | |
| p.81 | I | C | It is recommended to assess symptoms using methods that help patients to describe their experience. |