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invasive management. Patients with extensive myocardial damage, HF, hypotension, or arrhythmias may initially rest in bed before assessment of myocardial function and clinical stabilization. Prolongation of bed rest and limitation of physical activity may occasionally be required in patients with large infarcts or severe complications.

8.1.3 Length of stay in the intensive cardiac care unit

The optimal length of stay in the ICCU and hospital should be individualized according to the patient’s clinical situation, taking into account their baseline cardiac risk and comorbidities, baseline mental/functional status, and social support.410,411 Of note, the majority of adverse inhospital events occur early after admission and the initiation of treatment.

8.2 In-hospital care

8.2.1. Length of hospital stay The impact of both successful reperfusion and knowledge of the coronary anatomy (due to increasing rates of ICA) has resulted in progressive reductions in the length of stay after ACS, alongside significant reductions in 30-day mortality, suggesting that discharge within 72 h is not associated with late mortality.411–417 Candidates for early discharge after PCI can be identified using simple criteria.413,414 In one study, patients meeting the following criteria were considered to be ‘low risk’ and suitable for early discharge: age <70 years, LVEF >45%, one- or two-vessel disease, successful PCI, and no persistent arrhythmias.413 A recently published consensus document also presents a template and flow chart to support reasonable decision-making regarding post-procedural length of stay for a broad spectrum of patients undergoing PCI.418 Early (i.e. same day) transfer to a local hospital following successful PPCI is routine practice. This can be done safely under adequate monitoring and supervision in selected patients (i.e. patients without signs or symptoms consistent with ongoing myocardial ischaemia, without arrhythmias, who are haemodynamically stable, who are not requiring vasoactive or mechanical support, and who are not scheduled for further revascularization).419

8.2.2 Risk assessment

Early and late risk stratification soon after presentation is useful to aid decision-making in patients presenting with ACS.

8.2.2.1 Clinical risk assessment

All patients with ACS (in particular, patients with STEMI) should have an early assessment of short-term risk, including an evaluation of the extent of myocardial damage, the achievement of successful reperfusion, and the presence of clinical markers of high risk of further events (i.e. older age, tachycardia, hypotension, Killip class >I, anterior MI, previous MI, elevated initial serum creatinine, history of HF, peripheral arterial disease or anaemia). Several risk scores have been developed based on readily identifiable parameters in the acute phase before reperfusion.420,421 A number of prognostic models that aim to estimate the longer-term risk of all-cause mortality, or the combined risk of all-cause mortality or MI, have also been developed. These models have been formulated into clinical risk scores and, among these, the GRACE risk score offers the best discriminative performance and is therefore recommended for risk assessment.48,421–425 Additional information regarding the GRACE score is provided in the Supplementary data online. 8.2.2.2 Imaging risk assessment

LV dysfunction is a key prognostic factor for patients with ACS.426 It is recommended that the LVEF is determined before hospital discharge in all patients with ACS. Routine echocardiography after PPCI is recommended to assess resting LV, RV, and valvular function. In addition, echocardiography can be used to exclude early post-infarction mechanical complications and LV thrombus. In the limited number of cases in which echocardiography is suboptimal or inconclusive, CMR may be a valuable alternative.427–431 In patients presenting days after an acute ACS event with a completed MI, the presence of recurrent angina or documented ischaemia and proven viability in a large myocardial territory may help to guide the strategy of planned revascularization of an occluded IRA.192,432,433 In patients with a pre-discharge LVEF of ≤40%, re-evaluation of the LVEF 6–12 weeks after complete revascularization and optimal medical therapy is recommended to assess the potential need for primary prevention implantable cardioverter defibrillator (ICD) implantation.434 Additional parameters that are measured by imaging in these patients and that have been used as endpoints in clinical trials include: (i) infarct size (CMR, SPECT, and positron emission tomography); (ii) myocardium at risk (SPECT, CMR); (iii) MVO (CMR); and (iv) intra-myocardial haemorrhage (CMR). Infarct size, MVO and intra-myocardial haemorrhage are predictors of both long-term mortality and HF in STEMI survivors.435–438

8.2.2.3 Biomarkers for risk assessment

Beyond diagnostic utility, initial cTn levels add prognostic information in addition to clinical and ECG variables in terms of predicting the risk of short- and long-term mortality. While hs-cTn T and I have comparable diagnostic accuracy, hs-cTn T has slightly greater prognostic accuracy regarding mortality.61,439–441 Serial measurements are useful to identify peak levels of cTn for risk stratification purposes in patients with established MI. The higher the hs-cTn levels, the greater the risk of death.31,55,442 However, evidence is limited regarding the optimal time points of serial hs-cTn measurement. Serum creatinine and eGFR should also be determined in all patients with ACS because they affect prognosis and are key elements of the GRACE risk score.443 Similarly, natriuretic peptides (brain natriuretic peptide [BNP] and N-terminal pro-BNP [NT-pro BNP]) provide prognostic information in addition to cTn regarding the risk of death and acute HF, and the development of AF.444 Additional information on the use of biomarkers for this purpose is presented in the Supplementary data online.

8.2.2.4 Bleeding risk assessment

Major bleeding events are associated with increased mortality in patients with ACS.231 Further detail on scores that may be considered for estimation of bleeding risk is provided in the Supplementary data online, including Table S12.

8.2.2.5 Integrating ischaemic and bleeding risks

Major bleeding events affect prognosis in a similar way to spontaneous ischaemic complications.445,446 Given the trade-off between ischaemic and bleeding risks for any antithrombotic regimen, risk scores may be useful to tailor antithrombotic duration and intensity, in order to maximize ischaemic protection and minimize bleeding risk in the individual patient. Specific risk scores have been developed for patients on DAPT following PCI, in the settings of both CCS and ACS. Further detail on available scores is provided in the Supplementary data online.

ESC Guidelines                                                                                                                                                                                          3765

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