p.60 抽出テキスト

approach) did not achieve non-inferiority in terms of MACE. In addition, a post-hoc analysis of MACE between day 30 and 1 year demonstrated an increased risk in the restrictive transfusion strategy group.632 Therefore, no formal recommendation as to the optimal transfusion strategy (liberal vs. restrictive) in patients with ACS can be made at present. Although there are several classifications to grade the severity of thrombocytopaenia, clinically relevant thrombocytopaenia can be defined as a platelet count <100 000/μL or a relative drop in platelet count of 50% from baseline in the context of ACS. Thrombocytopaenia increases the risk of death, major bleeding events, and life-threatening thrombotic events.633,634 The ARC-HBR criteria define a platelet count <100 000/μL as a major criterion for HBR. Management of GP IIb/IIIa inhibitor- and heparin-induced thrombocytopaenia is discussed in the Supplementary data online.

12.3.2 Chronic kidney disease

Moderate to severe CKD (stages III–V) is present in more than 30% of ACS patients.635 Patients with ACS and concomitant CKD receive less interventional and pharmacological treatment and have a worse prognosis than patients with normal kidney function.636–638 Likely contributing factors to this worse prognosis include a larger number of comorbidities and an increased risk of in-hospital complications, including serious bleeding complications.639 Although evidence from RCTs is lacking, data from observational and registry-based studies indicate that ACS patients with moderate to severe CKD have a better prognosis with early revascularization than with medical therapy alone.640,641 The type and dose of antithrombotic agent (see Supplementary data online, Table S15) and the amount of contrast agent should be considered based on kidney function.635,642 In relation to supplementary i.v. hydration during and after revascularization, the evidence around choice, timing, and duration of treatment is somewhat conflicting.643 Taking the clinical circumstances and patient characteristics into consideration, i.v. hydration should be considered as part of the management of ACS patients with a low eGFR undergoing invasive management to minimize the risk of contrast-induced nephropathy.250,635,642,644,645 For recommendations on long-term treatment in patients with ACS and concomitant CKD, please refer to the 2021 ESC Guidelines on cardiovascular disease prevention.646

12.3.3 Diabetes mellitus

ACS patients with diabetes mellitus (DM) may more commonly present with non-specific symptoms, which can lead to delays in both diagnosis and access to treatment.647,648 Both treatment in the acute phase and risk factor management post-ACS is poorer in patients with DM and these patients tend to have more advanced CAD at diagnosis. These factors likely contribute to the worse long-term prognosis associated with ACS in patients with DM, particularly in patients requiring insulin treatment.649–651 All patients with ACS, regardless of a history of DM, should have their glycaemic status evaluated during hospitalization. Given that the ACS itself may give rise to hyperglycaemia due to catecholamine-induced stress, a diagnosis of DM made during hospitalization should be subsequently confirmed. While several studies have shown the benefits of managing hyperglycaemia (>11.0 mmol/L or 200 mg/ dL) in hospitalized ACS patients, the risk of hypoglycaemia-related events when using intensive insulin therapy should not be neglected.652–654 Glucose lowering is important in order to prevent microvascular complications in patients with DM. However, recent trial evidence has shown that the reduction in the risk of new ACS events, HF, and renal impairment with glucose-lowering medications like sodium–glucose co-transporter 2 (SGLT2) inhibitors or glucagon-like peptide-1 receptor agonists (GLP-1-RA) is independent of baseline glycosylated haemoglobin (HbA1c) levels.655–657 This should be taken into consideration when choosing glucose-lowering therapy for patients with DM and concomitant CAD. For further details, please refer to the 2023 ESC Guidelines on diabetes and cardiovascular diseases and the 2021 ESC Guidelines on cardiovascular disease prevention.646,658

12.3.4 Older adults with frailty and multimorbidity

12.3.4.1. The older person Older adults represent an increasing proportion of ACS patients. One of the major predictors of adverse outcomes following ACS is age, but patients aged ≥75 years are often excluded from or under-represented in clinical trials.659,660 Older age is associated with frailty, multimorbidity, and a greater risk of both ischaemic and bleeding events in patients with ACS.661 Hs-cTn assays have an excellent diagnostic performance in the older person, but the specificity of the test is lower than in younger patients, and elevated cTn levels are more commonly associated with conditions other than ACS in older patients.662 There are limited data on the optimal management of older adults with ACS.663 A small RCT enrolling older patients (≥80 years) with NSTE-ACS reported the superiority of an invasive vs. a conservative strategy in the reduction of the composite of MI, need for urgent revascularization, stroke, and death. No treatment effect was shown for allcause death and the benefit associated with the invasive strategy was diluted with increasing age.664 In the absence of robust clinical trial evidence, decisions regarding how to manage older patients should be individualized based on patient characteristics (i.e. ischaemic and bleeding risks, estimated life expectancy, comorbidities, the need for non-cardiac surgery, quality of life, frailty, cognitive and functional impairment, patient values and preferences, and the estimated risks and benefits of an invasive strategy). In the context of STEMI, PPCI has drastically improved outcomes for all ages. However, data are limited in the ‘very old’ cohort, with lack of formal assessment of frailty or comorbidity.665 In the context of CS and cardiac arrest, age is an independent predictor of mortality following PCI.666,667 In the absence of robust RCT data, PPCI should be considered for all patients with STEMI. When PPCI cannot be performed in a timely manner, fibrinolysis may be a reasonable strategy in these patients. For details regarding pharmacotherapy in older patients, please see the Supplementary data online.

12.3.4.2 Frailty and multimorbidity

Geriatric syndromes (i.e. frailty and multimorbidity) are associated with adverse outcomes in older patients with ACS.668,669 Frailty is a syndrome characterized by reduced biological reserve, leading to a failure of homeostatic mechanisms following stressor events, including ACS. There is a lack of consensus on which frailty assessment tool is optimal in older patients with CV disease.670,671 Frail patients with NSTE-ACS less frequently receive ACS pharmacotherapies and invasive assessment, have more complex coronary disease, have longer durations of hospital stay, and are at higher risk of death.672 Specifically, frail patients are reported to have a higher rate of a composite of all-cause mortality, MI, stroke, unplanned

ESC Guidelines                                                                                                                                                                                          3779

Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026