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revascularization, and major bleeding.673 Frail older adults with NSTE-ACS have poor health-related quality of life (HRQoL) at baseline. Invasive management appears to be associated with modest improvements in HRQoL through to 1 year follow-up in these patients. This improvement in HRQoL is most marked in frail and pre-frail patients, who receive a proportionally larger benefit than robust patients.674 In older adults with NSTE-ACS referred for coronary angiography, the presence of multimorbidity is associated with an increased risk of long-term adverse CV events, driven by a higher risk of all-cause mortality.675 Undiagnosed cognitive impairment is also common in older patients with NSTE-ACS undergoing ICA, and these patients are more likely to experience MACE at 1 year.676 In the absence of robust RCT data to inform healthcare professionals about the management of frail patients presenting with ACS, it is recommended to adapt a holistic approach to individualize interventional and pharmacological treatments after careful evaluation of risks vs. benefits. To aid in decision-making, the routine assessment of frailty (e.g. Rockwood Frailty Score) and comorbidity (e.g. Charlson index) in ACS patients is recommended. Following risk stratification using frailty assessment and evaluation of the comorbidity burden, it may be reasonable to offer optimal medical therapy plus an invasive strategy to frail patients at high risk of future CV events and low risk of complications, and to offer optimal medical therapy alone to those who are deemed to be at low risk of future events with a high risk of developing procedural complications. For those patients for whom any form of treatment might be futile, then a palliative end-of-life care approach should be considered.

12.3.5 Pregnancy

Acute coronary syndrome diagnostic criteria are the same for pregnant and non-pregnant patients.677 Pregnant women with STEMI should not be managed differently to non-pregnant women. Given the high mortality associated with STEMI in pregnancy, PPCI is the preferred reperfusion therapy.678 The management plan for pregnant women with ACS should be determined by a multidisciplinary team consisting of cardiologists, obstetricians, anaesthesiologists, and neonatologists, and these patients should be treated in an intensive care unit that can provide maternal monitoring and obstetric care.678,679 ACS treatment should not be delayed for delivery. Delivery should be ideally postponed for at least 2 weeks post-ACS as there is increased risk of maternal mortality during this time.678 It has been demonstrated that SCAD is the most common cause of AMI in pregnancy, and this tends to occur mainly in the late pregnancy or early post-partum periods.680,681 Further details are provided in the Supplementary data online.

12.3.6 Drug abuse

Acute coronary syndrome in the setting of drug abuse is covered in the Supplementary data online.

12.3.7 Patients with cancer

The four most common types of cancer in patients with ACS are prostate, breast, colon, and lung.682 Patients with a history of cancer should be treated like all other ACS patients, but the management of ACS patients with active cancer has some specific issues that need to be taken into consideration. Outcomes vary across types of cancer and the balance between the ischaemic and bleeding risks should be considered on an individual basis.

The percentage of ACS patients with a current diagnosis of cancer is rising, and currently constitutes ∼3% of patients in large observational studies.683 Patients with active cancer presenting with ACS pose important challenges as there are significant gaps in scientific knowledge. Therefore, recommendations based on solid evidence are scarce. Patients with active cancer presenting with ACS tend to be older, with a larger number of comorbidities and more extensive CAD. These patients often have concomitant haematologic and coagulation abnormalities that may present a challenge with respect to both the use of antithrombotic therapy and the performing of PCI.684 Observational studies have reported that ACS in patients with cancer is associated with increased risk of major CV events, bleeding, and cardiac and non-cardiac mortality.682,683,685,686 As per the ARC-HBR criteria, patients with active cancer diagnosed in the past 12 months are considered as HBR. The diagnosis of ACS in patients with cancer should be based on the same principles as in patients without cancer. The management of ACS in patients with cancer can be challenging because of frailty, increased bleeding risk, thrombocytopaenia, and increased thrombotic risk.687 Temporary interruption of cancer treatment and an urgent multidisciplinary approach is recommended.688 Cancer patients with ACS have been reported to less frequently undergo invasive management; however, invasive management (and PCI with DES if needed) is recommended in ACS patients with cancer, as long as the prognosis is >6 months or, irrespective of the prognosis, if the patient is unstable.689 Retrospective data have reported both a lower use of invasive management in cancer patients with STEMI, and better outcomes in patients who do undergo invasive management.682,686,689 Invasive management in patients with advanced cancer or life expectancy <6 months has been reported to not demonstrate a mortality benefit compared with a conservative approach and therefore a conservative strategy should be considered in these patients.690 When the coronary anatomy is not amenable for PCI, CABG surgery can be considered after a multidisciplinary team discussion and where the cancer prognosis is >12 months. Given that they are considered to be HBR, the preferred P2Y12 inhibitor for ACS patients with active cancer is clopidogrel.687 Potential drug–drug interactions with cancer therapies should be checked when using ticagrelor or clopidogrel, since some pharmacokinetic-based drug–drug interactions via CYP450 may occur. When acute ischaemia is provoked by cancer therapy, alternative cancer therapies should be considered after a multidisciplinary team discussion. Some specific cancer treatments can have cardiotoxic vascular effects that can lead to ACS (Supplementary data online, Table S16). Following ACS, a review of the cancer medications is recommended, and any cancer drug associated with thrombosis and MI should be stopped. Cancer therapies that are not associated with MI can be restarted once revascularization (when indicated) has been completed and the patient is stabilized on ACS medical therapy without complications. Additional information can be found in the Supplementary data online, including Supplementary data online, Table S16 and in the 2022 ESC Guidelines on cardio-oncology.684

12.3.8 Coronavirus disease (COVID-19)

A section on the impact of Coronavirus disease (COVID-19) on ACS management is presented in the Supplementary data online. Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026