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months unless there are concerns regarding HBR. Regarding P2Y12 receptor inhibitor choice, prasugrel and ticagrelor are recommended in preference to clopidogrel, and prasugrel should be considered in preference to ticagrelor for ACS patients who undergo PCI. Pre-treatment (i.e. treatment with a P2Y12 receptor inhibitor prior to coronary angiography) in patients with NSTE-ACS is not recommended routinely but may be considered for patients with STEMI undergoing PPCI. Parenteral anticoagulation is recommended for all patients at the time of diagnosis. Discontinuation of parenteral anticoagulation should be considered immediately after the invasive procedure. Some patients with ACS will also have an indication for long-term OAC, most commonly AF. In these patients, TAT for up to 1 week, followed by DAT using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel), is recommended as the default strategy. ACS with unstable presentation A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST elevation (or ST elevation equivalents), whereas routine immediate angiography is not recommended in patients with an ECG without persistent ST elevation (or equivalents). Temperature control (i.e. continuous monitoring of core temperature and active prevention of fever [i.e. >37.7°C]) is recommended in patients with OHCA who remain unresponsive after ROSC. In patients with CS complicating ACS, emergency coronary angiography is recommended, whereas the routine use of IABP in ACS patients with CS and no mechanical complications is not. Early care Following reperfusion, it is recommended to admit high-risk ACS patients, including all STEMI patients, to a CCU/ICCU. ECG monitoring for arrhythmias and ST-segment changes is recommended for at least 24 h after symptom onset in all high-risk patients with ACS. It is recommended that all hospitals participating in the care of high-risk ACS patients have an ICCU/CCU equipped to provide all required aspects of care including treatment of ischaemia, severe HF, arrhythmias, and common comorbidities. It is also recommended that the LVEF is determined before hospital discharge in all patients with ACS. Discharge of high-risk ACS patients within 48–72 h should be considered in selected patients if early rehabilitation and adequate follow-up are arranged. Technical aspects during PPCI Routine radial access and use of DES are the standard of care during PCI for ACS. Intravascular imaging should be considered to guide PCI and may be considered in patients with ambiguous culprit lesions. Routine thrombus aspiration is not recommended. CABG should be considered in patients with an occluded IRA when PCI is not feasible or unsuccessful and there is a large area of myocardium in jeopardy. In patients presenting with SCAD, 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. Management of patients with MVD For patients with MVD, 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. For patients with MVD presenting with CS, IRA-only PCI during the index procedure is recommended. For patients with STEMI undergoing PPCI, complete revascularization is recommended either during the index PCI or within 45 days. In patients presenting with NSTE-ACS and MVD, complete revascularization should be considered, preferably during the index procedure. For patients with STEMI, it is recommended that decisions regarding PCI of non-IRA are based on angiographic severity, whereas for patients with NSTE-ACS, functional invasive evaluation of non-IRA severity during the index procedure may be considered.

MINOCA The term MINOCA refers to the situation where patients present with symptoms suggestive of ACS and demonstrate troponin elevation and non-obstructive coronary arteries at the time of coronary angiography, i.e. coronary artery stenosis <50% in any major epicardial vessel. MINOCA is best considered as a working diagnosis that encompasses a heterogenous group of underlying causes (both cardiac and extra-cardiac) and is found in 1–14% of patients with ACS. In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to determine the underlying cause. CMR imaging is a key diagnostic tool in patients with a working diagnosis of MINOCA. Special patient subsets Chronic kidney disease: moderate to severe CKD is present in >30% of ACS patients. These patients receive less interventional and pharmacological treatment and have a worse prognosis in comparison to patients with normal kidney function. It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as for patients with normal kidney function. Older adults: in general, older adults should undergo the same diagnostic and treatment strategies, including invasive angiography and revascularization, as younger patients. Patients with cancer: management of ACS in patients with cancer can be challenging for several reasons, including frailty, increased bleeding risk, thrombocytopaenia, and increased thrombotic risk. An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months. A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (with expected survival <6 months) and/or very high bleeding risk. Long-term treatment Secondary prevention after ACS should be offered to every patient and should start as early as possible after the index event. This includes cardiac rehabilitation, lifestyle management, and pharmacological treatment, and has been shown to both increase quality of life and decrease morbidity and mortality.

Patient perspectives Some of the key first steps in the timely diagnosis and treatment of ACS are reliant on a comprehensive assessment of symptoms. An incomplete history or poorly elicited symptoms can result in delay or misdiagnosis. Patient-centred care is recommended as a critical tenet of routine clinical management and involves consideration of a patient’s physical, emotional, and psychological needs. The provision of care that is respectful of, and responsive to, individual patient preferences, needs and values, is important in the management of patients with ACS. It is recommended, as much as possible, to include ACS patients in decision-making. Preparing for discharge begins on admission. Educating and informing the patient using the teach back method and educationally appropriate material should be integrated into the patient care pathway. Quality indicators Acute coronary syndrome QIs aim to audit practice and improve clinical outcomes in real-life patients by demonstrating the gap between optimal guideline-based treatment and actual care of ACS patients. Subsequent measures to improve QI attainment can be implemented based on the local, regional, and global assessment of QIs. Downloaded from academic.oup.com/eurheartj/article/44/38/3720/7243210 by guest on 07 October 2026