ESC guidelines for all acute coronary syndromes published

Cardiovascular events are the number one cause of death. Guidelines for all acute coronary syndromes have been published just in time for the 2023 ESC Congress.

Guidelines for the treatment of unstable angina and myocardial infarction

The guidelines contain recommendations for the treatment of unstable angina and all types of myocardial infarction.

“Time is critical in acute coronary syndromes. When an artery supplying the heart with blood becomes blocked, the quicker we open the artery and restore flow, the less damage that occurs to the heart muscle,” says Prof Robert Byrne, Director of Cardiology and Professor of Cardiovascular Research at the Mater Private Network and RCSI University, Dublin, Ireland.

Chest pain that lasts longer than 15 minutes and/or recurs within an hour should be taken seriously. In such cases, an emergency call should be made immediately. Other symptoms include sweating, pain in the shoulder or arm, and indigestion.

Heart disease is the leading cause of death in both men and women. A common misconception is that acute coronary syndromes primarily affect men. However, women are also at risk and should seek medical help immediately if they experience symptoms. Alarmingly, several studies suggest that acute coronary syndromes are under-recognised and under-treated in women, even though women and men should generally receive the same treatments. Evidence-based therapy is essential, says Prof. Borja Ibanez of the National Centre for Cardiovascular Research (Spanish acronym: CNIC) and the Fundación Jiménez Díaz University Hospital-CIBERCV, Madrid, Spain.

The heart needs a constant supply of blood to function normally. However, blood flow can suddenly decrease or stop if a clot forms in an artery supplying the heart muscle, which is classified as acute coronary syndrome. The subtypes of acute coronary syndrome are defined according to the severity of the circulatory disturbance and its consequences: It is unstable angina (when there is no irreversible damage to the heart muscle) or myocardial infarction (heart attack) - when irreversible loss of the muscle occurs. In myocardial infarction, a further distinction is made between complete and partial blockages. Prof Ibanez emphasises:

"One of the key aims of these guidelines is to highlight that acute coronary syndromes encompass a spectrum of conditions. Some patients have mild symptoms while others become critically ill very quickly. Despite this, much of the management follows the same principles, and this document provides a comprehensive overview."

The guidelines provide detailed advice on treatment, including medications such as blood thinners (anticoagulants and antiplatelet agents). Most patients receive a coronary angiogram. If this shows that an artery supplying the heart is completely blocked, a stent should be inserted through a catheter in the wrist at a specialised centre. Patients in geographically remote areas without a specialised centre may receive an intravenous clot-busting drug instead. If there is no complete blockage, stent insertion, open bypass surgery, or drug therapy alone may be considered.

Long-term treatment after acute coronary syndrome is crucial

After an acute coronary syndrome, long-term treatment is crucial as patients are at increased risk of a recurrence of a cardiovascular event. Treatment includes medications such as antiplatelet agents and continuous control of cholesterol levels.

Patients should participate in a supervised cardiac rehabilitation programme where they are encouraged to adopt a healthy lifestyle, including higher activity levels and a healthier diet, smoking cessation, and where appropriate, measures to manage psychosocial stress. “This will reduce the chances of recurrent events and improve quality of life,” says Prof Byrne. As some patients who suffer a heart attack have an increased risk of developing heart failure, this can be reduced with additional medication.

Cardiovascular events and cancer: what to watch out for?

The guidelines also include a new section on the treatment of acute coronary syndromes in patients with cancer. Cancer patients are at increased risk of acute coronary syndromes due to risk factors such as smoking, type of cancer and treatment with chemotherapy and radiotherapy.

The number of cancers continues to increase, but more patients with cancer are surviving thanks to better treatments; the main cause of death is cardiovascular disease. People with cancer are at high risk of bleeding, and the guidelines say to consider this when making treatment decisions. The guidelines recommend an invasive strategy (e.g. angiography and insertion of a stent) in patients with cancer whose survival is estimated to be at least 6 months. Temporary interruption of cancer therapy is recommended if it is suspected to be a cause of acute coronary syndrome.

In addition, the guidelines emphasise that patients should be actively involved in therapy decisions. In doing so, the individual needs and preferences of the patients should be taken into account. In addition, information about possible adverse events, radiation exposure and alternative options must of course be provided.

  1. ESC press release: "First ESC Guidelines covering all acute coronary syndromes published today", 25 August 2023.