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The new ESC acute coronary syndrome guideline and its impact in the CPU and emergency department setting

Die neue ESC-Leitlinie zum akuten Koronarsyndrom und ihre Auswirkungen auf die Chest Pain Unit und zentrale Notaufnahme

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Abstract

The new guideline on acute coronary syndrome (ACS) of the European Society of Cardiology (ESC) replaces two separate guidelines on ST-elevation myocardial infarction (STEMI) and non-ST-elevation (NSTE) ACS. This change of paradigm reflects the experts view that the ACS is a continuum, starting with unstable angina and ending in cardiogenic shock or cardiac arrest due to severe myocardial ischemia. Secondary, partly non-atherosclerotic-caused myocardial infarctions (“type 2”) are not integrated in this concept.

With respect to acute care in the setting of emergency medicine and the chest pain unit structures, the following new aspects have to be taken into account:

1. New procedural approach as “think A.C.S.” meaning “abnormal ECG,” “clinical context,” and “stable patient”

2. New recommendation regarding a holistic approach for frail patients

3. Revised recommendations regarding imaging and timing of invasive strategy in suspected NSTE-ACS

4. Revised recommendations for antiplatelet and anticoagulant therapy in STEMI

5. Revised recommendations for cardiac arrest and out-of-hospital cardiac arrest

6. Revised recommendations for in-hospital management (starting in the CPU/ED) and ACS comorbid conditions

In summary, the changes are mostly gradual and are not based on extensive new evidence, but more on focused and healthcare process-related considerations.

Zusammenfassung

Die neue Leitlinie zum akuten Koronarsyndrom (ACS) der Europäischen Gesellschaft für Kardiologie (ESC) ersetzt 2 separate Leitlinien zum ST-Hebungs-Infarkt („ST-elevation myocardial infarction“, STEMI) und zum ACS ohne ST-Hebungen („non-ST-elevation“, NSTE-ACS). Dieser Paradigmenwechsel spiegelt die Expertenperspektive wider, dass das ACS ein Kontinuum darstellt, das mit einer instabilen Angina pectoris beginnt und mit einem kardiogenen Schock oder Herzstillstand aufgrund einer schweren Myokardischämie endet. Sekundäre, teilweise nichtatherosklerotisch bedingte Myokardinfarkte („Typ 2“) sind in dieses Konzept nicht integriert. Im Hinblick auf die Akutversorgung im Rahmen der Notfallmedizin und der Chest-Pain-Unit-Strukturen (CPU) sind folgende neue Aspekte zu berücksichtigen:

1. Neuer prozessualer Ansatz als „think A.C.S.“, d. h. „abnormales EKG“, „klinischer Kontext“ und „stabiler Patient“

2. Neue Empfehlung für einen ganzheitlichen Ansatz bei gebrechlichen Patienten

3. Überarbeitete Empfehlungen zur Bildgebung und zum Zeitpunkt der invasiven Strategie bei Verdacht auf NSTE-ACS

4. Überarbeitete Empfehlungen zur Thrombozytenaggregationshemmer- und Antikoagulanzientherapie bei STEMI

5. Revidierte Empfehlungen für Herzstillstand und außerklinischen Herzstillstand

6. Überarbeitete Empfehlungen für das Management im Krankenhaus (beginnend in der Notaufnahme/CPU) und für ACS-Komorbiditäten

Zusammenfassend lässt sich sagen, dass die Änderungen größtenteils schrittweise erfolgen und nicht auf massiven neuen Erkenntnissen beruhen, sondern eher auf gezielten und prozessbezogenen Überlegungen zum Versorgungsprozess.

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Authors and Affiliations

  1. Notfall- und Akutmedizin mit Chest Pain Units, Charité—Universitätsmedizin Berlin, Campus Mitte und Virchow-Klinikum, Charitéplatz 1, 10117, Berlin, Germany

    Martin Möckel FESC, FAHA

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  1. Martin Möckel FESC, FAHA
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Correspondence to Martin Möckel FESC, FAHA.

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Conflict of interest

M. Möckel declares speakers honoraria and consulting fees from BRAHMS GmbH, Roche Diagnostics and AstraZeneca and research support from Roche Diagnostics.

For this review article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.

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Möckel, M. The new ESC acute coronary syndrome guideline and its impact in the CPU and emergency department setting. Herz (2024). https://doi.org/10.1007/s00059-024-05241-6

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