Table 1.
Comparative overview and key changes in the 2023 ESC Guidelines for Acute Coronary Syndromes.
| Topic | Previous ACS Guidelines | 2023 ACS Guidelines | Significance of Change |
|---|---|---|---|
| Invasive Treatment in NSTE-ACS | An early invasive strategy within 24 h is recommended in patients with any of the following high-risk criteria: | An early invasive strategy within 24 h should be considered in patients with at least one of the following high-risk criteria:
|
Shift from Class I to Class IIa, reflecting real-world challenges in rapid patients’ referral and lack of conclusive superiority of a routine early invasive strategy. |
| Pre-treatment in STEMI | A potent P2Y12 inhibitor (prasugrel or ticagrelor), or clopidogrel if these are not available or are contraindicated, is recommended before (or at latest at the time of) PCI, and maintained over 12 months, unless there are contraindications such as excessive risk of bleeding (Class I LoE A) [2] |
Pre-treatment with a P2Y12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy (Class IIb LoE B) |
Pre-treatment of STEMI may be considered but should not represent a routine approach. |
| Multivessel Treatment Strategies | (A) Routine immediate revascularization of non-culprit lesions in NSTE-ACS patients with multivessel disease presenting with CS is not recommended (Class III LoE B) [3] | (A) Staged PCI of non-IRA should be considered (Class IIa LoE C) | Upgrade to Class I, aligning with evidence from recent trials, with the exception of a cardiogenic shock presentation. |
| (B) Routine revascularization of non-IRA lesions should be considered in STEMI patients with multivessel disease before hospital discharge (Class IIa LoE A) [2] |
(B) Complete revascularization is recommended either during the index PCI procedure or within 45 days (Class I LoE A) |
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| (C) Complete revascularization during index PCI may be considered in NSTE-ACS patients with multi- vessel disease (Class IIb LoE B) [3] | (C) In patients presenting with NSTE-ACS and MVD, complete revascularization should be considered, preferably during the index procedure (Class IIa LoE C) |
||
| Anatomy vs. Physiology for Non-Culprit Lesions in STEMI | No clear indication of how to guide non-IRA lesions’ revascularization | It is recommended that the PCI of the non-IRA is based on angiographic severity (Class I LoE B) |
Decision mostly driven by angiographic severity. Not recommended using FFR during index STEMI procedure. |
| Role of non-invasive Imaging | In patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with suspected ACS, a non-invasive stress test (preferably with imaging) for inducible ischaemia or CCTA is recommended before deciding on an invasive approach (Class I LoE B) [3] |
In patients with suspected ACS, non-elevated (or uncertain) hs-cTn, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered (Class IIa LoE A) # |
Non-invasive imaging is no more recommended on a routine base, but should be considered in patients with a dubious presentation. |
| Role of intracoronary imaging | Intracoronary imaging should be considered to diagnose SCAD if suspected (Class IIa LoE C) [3] |
Intravascular imaging should be considered to guide PCI (Class IIa LoE A) § |
No change in class of recommendation but broader application of intracoronary imaging to guide PCI. This reflects the recent influx of data demonstrating significant improvements in patient outcomes when intracoronary imaging guides PCI. |
| Antiplatelet Therapy Modulation | A P2Y12 receptor inhibitor is recommended in addition to aspirin and maintained over 12 months unless there are contraindications or an excessive risk of bleeding (Class I LoE A) [3] |
In all ACS patients, a P2Y12 receptor inhibitor is recommended in addition to aspirin, given as an initial oral LD followed by an MD for 12 months unless there is HBR (Class I LoE A) * |
No change in recommendations irrespective of the accumulating evidence of shorter DAPT especially in HBR. A standardized approach is advised, which should or may be nuanced based on patients’ characteristics. No recommendations for a routine treatment personalization. |
| Colchicine | Not prominently featured | Low-dose colchicine (0.5 mg once a day) may be considered, particularly if other risk factors are insufficiently controlled or if recurrent cardiovascular disease events occur under optimal therapy (Class IIb LoE A) |
New recommendation for anti-inflammatory agents to target secondary prevention. |
| Adherence boosting strategies and polypill | Not prominently featured | A polypill should be considered as an option to improve adherence and outcomes in secondary prevention after ACS (Class IIa LoE B) |
New recommendation for the implementation of a polypill, with more attention to adherence-boosting strategies. |
ACS: acute coronary syndrome; CCTA: Coronary Computed Tomography Angiography; FFR: Fractional Flow Reserve; GRACE: Global Registry of Acute Coronary Events; HBR: High Bleeding Risk; hs-cTn: High-Sensitivity Cardiac Troponin; IRA: Infarct-Related Artery; LD: loading dose; LoE: level of evidence; MD: maintenance dose; NSTE-ACS: Non-ST-elevation acute coronary syndrome; NSTEMI: Non-ST-elevation myocardial infarction; PCI: percutaneous coronary intervention; STEMI: ST-elevation myocardial infarction. # In patients with a working diagnosis of MINOCA cardiac magnetic resonance (CMR) imaging is recommended after invasive angiography if the final diagnosis is not clear (Class I LoE B). § Intravascular imaging (preferably optical coherence tomography) may be considered in patients with ambiguous culprit lesions. (Class IIb LoE C). * Deviations (i.e., abbreviated DAPT or DAPT de-escalation) from this default strategy could be adopted based on clinical scenario (see the text).