august 2020 • European Heart Journal

2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)

Collet J-P, et al.

DOI: https://doi.org/10.1093/eurheartj/ehaa575

Content curated by:Clara Jasmins

Key message

The 2020 ESC Guidelines for the management of acute coronary syndrome without ST-segment elevation represents the official position of ESC about this topic. They took a comprehensive review of the published evidence and weighted and graded the recommendations according to predefined scales.

Analysis

Population

Patients with acute chest discomfort

Method

The Members of this Task Force were selected by the ESC, including representation from its relevant ESC sub-specialty groups. Selected experts in the field undertook a comprehensive review of the published evidence for management of a given condition according to ESC Committee for Practice Guidelines (CPG) policy. A critical evaluation of diagnostic and therapeutic procedures was performed, including assessment of the riskbenefit ratio. The level of evidence and the strength of the recommendation of particular management options were weighed and graded according to predefined scales, as outlined below.

Results

1. Diagnosis and risk stratification - It is recommended to base diagnosis and initial short-term risk stratification on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and laboratory results including hs-cTn. (I, B) - It is recommended to measure cardiac troponins with high-sensitivity assays immediately after admission and obtain the results within 60 min of blood sampling. (I, B) - It is recommended to obtain a 12-lead ECG within 10 min after first medical contact and to have it immediately interpreted by an experienced physician. (I, B) - It is recommended to obtain an additional 12-lead ECG in case of recurrent symptoms or diagnostic uncertainty. (I, C) - The ESC 0 h/1 h algorithm with blood sampling at 0 h and 1 h is recommended if an hs-cTn test with a validated 0 h/1 h algorithm is available. (I, B) - Additional testing after 3 h is recommended if the first two cardiac troponin measurements of the 0 h/1 h algorithm are not conclu- sive and the clinical condition is still suggestive of ACS. (I, B) - As an alternative to the ESC 0 h/1 h algorithm, it is recommended to use the ESC 0 h/2 h algorithm with blood sampling at 0 h and 2 h, if an hs-cTn test with a validated 0 h/2 h algorithm is available. (I, B) - Additional ECG leads (V3R, V4R, V7􏰀V9) are recommended if ongoing ischaemia is suspected when standard leads are inconclusive. (I, C) - For initial diagnostic purposes, it is not recommended to routinely measure additional biomarkers such as h-FABP or copeptin, in addition to hs-cTn (III, B) 2. Imaging - In patients presenting with cardiac arrest or haemodynamic instability of presumed cardiovascular origin, echocardiography is recom- mended and should be performed by trained physicians immediately following a 12-lead ECG. (I, C) - In patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with a suspected ACS, a non-invasive stress test (preferably with imaging) for inducible ischaemia or CCTA is recommended before deciding on an invasive approach. (I, B) - Echocardiography is recommended to evaluate regional and global LV function and to rule in or rule out differential diagnoses. (I, C) - CCTA is recommended as an alternative to ICA to exclude ACS when there is a low-to-intermediate likelihood of CAD and when cardiac troponin and/or ECG are normal or inconclusive. (I, A) 3. Monitoring - Continuous rhythm monitoring is recommended until the diagnosis of NSTEMI has been established or ruled out. (I, C) - It is recommended to admit NSTEMI patients to a monitored unit. (I, C) - Rhythm monitoring up to 24 h or to PCI (whichever comes first) is recommended in NSTEMI patients at low risk for cardiac arrhythmias. (I, C) - Rhythm monitoring for >24 h is recommended in NSTEMI patients at increased risk for cardiac arrhythmias. (I, C) 4. Recommendations on biomarker measurements for prognostic stratification - Beyond its diagnostic role, it is recommended to measure hs-cTn serially for the estimation of prognosis. (I, B) - The measurement of additional biomarkers, such as mid-regional pro-A-type natriuretic peptide, high-sensitivity C-reactive protein, mid-regional pro-adrenomedullin, GDF-15, copeptin, and h-FABP is not recommended for routine risk or prognosis assessment. (III, B) 5. Recommendations for antithrombotic treatment in non-ST-segment elevation acute coronary syndrome patients undergoing percuta- neous coronary intervention 5.1 Antiplatelet treatment - Aspirin is recommended for all patients without contraindications at an initial oral LD of 150-300 mg (or 75-250 mg i.v.), and at a MD of 75-100 mg o.d. for long-term treatment. (i, A) - 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. (I, A) - Prasugrel in P2Y12 receptor inhibitor-na ̈ıve patients proceeding to PCI (60 mg LD, 10 mg/d as standard dose, 5 mg/d for patients aged ≥75 years or with a body weight <60 kg). (I, B) - Ticagrelor irrespective of the planned treatment strategy (invasive or conservative) (180 mg LD, 90 mg b.i.d.). (I, B) - Clopidogrel (300-600 mg LD, 75 mg daily dose), only when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated. (I, C) - Treatment with GP IIb/IIIa antagonists in patients in whom coronary anatomy is not known and is not recommended (III, A) - It is not recommended to administer routine pre-treatment with a P2Y12 receptor inhibitor in patients in whom coronary anatomy is not known and an early invasive management is planned. (III, A) 5.2 Peri-interventional anticoagulant treatment - Parenteral anticoagulation is recommended for all patients, in addition to antiplatelet treatment, at the time of diagnosis and, especially, during revascularization procedures according to both ischaemic and bleeding risks (I, A) - UFH (weight-adjusted i.v. bolus during PCI of 70-100 IU/kg, or 50-70 IU/kg in combination with a GP IIb/IIIa inhibitor; activated clotting time target range of 250-350 s, or 200-250 s if a GP IIb/IIIa inhibitor is given) is recommended in patients undergoing PCI. (I, A) - In cases of medical treatment or logistical constraints for transferring the patient to PCI within the required time frame, fondaparinux is recommended and, in such cases, a single bolus of UFH is recommended at the time of PCI. (I, B) - It is recommended to select anticoagulation according to both ischaemic and bleeding risks, and according to the efficacy-safety profile of the chosen agent. (I, C) - Crossover of UFH and LMWH is not recommended. (III, B) 6. Recommendations for post-interventional and maintenance treatment in patients with non-ST-segment elevation acute coronary syndrome - In patients with NSTE-ACS treated with coronary stent implantation, DAPT with a P2Y12 receptor inhibitor on top of aspirin is rec- ommended for 12 months unless there are contraindications such as excessive risk of bleeding. (I, A) 7. Recommendations for anti-ischaemic drugs in the acute phase of non-ST-segment elevation acute coronary syndrome - Sublingual or i.v. nitrates and early initiation of beta-blocker treatment are recommended in patients with ongoing ischaemic symptoms and without contraindications. (I, C) - It is recommended to continue chronic beta-blocker therapy unless the patient is in overt heart failure. (I, C) - i.v. nitrates are recommended in patients with uncontrolled hypertension or signs of heart failure. (I, C) 8. Recommendations for combining antiplatelet agents and anticoagulants in non-ST-segment elevation acute coronary syndrome patients requiring chronic oral anticoagulation - Stroke prevention should be offered to AF patients with ≥1 non-sex CHA2DS2-VASc stroke risk factors (score of ≥1 in males or ≥2 in females). For patients with ≥2 non-sex stroke risk factors, OAC is recommended (I, A) 9. Patients undergoing coronary stenting 9.1 Anticoagulation - During PCI, additional parenteral anticoagulation is recommended, irrespective of the timing of the last dose of all NOACs and if INR is <2.5 in VKA-treated patients. (I, C) 9.2 Antiplatelet treatment - In patients with AF and CHA2DS2-VASc score ≥1 in men and ≥2 in women, after a short period of TAT (up to 1 week from the acute event), DAT is recommended as the default strategy using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel). (I, A) - Periprocedural DAPT administration consisting of aspirin and clopidogrel up to 1 week is recommended. (I, A) - Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. (I, B) - The use of ticagrelor or prasugrel as part of TAT is not recommended. (III, C) 10.Recommendations for coronary revascularization 10.1 Timing of invasive strategy - An immediate invasive strategy (<2 h) is recommended in patients with at least one of the following very high-risk criteria: • Haemodynamic instability or CS. • Recurrent or refractory chest pain despite medical treatment. • Life-threatening arrhythmias. • Mechanical complications of MI. • Heart failure clearly related to NSTE-ACS. • Presence of ST-segment depression >1 mm in ≥6 leads additional to ST-segment elevation in aVR and/or V1. (I, C) - An early invasive strategy within 24 h is recommended in patients with any of the following high-risk criteria: • Diagnosis of NSTEMI suggested by the diagnostic algorithm • Dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischaemia. • Transient ST-segment elevation. • GRACE risk score >140. (I, A) - A selective invasive strategy after appropriate ischaemia testing or detection of obstructive CAD by CCTA is recommended in patients considered at low risk. (I, A) 10.2 Technical aspects - Radial access is recommended as the standard approach, unless there are overriding procedural considerations. (I, A) - DES are recommended over bare-metal stents for any PCI irrespective of: • Clinical presentation. • Lesion type. • Planned non-cardiac surgery. • Anticipated duration of DAPT. • Concomitant anticoagulant therapy (I, A) - It is recommended to base the revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease severity [i.e. the distribution and angiographic lesion characteristics (e.g. SYNTAX score)], according to the principles for stable CAD. However, the decision on immediate PCI of the culprit stenosis does not require Heart Team consultation. (I, B) 11. Recommendations for myocardial infarction with non-obstructive coronary arteries - In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses. (I, C) - It is recommended to perform CMR in all MINOCA patients without an obvious underlying cause (I, B) - It is recommended to manage patients with an initial diagnosis of MINOCA and a final established underlying cause according to the disease-specific guidelines. (I, C) 12. Recommendations for non-ST-segment elevation acute coronary syndrome patients with heart failure or cardiogenic shock - Emergency coronary angiography is recommended in patients with CS complicating ACS. (I, B) - Emergency PCI of the culprit lesion is recommended for patients with CS due to NSTE-ACS, independent of the time delay from symptom onset, if the coronary anatomy is amenable to PCI (I, B) - Emergency CABG is recommended for patients with CS if the coronary anatomy is not amenable to PCI. (I, B) - It is recommended to perform emergency echocardiography without delay to assess LV and valvular function and exclude mechanical complications. (I, C) - In cases of haemodynamic instability, emergency surgical or catheter-based repair of mechanical complications of ACS is recommended, as decided by the Heart Team. (I, C) - Routine use of IABP in patients with CS and no mechanical complications due to ACS is not recommended (III, B) - Routine immediate revascularization of non-culprit lesions in NSTE-ACS patients with multivessel disease presenting with CS is not recommended.(III, B) 13. Recommendations for diabetes mellitus in non-ST-segment elevation acute coronary syndrome patients - It is recommended to screen all patients with NSTE-ACS for diabetes and to monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycaemia. (I, C) - Avoidance of hypoglycaemia is recommended. (I, B) 14. Recommendations for patients with chronic kidney disease and non-ST-segment elevation acute coronary syndrome 14.1 Risk stratification in CKD - 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 renal function. (I, C) - It is recommended to assess kidney function by eGFR in all patients. (I, C) 14.2 Myocardial revascularization in patients with CKD - Use of low or iso-osmolar contrast media (at lowest possible volume) are recommended in invasive strategies (I, A) 15. Recommendations for older persons with non-ST-segment elevation acute coronary syndrome - It is recommended to apply the same diagnostic strategies in older patients as for younger patient (I, B) - It is recommended to apply the same interventional strategies in older patients as for younger patients. (I, B) - The choice of antithrombotic agent and dosage, as well as secondary preventions, should be adapted to renal function, as well as spe- cific contraindications. (I, B) 16. It is recommended to base the revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease severity [i.e. the distribution and angiographic lesion characteristics (e.g. SYNTAX score)], according to the principles for stable CAD.350 However, the decision on immediate PCI of the culprit stenosis does not require Heart Team consultation. Recommendations for myocardial infarction with non-obstructive coronary arteries In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses. It is recommended to perform CMR in all MINOCA patients without an obvious underlying cause.370 It is recommended to manage patients with an initial diagnosis of MINOCA and a final established underlying cause according to the disease-specific guideline Recommendations for non-ST-segment elevation acute coronary syndrome patients with heart failure or cardiogenic shock 1. Diagnosis and risk stratification - It is recommended to base diagnosis and initial short-term risk stratification on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and laboratory results including hs-cTn. (I, B) - It is recommended to measure cardiac troponins with high-sensitivity assays immediately after admission and obtain the results within 60 min of blood sampling. (I, B) - It is recommended to obtain a 12-lead ECG within 10 min after first medical contact and to have it immediately interpreted by an experienced physician. (I, B) - It is recommended to obtain an additional 12-lead ECG in case of recurrent symptoms or diagnostic uncertainty. (I, C) - The ESC 0 h/1 h algorithm with blood sampling at 0 h and 1 h is recommended if an hs-cTn test with a validated 0 h/1 h algorithm is available. (I, B) - Additional testing after 3 h is recommended if the first two cardiac troponin measurements of the 0 h/1 h algorithm are not conclu- sive and the clinical condition is still suggestive of ACS. (I, B) - As an alternative to the ESC 0 h/1 h algorithm, it is recommended to use the ESC 0 h/2 h algorithm with blood sampling at 0 h and 2 h, if an hs-cTn test with a validated 0 h/2 h algorithm is available. (I, B) - Additional ECG leads (V3R, V4R, V7􏰀V9) are recommended if ongoing ischaemia is suspected when standard leads are inconclusive. (I, C) - For initial diagnostic purposes, it is not recommended to routinely measure additional biomarkers such as h-FABP or copeptin, in addition to hs-cTn (III, B) 2. Imaging - In patients presenting with cardiac arrest or haemodynamic instability of presumed cardiovascular origin, echocardiography is recom- mended and should be performed by trained physicians immediately following a 12-lead ECG. (I, C) - In patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin (preferably high sensitivity), but still with a suspected ACS, a non-invasive stress test (preferably with imaging) for inducible ischaemia or CCTA is recommended before deciding on an invasive approach. (I, B) - Echocardiography is recommended to evaluate regional and global LV function and to rule in or rule out differential diagnoses. (I, C) - CCTA is recommended as an alternative to ICA to exclude ACS when there is a low-to-intermediate likelihood of CAD and when cardiac troponin and/or ECG are normal or inconclusive. (I, A) 3. Monitoring - Continuous rhythm monitoring is recommended until the diagnosis of NSTEMI has been established or ruled out. (I, C) - It is recommended to admit NSTEMI patients to a monitored unit. (I, C) - Rhythm monitoring up to 24 h or to PCI (whichever comes first) is recommended in NSTEMI patients at low risk for cardiac arrhythmias. (I, C) - Rhythm monitoring for >24 h is recommended in NSTEMI patients at increased risk for cardiac arrhythmias. (I, C) 4. Recommendations on biomarker measurements for prognostic stratification - Beyond its diagnostic role, it is recommended to measure hs-cTn serially for the estimation of prognosis. (I, B) - The measurement of additional biomarkers, such as mid-regional pro-A-type natriuretic peptide, high-sensitivity C-reactive protein, mid-regional pro-adrenomedullin, GDF-15, copeptin, and h-FABP is not recommended for routine risk or prognosis assessment. (III, B) 5. Recommendations for antithrombotic treatment in non-ST-segment elevation acute coronary syndrome patients undergoing percuta- neous coronary intervention 5.1 Antiplatelet treatment - Aspirin is recommended for all patients without contraindications at an initial oral LD of 150-300 mg (or 75-250 mg i.v.), and at a MD of 75-100 mg o.d. for long-term treatment. (i, A) - 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. (I, A) - Prasugrel in P2Y12 receptor inhibitor-na ̈ıve patients proceeding to PCI (60 mg LD, 10 mg/d as standard dose, 5 mg/d for patients aged ≥75 years or with a body weight <60 kg). (I, B) - Ticagrelor irrespective of the planned treatment strategy (invasive or conservative) (180 mg LD, 90 mg b.i.d.). (I, B) - Clopidogrel (300-600 mg LD, 75 mg daily dose), only when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated. (I, C) - Treatment with GP IIb/IIIa antagonists in patients in whom coronary anatomy is not known and is not recommended (III, A) - It is not recommended to administer routine pre-treatment with a P2Y12 receptor inhibitor in patients in whom coronary anatomy is not known and an early invasive management is planned. (III, A) 5.2 Peri-interventional anticoagulant treatment - Parenteral anticoagulation is recommended for all patients, in addition to antiplatelet treatment, at the time of diagnosis and, especially, during revascularization procedures according to both ischaemic and bleeding risks (I, A) - UFH (weight-adjusted i.v. bolus during PCI of 70-100 IU/kg, or 50-70 IU/kg in combination with a GP IIb/IIIa inhibitor; activated clotting time target range of 250-350 s, or 200-250 s if a GP IIb/IIIa inhibitor is given) is recommended in patients undergoing PCI. (I, A) - In cases of medical treatment or logistical constraints for transferring the patient to PCI within the required time frame, fondaparinux is recommended and, in such cases, a single bolus of UFH is recommended at the time of PCI. (I, B) - It is recommended to select anticoagulation according to both ischaemic and bleeding risks, and according to the efficacy-safety profile of the chosen agent. (I, C) - Crossover of UFH and LMWH is not recommended. (III, B) 6. Recommendations for post-interventional and maintenance treatment in patients with non-ST-segment elevation acute coronary syndrome - In patients with NSTE-ACS treated with coronary stent implantation, DAPT with a P2Y12 receptor inhibitor on top of aspirin is rec- ommended for 12 months unless there are contraindications such as excessive risk of bleeding. (I, A) 7. Recommendations for anti-ischaemic drugs in the acute phase of non-ST-segment elevation acute coronary syndrome - Sublingual or i.v. nitrates and early initiation of beta-blocker treatment are recommended in patients with ongoing ischaemic symptoms and without contraindications. (I, C) - It is recommended to continue chronic beta-blocker therapy unless the patient is in overt heart failure. (I, C) - i.v. nitrates are recommended in patients with uncontrolled hypertension or signs of heart failure. (I, C) 8. Recommendations for combining antiplatelet agents and anticoagulants in non-ST-segment elevation acute coronary syndrome patients requiring chronic oral anticoagulation - Stroke prevention should be offered to AF patients with ≥1 non-sex CHA2DS2-VASc stroke risk factors (score of ≥1 in males or ≥2 in females). For patients with ≥2 non-sex stroke risk factors, OAC is recommended (I, A) 9. Patients undergoing coronary stenting 9.1 Anticoagulation - During PCI, additional parenteral anticoagulation is recommended, irrespective of the timing of the last dose of all NOACs and if INR is <2.5 in VKA-treated patients. (I, C) 9.2 Antiplatelet treatment - In patients with AF and CHA2DS2-VASc score ≥1 in men and ≥2 in women, after a short period of TAT (up to 1 week from the acute event), DAT is recommended as the default strategy using a NOAC at the recommended dose for stroke prevention and a single oral antiplatelet agent (preferably clopidogrel). (I, A) - Periprocedural DAPT administration consisting of aspirin and clopidogrel up to 1 week is recommended. (I, A) - Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. (I, B) - The use of ticagrelor or prasugrel as part of TAT is not recommended. (III, C) 10.Recommendations for coronary revascularization 10.1 Timing of invasive strategy - An immediate invasive strategy (<2 h) is recommended in patients with at least one of the following very high-risk criteria: • Haemodynamic instability or CS. • Recurrent or refractory chest pain despite medical treatment. • Life-threatening arrhythmias. • Mechanical complications of MI. • Heart failure clearly related to NSTE-ACS. • Presence of ST-segment depression >1 mm in ≥6 leads additional to ST-segment elevation in aVR and/or V1. (I, C) - An early invasive strategy within 24 h is recommended in patients with any of the following high-risk criteria: • Diagnosis of NSTEMI suggested by the diagnostic algorithm • Dynamic or presumably new contiguous ST/T-segment changes suggesting ongoing ischaemia. • Transient ST-segment elevation. • GRACE risk score >140. (I, A) - A selective invasive strategy after appropriate ischaemia testing or detection of obstructive CAD by CCTA is recommended in patients considered at low risk. (I, A) 10.2 Technical aspects - Radial access is recommended as the standard approach, unless there are overriding procedural considerations. (I, A) - DES are recommended over bare-metal stents for any PCI irrespective of: • Clinical presentation. • Lesion type. • Planned non-cardiac surgery. • Anticipated duration of DAPT. • Concomitant anticoagulant therapy (I, A) - It is recommended to base the revascularization strategy (ad hoc culprit lesion PCI/multivessel PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease severity [i.e. the distribution and angiographic lesion characteristics (e.g. SYNTAX score)], according to the principles for stable CAD. However, the decision on immediate PCI of the culprit stenosis does not require Heart Team consultation. (I, B) 11. Recommendations for myocardial infarction with non-obstructive coronary arteries - In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to differentiate true MINOCA from alternative diagnoses. (I, C) - It is recommended to perform CMR in all MINOCA patients without an obvious underlying cause (I, B) - It is recommended to manage patients with an initial diagnosis of MINOCA and a final established underlying cause according to the disease-specific guidelines. (I, C) 12. Recommendations for non-ST-segment elevation acute coronary syndrome patients with heart failure or cardiogenic shock - Emergency coronary angiography is recommended in patients with CS complicating ACS. (I, B) - Emergency PCI of the culprit lesion is recommended for patients with CS due to NSTE-ACS, independent of the time delay from symptom onset, if the coronary anatomy is amenable to PCI (I, B) - Emergency CABG is recommended for patients with CS if the coronary anatomy is not amenable to PCI. (I, B) - It is recommended to perform emergency echocardiography without delay to assess LV and valvular function and exclude mechanical complications. (I, C) - In cases of haemodynamic instability, emergency surgical or catheter-based repair of mechanical complications of ACS is recommended, as decided by the Heart Team. (I, C) - Routine use of IABP in patients with CS and no mechanical complications due to ACS is not recommended (III, B) - Routine immediate revascularization of non-culprit lesions in NSTE-ACS patients with multivessel disease presenting with CS is not recommended.(III, B) 13. Recommendations for diabetes mellitus in non-ST-segment elevation acute coronary syndrome patients - It is recommended to screen all patients with NSTE-ACS for diabetes and to monitor blood glucose levels frequently in patients with known diabetes or admission hyperglycaemia. (I, C) - Avoidance of hypoglycaemia is recommended. (I, B) 14. Recommendations for patients with chronic kidney disease and non-ST-segment elevation acute coronary syndrome 14.1 Risk stratification in CKD - 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 renal function. (I, C) - It is recommended to assess kidney function by eGFR in all patients. (I, C) 14.2 Myocardial revascularization in patients with CKD - Use of low or iso-osmolar contrast media (at lowest possible volume) are recommended in invasive strategies (I, A) 15. Recommendations for older persons with non-ST-segment elevation acute coronary syndrome - It is recommended to apply the same diagnostic strategies in older patients as for younger patient (I, B) - It is recommended to apply the same interventional strategies in older patients as for younger patients. (I, B) - The choice of antithrombotic agent and dosage, as well as secondary preventions, should be adapted to renal function, as well as specific contraindications. (I, B) 16. Recommendations for lifestyle managements after non-ST-segment elevation acute coronary syndrome - Improvement of lifestyle factors in addition to appropriate pharmacological management is recommended in order to reduce all- cause and cardiovascular mortality and morbidity and improve health-related quality of life. (I, A) - Cognitive behavioural interventions are recommended to help individuals achieve a healthy lifestyle. (I, A) - Multidisciplinary exercise-based cardiac rehabilitation is recommended as an effective means for patients with CAD to achieve a healthy lifestyle and manage risk factors in order to reduce all-cause and cardiovascular mortality and morbidity, and improve health-related quality of life. (I, A) - Involvement of multidisciplinary healthcare professionals (cardiologists, general practitioners, nurses, dieticians, physiotherapists, psy- chologists, pharmacists) is recommended in order to reduce all-cause and cardiovascular mortality and morbidity, and improve health-related quality of life. (I, A) - Psychological interventions are recommended to improve symptoms of depression in patients with CAD in order to improve health- related quality of life. (I, B) - Annual influenza vaccination is recommended for patients with CAD, especially in the older person, in order to improve morbidity (I, B) 17. Recommendations for pharmacological long-term management after non-ST-segment elevation acute coronary syndrome (excluding antithrombotic treatments) 17.1 Lipid-lowering drugs - Statins are recommended in all NSTE-ACS patients. The aim is to reduce LDL-C by ≥50% from baseline and/or to achieve LDL-C <1.4 mmol/L (<55 mg/dL) (I, A) - If the LDL-C goalf is not achieved after 4􏰀6 weeks with the maximally tolerated statin dose, combination with ezetimibe is recommended (I, B) - If the LDL-C goalf is not achieved after 4􏰀6 weeks despite maximally tolerated statin therapy and ezetimibe, the addition of a PCSK9 inhibitor is recommended. (I; B) 17.2 ACE inhibitors or ARBs - ACE inhibitors (or ARBs in cases of intolerance to ACE inhibitors) are recommended in patients with heart failure with reduced LVEF (<40%), diabetes, or CKD unless contraindicated (e.g. severe renal impairment, hyperkalaemia, etc.) in order to reduce all-cause and cardiovascular mortality and cardiovascular morbidity. (I, A) 17.3 Beta-blockers - Beta-blockers are recommended in patients with systolic LV dysfunction or heart failure with reduced LVEF (<40%). (I, A) 17.4 MRAs - MRAs are recommended in patients with heart failure with reduced LVEF (<40%) in order to reduce all-cause and cardiovascular mortality and cardiovascular morbidity. (I, A) 17.5 Proton pump inhibitors - Concomitant use of a proton pump inhibitor is recommended in patients receiving aspirin monotherapy, DAPT, DAT, TAT, or OAC monotherapy who are at high risk of gastrointestinal bleeding in order to reduce the risk of gastric bleeds. (I, A)

Abstract

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