1 2020 ESC Guidelin es 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-seg- ment elevation of the European Society of Cardiology (ESC) ESC Guidelines ESC Guidelines Authors/Task Force Members: Jean-Philippe Collet* (Chairperson) [AQ7](France), Holger Thiele* (Chairperson) (Germany), Emanuele Barbato (Italy), Olivier Barthélémy (France), Johann Bauersachs (Germany), Deepak L. Bhatt (USA), Paul Dendale (Belgium), Maria Dorobantu (Romania), Thor Edvardsen (Norway), Thierry Folliguet (France), Chris P. Gale (UK), Martine Gilard (France), Alexander Jobs (Germany), Peter Jüni (Canada), Ekaterini Lambrinou (Cyprus), Basil S. Lewis (Israel), Julinda Mehilli (Germany), Emanuele Meliga (Italy), Béla Merkely (Hungary), Christian Mueller (Switzerland), Marco Roffi (Switzerland), Frans H. Rutten (Netherlands), Dirk Sibbing (Germany), George C.M. Siontis (Switzerland) Document Reviewers: Adnan Kastrati (CPG Review Coordinator) (Germany), Mamas A. Mamas (CPG Review Coordinator) (UK), Victor Aboyans (France), Dominick J. Angiolillo (USA), Hector Bueno (Spain), Raffaele Bugiardini (Italy), Robert A. Byrne (Ireland), Silvia Castelletti (Italy), Alaide Chieffo (Italy), Veronique Cornelissen (Belgium), Filippo Crea (Italy), Victoria Delgado (Netherlands), Heinz Drexel (Austria), Marek Gierlotka (Poland), Sigrun Halvorsen (Norway), Kristina Hermann Haugaa (Norway), Ewa A. Jankowska (Poland), Hugo A. Katus (Germany), Tim Kinnaird (UK), Jolanda Kluin (Netherlands), Vijay Kunadian (UK), Ulf Landmesser (Germany), Christophe Leclercq (France), Maddalena Lettino (Italy), Leena Meinila (Finland), Darren My- lotte (Ireland), Gjin Ndrepepa (Germany), Elmir Omerovic (Sweden), Roberto F. E. Pedretti (Ita- ly), Steffen E. Petersen (UK), Anna Sonia Petronio (Italy), Gianluca Pontone (Italy), Bogdan A. Popescu (Romania), Tatjana Potpara (Serbia), Kausik K. Ray (UK), Flavio Luciano Ribichini (Ita- ly), Dimitrios J. Richter (Greece), Evgeny Shlyakhto (Russian Federation), Iain A. Simpson (UK), Miguel Sousa-Uva (Portugal), Robert F. Storey (UK), Rhian M. Touyz (UK), Marco Valgimigli (Switzerland), Pascal Vranckx (Belgium), Robert W. Yeh (USA) The disclosure forms of all ex- perts involved in the development of these guidelines are available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background informa- tion and detailed discussion of the data that have provided the basis for the Guidelines see European Heart Journal online. * Corresponding authors: Jean-Philippe Collet, Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardio- logie, Hôpital Pitié-Salpêtrière (Assistance Publique- Hôpitaux de Paris) (AP-HP), 83, boulevard de l'Hôpital, 75013 Paris, France. Tel + 33 01 42 16 29 62, E-mail: [email protected]. Holger Thiele, Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig, Strümpellstr. 39, 04289 Leipzig, Germany. Tel: +49 341 865 1428, Fax: +49 341 865 1461, E- mail: [email protected]. ESC Committee for Practice Guidelines (CPG) and National Cardiac Societies document reviewers: listed in the Appendix. ESC entities having participated in the development of this document: Associations: Association for Acute CardioVascular Care (ACVC), Association of Cardiovascular Nursing & Allied Professions (AC- NAP), European Association of Cardiovascular Imaging (EACVI), European Association of Preventive Cardiology (EAPC), European © Copyrights 2020 Association of Percutaneous Cardiovascular Interventions (EAPCI), European Heart Rhythm Association (EHRA), Heart Failure As- sociation (HFA). Councils: Council for Cardiology Practice. Working Groups: Cardiovascular Pharmacotherapy, Cardiovascular Surgery, Coronary Pathophysiology and Microcirculation, Thrombosis. The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. No part of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of a written request to Oxford University Press, the publish- er of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC (journals.permis- [email protected]). Disclaimer. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge, and the evidence available at the time of their publication. The ESC is not responsible in the event of any contradiction, discrepancy and/or ambiguity between the ESC Guidelines and any other official recommendations or guidelines issued by the relevant public health authorities, in particular in relation to good use of healthcare or therapeutic strategies. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment, as well as in the determination and the implementation of preventive, diagnostic, or therapeutic medical strategies; however, the ESC Guidelines do not override, in any way whatsoever, the individual responsibility of health professionals to make appropriate and accurate decisions in consideration of each patient’s health condition and in consultation with that patient and, where appropri- ate and/or necessary, the patient’s caregiver. Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the relevant official updated recommendations or guidelines issued by the competent public health authori- ties, in order to manage each patient’s case in light of the scientifically accepted data pursuant to their respective ethical and professional obligations. It is also the health professional’s responsibility to verify the applicable rules and regulations relating to drugs and medical devices at the time of prescription. Keywords: Guidelines acute cardiac care acute coronary syndrome angioplasty anticoagulation antiplatelet apixa- ban aspirin atherothrombosis betablockers bleedings bivalirudin bypass surgery cangrelor chest pain unit clopidog- rel dabigatran diabetes dual antithrombotic therapy early invasive strategy edoxaban enoxaparin European Society of Cardiology fondaparinux glycoprotein IIb/IIIa inhibitors heparin high-sensitivity troponin minoca myocardial ischae- mia myocardial infarction nitrates non-ST-elevation myocardial infarction platelet inhibition prasugrel recommenda- tions revascularization rhythm monitoring rivaroxaban stent ticagrelor triple therapy unstable angina Table of contents •1. Abbreviations and acronyms 5 •2. 1 Preamble 7 •3. 2 Introduction 8 •4. 2.1 Definitions 8 •5. 2.1.1 Universal definition of myocardial infarction 8 •6. 2.1.1.1 Type 1 myocardial infarction 8 •7. 2.1.1.2 Type 2 myocardial infarction 9 •8. 2.1.1.3 Types 3–5 myocardial infarction 9 •9. 2.1.2 Unstable angina in the era of high-sensitivity cardiac troponin assays 9 •10. 2.2 Epidemiology 9 •11. 2.3 What is new? 9 •12. 2.4 Number and breakdown of classes of recommendations (Supplementary Data) 10 •13. 3 Diagnosis 10 © Copyrights 2020 •14. 3.1 Clinical presentation (Supplementary Data) 10 •15. 3.2 Physical examination (Supplementary Data) 10 •16. 3.3 Diagnostic tools 10 •17. 3.3.1 Electrocardiogram 10 •18. 3.3.2 Biomarkers: high-sensitivity cardiac troponin 11 •19. 3.3.2.1 Central laboratory vs. point-of-care 12 •20. 3.3.2.2 Other biomarkers 13 •21. 3.3.3 Rapid ‘rule-in’ and ‘rule-out’ algorithms 13 •22. 3.3.4 Observe 15 •23. 3.3.4.1 Caveats of using rapid algorithms 15 •24. 3.3.4.2 Confounders of cardiac troponin concentration 15 •25. 3.3.4.3 Practical guidance on how to implement the European Society of Cardiology 0 h/1 h algorithm 16 •26. 3.3.4.4 Avoiding misunderstandings: time to decision = time of blood drawrn-around time 16 •27. 3.3.5 Non-invasive imaging 17 •28. 3.3.5.1 Functional evaluation 17 •29. 3.3.5.2 Anatomical evaluation 17 •30. 3.4 Differential diagnosis 17 •31. 4 Risk assessment and outcomes 19 •32. 4.1 Electrocardiogram indicators (Supplementary Data) 19 •33. 4.2 Biomarkers 19 •34. 4.3 Clinical scores for risk assessment (Supplementary Data) 19 •35. 4.4 Bleeding risk assessment 20 •36. 4.5 Integrating ischaemic and bleeding risks 21 •37. 5 Pharmacological treatments 21 •38. 5.1 Antithrombotic treatment 21 •39. 5.1.1 Antiplatelet drugs and pre-treatment 23 •40. 5.1.1.1 Antiplatelet drugs and dual antiplatelet therapy 23 •41. 5.1.1.2 Pre-treatment 24 •42. 5.1.2 Peri-interventional anticoagulant treatment 26 •43. 5.1.3 Peri-interventional antiplatelet treatment 27 •44. 5.1.4 Post-interventional and maintenance treatment 27 •45. 5.2 Pharmacological treatment of ischaemia (Supplementary Data) 30 •46. 5.2.1 Supportive pharmacological treatment (Supplementary Data) 30 •47. 5.2.2 Nitrates and beta-blockers (Supplementary Data) 30 •48. 5.3 Managing oral antiplatelet agents in patients requiring long-termoral anticoagulants 30 •49. 5.3.1 Patients with atrial fibrillation without mechanical prosthetic heart valves ormoderate-to- severe mitral stenosis undergoing percutaneous coronary intervention or managedmedically (Sup‐ plementary Data) 30 © Copyrights 2020 •50. 5.3.2 Patients requiring vitamin K antagonists or undergoing coronary artery bypass surgery 32 •51. 5.4 Management of acute bleeding events (Supplementary Data) 34 •52. 5.4.1