New ESC guidelines for the management of acute coronary syndrome (ACS) patients presenting with non-STEMI, while similar to Australian guidelines are more “aggressive,” a leading cardiologist says.
Under the guidelines, released at the ESC 2011 Congress held in Paris last week, prasugrel was recommended for P2Y12 inhibitor-naive patients in whom coronary anatomy was known and who were undergoing PCI unless there was a high risk of life-threatening bleeding or other contraindications.
Ticagrelor was recommended for all patients at moderate to high risk of ischaemic events, regardless of initial treatment strategy and including those pre-treated with clopidogrel, which the taskforce advised should be discontinued when ticagrelor was commenced.
David Brieger, professor of cardiology at the University of Sydney, said the new guidelines, concurrently published in the European Heart Journal, may influence Australian practice, describing the recommendations for prasugrel and ticagrelor as “more aggressive.”
Professor Brieger, also head of coronary care and coronary interventions at Sydney’s Concord Hospital, said recommendations to use high-sensitivity troponin assays also reflected the 2011 National Heart Foundation of Australian/Cardiac Society of Australia and New Zealand Guidelines for the Management of Acute Coronary Syndromes.
However, a rapid rule-out protocol within zero to three hours of symptoms was a stronger recommendation in comparison, he said.
“That’s a bit more aggressive than us again. I think we are suggesting that there should be a troponin that is done at least three hours after the onset of symptoms.”
Professor Brieger said a recommendation to use the Can Rapid risk stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA guidelines (CRUSADE) bleeding risk score to estimate the risk of in-hospital bleeding, also reflected Australian guidelines.
“It’s nice to see an attempt to arrive at a consensus around bleeding risk scores and the difficulty integrating them into clinical practice because many of the patients that have high bleeding risk are also at high ischemic risk,” he said.
Proton pump inhibitors, although “preferably not omeprazole,” was recommended for patients taking anticoagulants with a history of gastrointestinal bleeding or peptic ulcers and was deemed appropriate for patients with multiple other risk factors.
Coronary CT angiography should be considered as an alternative to invasive angiography to exclude ACS when there is low to intermediate likelihood of coronary artery disease and when troponin and ECG are inconclusive, the guideline taskforce recommended.
To access the full guidelines click here