This article summarises the 2023 ESC guidelines for ACS, focusing on changes, patient management, diagnostic strategies, interventional cardiology, secondary prevention, MINOCA, and patient engagement, while highlighting the need for more diverse clinical trial participation.

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The main cause of death globally is cardiovascular disease, particularly ischaemic heart disease. International standards provide suggestions for the best patients' evidence-based treatment. The European Society of Cardiology (ESC) 2023 Guidelines for Acute Coronary Syndromes were released. ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina have been grouped together for the first time in new ESC guidelines for the management of acute coronary syndromes (ACS). Here is an overview of the most important suggestions below.

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What has changed in the 2023 ACS guidelines?

1. For the first time, a comprehensive "ACS" guideline covering unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI) has been released.
2. Consider ACS at first evaluation:

• A- Abnormal ECG?
• C-Clinical context?
• S-Stable patient?

3. Comprehensive patient treatment is emphasised from the time of admission till follow-up.
4. To enable a thorough assessment and care of patients with ACS, the idea of working diagnostic to final diagnosis is established.
5. Long-term patient management is also emphasised.
6. The guideline offers patient insights for the first time thanks to patient participation as a task force member.

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How does it impact interventional cardiology?

1. The focus of the revised recommendations is on complete therapy from the beginning of symptoms through management and follow-up.
2. Patients with NSTEACS are categorised as:

• Very high risk
• High-risk
• Non-high risk

Patients with a working diagnosis of NSTE-ACS and any of the following extremely high-risk criteria are urged to have an emergency (i.e. as soon as feasible) angiography and PCI if needed:

1. Haemodynamic instability or cardiogenic shock
2. Recurrent or persistent chest pain resistant to medical treatment
3. Acute heart failure presumed secondary to ongoing myocardial ischaemia
4. Life-threatening arrhythmias or cardiac arrest after presentation
5. Mechanical complications
6. Recurrent dynamic ECG changes suggestive of ischaemia (especially with intermittent ST-elevation elevation)

In patients with a working diagnosis of NSTE-ACS and any of the following high-risk criteria, an early invasive approach is routine invasive angiography (and PCI if necessary) within 24 hours of presentation:

1. A verified NSTEMI diagnosis based on the most recent ESC hs-cTn approved methodologies
2. Dynamic alterations in the ST-segment or T-wave
3. A transient increase in the ST segment
4. A GRACE risk score of 140 or higher

Consider antithrombotic therapy:

1. Dual antiplatelet therapy for 12 months is advised as a standard course of action. Alternative regimens can be used based on bleeding and ischaemic risks.
2. In patients who are event-free after 3–6 months of DAPT and who are not at high ischaemic risk, single antiplatelet therapy (preferably with a P2Y12 receptor inhibitor) should be considered.
3. In high-bleeding risk patients, aspirin or P2Y12 receptor inhibitor monotherapy after 1 month of DAPT may be considered.
4. Routine pre-treatment with a P2Y12 receptor inhibitor is not recommended in NSTE-ACS patients in whom coronary anatomy is not known and early invasive management (<24 hours) is planned.

Consider revascularisation:

1. In STEMI, complete revascularisation is advised either during the initial PCI procedure or within 45 days.
2. In patients with spontaneous coronary artery dissection, PCI is only advised for those who have symptoms and signs of ongoing myocardial ischaemia, a significant amount of myocardium that is at risk, and reduced antegrade flow.
3. In patients with cardiogenic shock, stepwise PCI of non-IRA should be taken into consideration.
4. Intravascular imaging should be taken into consideration to guide PCI.
5. It is advised that PCI of the non-IRA be based on angiographic severity in patients with multivessel disease and hemodynamically stable STEMI.
6. During the index procedure, invasive epicardial functional testing of non-culprit portions of the IRA is not advised.

For secondary prevention, consider the following:

1. For patients who were already on lipid-lowering therapy before admission for index ACS, it is recommended to intensify lipid-lowering therapy during the index ACS hospitalisation.
2. Low-dose colchicine (0.5 mg once a day) may be considered, especially if other risk factors are insufficiently controlled or if recurrent cardiovascular disease events occur under optimal therapy.
3. Combination therapy with a high-dose statin and ezetimibe may be considered during index hospitalisation.

MINOCA:

1. If the final diagnosis is unclear in individuals with a working diagnosis of MINOCA, CMR imaging is advised following invasive angiography.
2. It is advised to treat MINOCA in accordance with the definitive underlying diagnosis, in accordance with the relevant disease-specific criteria.
3. It is advised to use a diagnostic methodology to identify the underlying underlying final diagnosis in all patients having an initial working diagnosis of MINOCA.

People in a particular group:

1. It is advised to choose a long-term glucose-lowering medication based on the occurrence of comorbidities, such as obesity, chronic renal disease, and heart failure.
2. After carefully weighing the risks and advantages, a comprehensive strategy is advised for fragile older patients with comorbidities to individualise interventional and pharmaceutical therapy.
3. In patients with cancer who come with high-risk ACS and an anticipated survival of less than six months, an invasive approach is advised.

Patient standpoint:

1. It is advised that patient values be utilised to guide all treatment choices by evaluating and adhering to each patient's unique preferences, requirements, and beliefs.
2. It is advised to include ACS patients in decision-making (to the extent that their condition permits) and to tell them about the dangers of radiation exposure, adverse outcomes, and other choices. The conversation should be aided with decision aids.
3. It is advised to evaluate symptoms using techniques that enable patients to articulate their problems.

Missing information:

1. Men make up about 70% of the trial participants in the majority of RCTs. As a result, additional information about the optimal treatment for women with ACS is required. Future clinical studies must include a greater proportion of female patients if they are to provide the best guidance for treating ACS in female patients.
2. Clinical trials have a low representation of older adults. Consequently, further research is required to determine how to effectively treat older persons with ACS.

The updated ACS guidelines provide some crucial suggestions for enhancing the health and well-being of our patients with acute coronary syndrome.

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.