Cardiologists recommend complete revascularization, intravascular imaging in new ACS guidelines
U.S. medical societies have collaborated on new acute coronary syndrome (ACS) guidelines focused on the comprehensive management of patients presenting with unstable angina, ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).
The American College of Cardiology (ACC) and American Heart Association published the new guidelines with assistance from the American College of Emergency Physicians, National Association of EMS Physicians and Society for Cardiovascular Angiography & Interventions. The recommendations are available in full in both JACC and Circulation.[1, 2]
“Patients with ACS are at the highest risk for cardiovascular complications both acutely and chronically, which emphasizes the importance of staying up-to-date on the most recent evidence presented in this guideline,” writing group chair Sunil V. Rao, MD, an interventional cardiologist with NYU Langone Health, said in a statement. “With appropriate management, we can improve outcomes both in the hospital and over the long term.”
Pharmacologic highlights from new ACS guidelines
The groups emphasized that high-intensity statin therapy should be prescribed for all ACS patients and dual antiplatelet therapy (DAPT) with aspirin and an oral P2Y12 inhibitor should be the default strategy for ACS patients who do not face a high bleeding risk. If there is a significant risk of bleeding, they added, clinicians have a variety of different options to choose from when making treatment decisions.
When patients are already on maximally tolerated statin and have a low-density lipoprotein cholesterol level of ≥70 mg/dL, they should also be treated with a nonstatin lipid-lowering agent such as ezetimibe or evolocumab.
Procedural highlights from new ACS guidelines
Complete revascularization is recommended for both STEMI and NSTEMI patients, with heart teams choosing the right revascularization method for that patient’s needs. When the patient presents with both ACS and cardiogenic shock, meanwhile, emergency revascularization of the culprit vessel remains the safest available treatment option.
The use of a microaxial heart pump may also be necessary for some cardiogenic shock patients. This recommendation follows late-breaking data from the DanGer Shock trial, which examined the safety and effectiveness of treatment with Johnson & Johnson MedTech’s Impella device. The authors did note that the use of this device could potentially be associated with an increased risk of certain complications—more data is still required to learn more.
In addition, the new recommendations highlighted the benefits of using a transradial approach for percutaneous coronary intervention (PCI) over a transfemoral approach. This can reduce the patient’s risk of bleeding after treatment, experiencing vascular complications or dying. On a similar note, intravascular imaging guidance during PCI received a Class 1 recommendation. Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are both recognized as effective strategies in these patients.
“Both IVUS and OCT play essential roles in evaluating the necessity for lesion preparation, choosing the appropriate stent size, reducing the likelihood of geographical errors, confirming proper stent expansion, identifying complications and determining the underlying reasons for stent failure,” the authors explained.
Remaining evidence gaps related to treating ACS
Another key component of the new guidelines was a list of remaining evidence gaps that researchers still need to evaluate going forward.
“The treatment of ACS has been the subject of thousands of clinical trials comprising very large numbers of patients,” the authors wrote. “As such, its management is guided by the largest evidence base in clinical medicine. Despite this, there are numerous unanswered questions, evidence gaps, and areas for further study.”
For example, the groups noted that it is still not clear how long patients should undergo telemetry monitoring when hospitalized for ACS. And, as they explained, “whether multivessel PCI in the ACS setting should be guided by angiography or physiology is still a matter of debate.”
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Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.