Management of non-ST-segment elevation acute coronary syndrome: comparison of the updated guidelines from North America and Europe

Abstract

The American College of Cardiology/American Heart Association and the European Society of Cardiology published updated guidelines in 2011 for the management of patients with non-ST-segment elevation acute coronary syndrome. In this article, we highlight the most important new recommendations, review their supporting data, describe differences between the guidelines, and discuss new literature published since the latest guidelines were released. Key updates include detailed guidance regarding early risk stratification, use of coronary computed tomography angiography, selection of initial management strategy, novel antiplatelet agents, and new measures to enhance performance and quality. Major unique recommendations in the European Society of Cardiology guideline include endorsement of ticagrelor inhibitor or prasugrel (after delineation of coronary anatomy) as the first choice of P2Y12 inhibitors, establishment of protocols to identify patients for percutaneous coronary interventions vs. coronary artery bypass surgery, and use of the CRUSADE bleeding score. Meanwhile, unique recommendations in the American College of Cardiology/American Heart Association guideline include administration of prasugrel in selected patients before coronary angiography and consideration of continued dual antiplatelet therapy beyond 15 months after drug-eluting stent placement. Both guidelines include new recommendations endorsing platelet function and genetic testing in selected patients on clopidogrel, renal protection strategies, and less aggressive in patient's glycemic control. As these guidelines represent the most evidence-based approach, health care providers should become familiar with these updated recommendations to ensure optimal treatment of their patients with non-ST-segment elevation acute coronary syndrome.