CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 5, September/October 2011
288
AFRICA
New ESC guidelines for acute coronary syndromes (NSTEMI)
Representatives of the
Cardiovascular
Journal of Africa
attending the ESC in
Paris interviewed Prof Robert F Storey,
University of Sheffield, United Kingdom,
a member of the ESC task force who
worked on the recently released guide-
lines.
Of particular importance for South
Africa is Dr Storey’s view that the task
force was selected from a wide body of
experts, ensuring that all geographical
regions were covered as far as possible.
Middle-income regions were well repre-
sented (Croatia, Romania, Poland, Israel,
Czech Republic, Hungary, Russia).
While Africa was not represented,
recent data from the INTER-HEART
study and other large studies which
were used to support the ESC guide-
line’s approach are increasingly involving
African patients (although still a minor-
ity), e.g. ACUITY, CURE, GRACE,
PLATO, OPTIMA.
Use of NEW antiplatelet agents
Among the notable new inclusions in
these guidelines are recommenda-
tions on the use of the new antiplatelet
drugs, ticagrelor and prasugrel, which
only became available in the past two
years. Ticagrelor is recommended for
all patients at moderate-to-high risk of
ischaemic events (including those pre-
treated with clopidogrel) and patients
with unknown coronary anatomy.
Prasugrel is recommended for those
patients who are ‘clopidogrel naïve’ in
whom coronary anatomy is known and
who are proceeding to PCI, unless there
is a high risk of life-threatening bleeding
or other contraindications. In terms of this
recommendation, Dr Storey pointed out
that the results of the ongoing TRILOGY
ACS study would be required to assess
the efficacy and safety of prasugrel in
patients who are managed medically in
order to consider an expanded indication
for this drug.
In these guidelines, clopidogrel is
reserved for those patients who cannot
take ticagrelor or prasugrel. The guide-
lines cite the PLATelet inhibition and
patient Outcomes (PLATO) and TRITON-
TIMI 38 trials as evidence of the superior-
ity of the new drugs over clopidogrel.
Use of GP IIb/IIIa receptor
inhibitors
The use of GPIIb/IIIa receptor inhibi-
tors is comprehensively dealt with and
summarised in Table 1.
Risk stratification with hs
troponin assays
There are also notable introductions in
the sections on diagnosis. Risk stratifica-
tion now takes into account the introduc-
tion of high-sensitivity troponin assays.
These have largely replaced conventional
troponin assays because of their higher
diagnostic sensitivity. Accordingly, the
new guidelines recommend the imple-
mentation of a rapid rule-out protocol
when these high-sensitivity assays are
available. It seems likely that the guide-
lines will change clinical practice in the
diagnostic work-up when applying this
fast-track protocol.
However, whatever the new introduc-
tions, the range of non-ST-segment eleva-
tion acute coronary syndromes remains
as wide and as frequent as ever. The
guidelines put annual incidence at three
per thousand population, with patients
described as a heterogeneous group with
a variable prognosis. Risk stratifica-
tion therefore remains essential to their
management.
USE of bleeding scores
(CRUSADE)
With bleeding still acknowledged as
a major risk factor for patients with
suspected non-ST-segment elevation acute
coronary syndromes, the 2011 guidelines
recommend use of the Can Rapid risk
stratification of Unstable angina patients
Suppress Adverse outcomes with Early
implementation of the ACC/AHA guide-
lines (CRUSADE) risk score to estimate
the risk of in-hospital bleeding. ‘It’s prob-
ably the best validated score because it’s
based on more than 70 000 patients of the
CRUSADE registry and was validated in
a cohort of [more than] 17 000 patients’,
says task force chairman Prof Christian
Hamm. ‘So it’s really very solid data.’
Previous guidelines have recommend-
ed the GRACE risk score to predict
ischaemic events. However, says Hamm,
the new recommendation to also use the
CRUSADE score to estimate the risk of
in-hospital bleeding will enable doctors
to tailor treatment according to both risk
scores. This, he adds, along with the
introduction of high-sensitivity troponin
assays for diagnosis, are two ‘practice-
changing’ recommendations of the new
guidelines.
1.
ESC Guidelines for the Management of
Acute Coronary Syndromes in patients
presenting without persistent ST-segment
elevation.
Eur Heart J
doi: 10:1093/
eurheart/her 236.
TABLE 1. RECOMMENDATIONS FOR GP IIB/IIIA RECEPTOR INHIBITORS
Recommendations
Class
a
Level
b
The choice of combination of oral antiplatelet agents, a GP IIb/IIIa receptor inhibi-
tor, and anticoagulants should be made in relation to the risk of ischaemic and
bleeding events
I
C
Among patients who are already treated with DAPT, the addition of a GP IIb/IIIa
receptor inhibitor for high-risk PCI (elevated troponin, visible thrombus) is recom-
mended if the risk of bleeding is low
I
B
Eptifibatide or tirofiban added to aspirin should be considered prior to angiography
in high-risk patients not preloaded with P2Y
12
inhibitors
IIa
C
In high-risk patients, eptifibatide or tirofiban may be considered prior to early angi-
ography in addition to DAPT, if there is ongoing ischaemia and the risk of bleeding
is low
Iib C
GP Iib/IIa receptor inhibitors are not recommended routinely before angiography in
an invasive treatment strategy
III
A
GP Iib/IIa receptor inhibitors are not recommended for patients on DAPT who are
treated conservatively
III
A
a
Class of recommendation with class 1 being the highest level.
b
Level of evidence with A being the highest with randomised clinical trials in support of the recom-
mendations.
DAPT
=
dual (oral) antiplatelet therapy; GP
=
glycoprotein; PCI
=
percutaneous coronary interven-
tion.
