Abstract
Multiple new recommendations have been introduced in the 2020 ESC guidelines for the management of acute coronary syndromes with a focus on diagnosis, prognosis, and management of patients presenting without persistent ST-segment elevation. Most recommendations are supported by high-quality scientific evidence. The guidelines provide solutions to overcome obstacles presumed to complicate a convenient interpretation of troponin results such as age-, or sex-specific cutoffs, and to give practical advice to overcome delays of laboratory reporting. However, in some areas, scientific support is less well documented or even missing, and other areas are covered rather by expert opinion or subjective recommendations. We aim to provide a critical appraisal on several recommendations, mainly related to the diagnostic and prognostic assessment, highlighting the discrepancies between Guideline recommendations and the existing scientific evidence.
Highlights
In August 2020, the European Society of Cardiology (ESC) presented the Guidelines on NSTE-ACS during the Annual Congress that was held on a virtual platform [1]
The diagnosis of acute myocardial infarction (AMI) has remained challenging and still chest pain and/or dyspnea are amongst the most prevalent symptoms leading to emergency department (ED) admission in the USA [3]
Guidelines endorse measures for a more convenient, user-friendly interpretation of cTn results such as the recommendation to abstain from age, sex, or comorbidity-adapted decision cutoffs the use of sex-specific cutoffs has been endorsed by the 4th version of the Universal Definition of Myocardial Infarction (UDMI)
Summary
In August 2020, the European Society of Cardiology (ESC) presented the Guidelines on NSTE-ACS during the Annual Congress that was held on a virtual platform [1]. Wildi K et al [43] directly compared the ADP 2-h protocol against the ESC 0/2 h protocol only for rule out (but not for rule-in) in two independent cohorts, namely the APACE study and the ADAPT trial Both algorithms provided very high and comparable safety as quantified by the NPV and sensitivity for AMI and major adverse cardiac events (MACE) at 30 days in patients triaged toward rule out. The 2015 ESC NSTE-ACS Guidelines [2] recommend use of the ESC 0 h/3 h algorithm based on several large observational studies that conferred evidence beyond doubt on the superiority of the ESC 0 h/3 h algorithm over the standard protocol with blood sampling at 0 h and 6–9 h in the absence of a high-sensitivity cardiac troponin assay. A substudy from TRAPID-AMI [55] investigating the role of Copeptin combined with hs-cTn elegantly demonstrated that exclusion of high-risk patients resulted in 100% sensitivity and 100%NPV, without any Reichlin T, 2009
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