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30.11.2023 | Schwerpunkt

Management des akuten Koronarsyndroms

ESC-Leitlinie 2023

verfasst von: Maria Buske, Hans-Josef Feistritzer, Alexander Jobs, Prof. Dr. med. Holger Thiele

Erschienen in: Herz | Ausgabe 1/2024

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Zusammenfassung

Die neuen Leitlinien der European Society of Cardiology (ESC) zum Management des akuten Koronarsyndroms (ACS) von 2023 umfassen sowohl Neuerungen der Leitlinie zum ST-Strecken-Hebungs-Myokardinfarkt (STEMI) als auch zum akuten Koronarsyndrom ohne ST-Strecken-Hebung (NSTE-ACS). Damit wurden die vormals getrennten Leitlinien von 2017 bzw. 2020 überarbeitet und zusammengefasst. Dabei werden die Themen Diagnostik, Akutmanagement, antithrombotische Therapie, außerklinischer Herzstillstand und kardiogener Schock, invasive Strategien sowie die Langzeittherapie behandelt. Die Neuerungen gegenüber älteren Leitlinien betreffen unter anderem den Empfehlungsgrad zum Zeitpunkt der invasiven Diagnostik beim akuten Koronarsyndrom ohne ST-Hebungen (NSTE-ACS), das Vorgehen der Revaskularisation bei koronarer Mehrgefäßerkrankung sowie alternative Regime der antithrombotischen Therapie bei Patienten mit hohem Blutungsrisiko.

Byrne RA, Rossello X, Coughlan JJ et al (2023) 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 44(38):3720–3826PubMedCrossRef

Thygesen K, Alpert JS, Jaffe AS et al (2018) Fourth universal definition of myocardial infarction (2018). Circulation 138(20):e618–e651PubMedCrossRef

Chew DP, Lambrakis K, Blyth A et al (2019) A Randomized Trial of a 1-Hour Troponin T Protocol in Suspected Acute Coronary Syndromes: The Rapid Assessment of Possible Acute Coronary Syndrome in the Emergency Department With High-Sensitivity Troponin T Study (RAPID-TnT). Circulation 140(19):1543–1556PubMedCrossRef

Stoyanov KM, Hund H, Biener M et al (2020) RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction. Eur Heart J Acute Cardiovasc Care 9(1):39–51PubMedCrossRef

Twerenbold R, Costabel JP, Nestelberger T et al (2019) Outcome of applying the ESC 0/1-hour algorithm in patients with suspected myocardial infarction. J Am Coll Cardiol 74(4):483–494PubMedCrossRef

Kite TA, Kurmani SA, Bountziouka V et al (2022) Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials. Eur Heart J 43(33):3148–3161PubMedPubMedCentralCrossRef

Jobs A, Mehta SR, Montalescot G et al (2017) Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 390(10096):737–746PubMedCrossRef

Wiviott SD, Braunwald E, McCabe CH et al (2007) Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 357(20):2001–2015PubMedCrossRef

Wallentin L, Becker RC, Budaj A et al (2009) Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 361(11):1045–1057PubMedCrossRef

10.

Schupke S, Neumann FJ, Menichelli M et al (2019) Ticagrelor or prasugrel in patients with acute coronary syndromes. N Engl J Med 381(16):1524–1534PubMedCrossRef

11.

Koul S, Smith JG, Götberg M et al (2018) No benefit of ticagrelor pretreatment compared with treatment during percutaneous coronary intervention in patients with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Circ Cardiovasc Interv 11(3):e5528PubMedCrossRef

12.

Montalescot G, van ’t Hof AW, Lapostolle F et al (2014) Prehospital ticagrelor in ST-segment elevation myocardial infarction. N Engl J Med 371(11):1016–1027PubMedCrossRef

13.

Tarantini G, Mojoli M, Varbella F et al (2020) Timing of oral P2Y(12) inhibitor administration in patients with non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 76(21):2450–2459PubMedCrossRef

14.

Palmerini T, Della Riva D, Benedetto U et al (2017) Three, six, or twelve months of dual antiplatelet therapy after DES implantation in patients with or without acute coronary syndromes: an individual patient data pairwise and network meta-analysis of six randomized trials and 11 473 patients. Eur Heart J 38(14):1034–1043PubMedPubMedCentral

15.

Hahn JY, Song YB, Oh JH et al (2018) 6‑month versus 12-month or longer dual antiplatelet therapy after percutaneous coronary intervention in patients with acute coronary syndrome (SMART-DATE): a randomised, open-label, non-inferiority trial. Lancet 391(10127):1274–1284PubMedCrossRef

16.

Kedhi E, Fabris E, van der Ent M et al (2018) Six months versus 12 months dual antiplatelet therapy after drug-eluting stent implantation in ST-elevation myocardial infarction (DAPT-STEMI): randomised, multicentre, non-inferiority trial. BMJ 363:k3793PubMedPubMedCentralCrossRef

17.

De Luca G, Damen SA, Camaro C et al (2019) Final results of the randomised evaluation of short-term dual antiplatelet therapy in patients with acute coronary syndrome treated with a new-generation stent (REDUCE trial). EuroIntervention 15(11):e990–e998PubMedCrossRef

18.

Hahn JY, Song YB, Oh JH et al (2019) Effect of P2Y12 inhibitor monotherapy vs dual antiplatelet therapy on cardiovascular events in patients undergoing percutaneous coronary intervention: the SMART-CHOICE randomized clinical trial. JAMA 321(24):2428–2437PubMedPubMedCentralCrossRef

19.

Mehran R, Baber U, Sharma SK et al (2019) Ticagrelor with or without aspirin in high-risk patients after PCI. N Engl J Med 381(21):2032–2042PubMedCrossRef

20.

Watanabe H, Domei T, Morimoto T et al (2019) Effect of 1‑month dual antiplatelet therapy followed by clopidogrel vs 12-month dual antiplatelet therapy on cardiovascular and bleeding events in patients receiving PCI: the STOPDAPT‑2 randomized clinical trial. JAMA 321(24):2414–2427PubMedPubMedCentralCrossRef

21.

Vranckx P, Valgimigli M, Jüni P et al (2018) Ticagrelor plus aspirin for 1 month, followed by ticagrelor monotherapy for 23 months vs aspirin plus clopidogrel or ticagrelor for 12 months, followed by aspirin monotherapy for 12 months after implantation of a drug-eluting stent: a multicentre, open-label, randomised superiority trial. Lancet 392(10151):940–949PubMedCrossRef

22.

Baber U, Dangas G, Angiolillo DJ et al (2020) Ticagrelor alone vs. ticagrelor plus aspirin following percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes: TWILIGHT-ACS. Eur Heart J 41(37):3533–3545PubMedCrossRef

23.

Kim BK, Hong SJ, Cho YH et al (2020) Effect of ticagrelor monotherapy vs ticagrelor with aspirin on major bleeding and cardiovascular events in patients with acute coronary syndrome: the TICO randomized clinical trial. JAMA 323(23):2407–2416PubMedPubMedCentralCrossRef

24.

Watanabe H, Morimoto T, Natsuaki M et al (2022) Comparison of clopidogrel monotherapy after 1 to 2 months of dual antiplatelet therapy with 12 months of dual antiplatelet therapy in patients with acute coronary syndrome: the STOPDAPT‑2 ACS randomized clinical trial. JAMA Cardiol 7(4):407–417PubMedPubMedCentralCrossRef

25.

Valgimigli M, Frigoli E, Heg D et al (2021) Dual antiplatelet therapy after PCI in patients at high bleeding risk. N Engl J Med 385(18):1643–1655PubMedCrossRef

26.

Giustino G, Mehran R, Dangas GD et al (2017) Characterization of the average daily Ischemic and bleeding risk after primary PCI for STEMI. J Am Coll Cardiol 70(15):1846–1857PubMedCrossRef

27.

Sibbing D, Aradi D, Jacobshagen C et al (2017) Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome undergoing percutaneous coronary intervention (TROPICAL-ACS): a randomised, open-label, multicentre trial. Lancet 390(10104):1747–1757PubMedCrossRef

28.

Claassens DMF, Vos GJA, Bergmeijer TO et al (2019) A genotype-guided strategy for oral P2Y12 inhibitors in primary PCI. N Engl J Med 381(17):1621–1631PubMedCrossRef

29.

Cuisset T, Deharo P, Quilici J et al (2017) Benefit of switching dual antiplatelet therapy after acute coronary syndrome: the TOPIC (timing of platelet inhibition after acute coronary syndrome) randomized study. Eur Heart J 38(41):3070–3078PubMedCrossRef

30.

Kim CJ, Park MW, Kim MC et al (2021) Unguided de-escalation from ticagrelor to clopidogrel in stabilised patients with acute myocardial infarction undergoing percutaneous coronary intervention (TALOS-AMI): an investigator-initiated, open-label, multicentre, non-inferiority, randomised trial. Lancet 398(10308):1305–1316PubMedCrossRef

31.

Shoji S, Kuno T, Fujisaki T et al (2021) De-escalation of dual antiplatelet therapy in patients with acute coronary syndromes. J Am Coll Cardiol 78(8):763–777PubMedCrossRef

32.

Laudani C, Greco A, Occhipinti G et al (2022) Short duration of DAPT versus de-escalation after percutaneous coronary intervention for acute coronary syndromes. JACC Cardiovasc Interv 15(3):268–277PubMedCrossRef

33.

Smits PC, Frigoli E, Tijssen J et al (2021) Abbreviated antiplatelet therapy in patients at high bleeding risk with or without oral anticoagulant therapy after coronary stenting: an open-label, randomized, controlled trial. Circulation 144(15):1196–1211PubMedPubMedCentralCrossRef

34.

Patterson T, Perkins GD, Hassan Y et al (2018) Temporal trends in identification, management, and clinical outcomes after out-of-hospital cardiac arrest: insights from the myocardial Ischaemia national audit project database. Circ Cardiovasc Interv 11(6):e5346PubMedCrossRef

35.

Byrne R, Constant O, Smyth Y et al (2008) Multiple source surveillance incidence and aetiology of out-of-hospital sudden cardiac death in a rural population in the West of Ireland. Eur Heart J 29(11):1418–1423PubMedCrossRef

36.

Kroupa J, Knot J, Ulman J et al (2017) Characteristics and survival determinants in patients after out-of-hospital cardiac arrest in the era of 24/7 coronary intervention facilities. Heart Lung Circ 26(8):799–807PubMedCrossRef

37.

Lemkes JS, Janssens GN, van der Hoeven NW et al (2020) Coronary angiography after cardiac arrest without ST segment elevation: one-year outcomes of the COACT randomized clinical trial. JAMA Cardiol 5(12):1358–1365PubMedCrossRef

38.

Desch S, Freund A, Akin I et al (2021) Angiography after out-of-hospital cardiac arrest without ST-segment elevation. N Engl J Med 385(27):2544–2553PubMedCrossRef

39.

Dankiewicz J, Cronberg T, Lilja G et al (2021) Hypothermia versus normothermia after out-of-hospital cardiac arrest. N Engl J Med 384(24):2283–2294PubMedCrossRef

40.

Hochman JS, Sleeper LA, Webb JG et al (1999) Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK investigators. Should we Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. N Engl J Med 341(9):625–634PubMedCrossRef

41.

Thiele H, Zeymer U, Neumann F‑J et al (2012) Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 367(14):1287–1296PubMedCrossRef

42.

Ostadal P, Rokyta R, Karasek J et al (2023) Extracorporeal membrane oxygenation in the therapy of cardiogenic shock: results of the ECMO-CS randomized clinical trial. Circulation 147(6):454–464PubMedCrossRef

43.

Thiele H, Zeymer U, Akin I et al (2023) Extracorporeal life support in infarct-related cardiogenic shock. N Engl J Med

44.

Valgimigli M, Gagnor A, Calabró P et al (2015) Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet 385(9986):2465–2476PubMedCrossRef

45.

Jolly SS, Yusuf S, Cairns J et al (2011) Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet 377(9775):1409–1420PubMedCrossRef

46.

Thiele H, Akin I, Sandri M et al (2017) PCI strategies in patients with acute myocardial infarction and cardiogenic shock. N Engl J Med 377(25):2419–2432PubMedCrossRef

47.

Wald DS, Morris JK, Wald NJ et al (2013) Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med 369(12):1115–1123PubMedCrossRef

48.

Gershlick AH, Khan JN, Kelly DJ et al (2015) Randomized trial of complete versus lesion-only revascularization in patients undergoing primary percutaneous coronary intervention for STEMI and multivessel disease. J Am Coll Cardiol 65(10):963–972PubMedPubMedCentralCrossRef

49.

Engstrøm T, Kelbæk H, Helqvist S et al (2015) Complete revascularisation versus treatment of the culprit lesion only in patients with ST-segment elevation myocardial infarction and multivessel disease (DANAMI-3—PRIMULTI): an open-label, randomised controlled trial. Lancet 386(9994):665–671PubMedCrossRef

50.

Smits PC, Abdel-Wahab M, Neumann F‑J et al (2017) Fractional flow reserve–guided multivessel angioplasty in myocardial infarction. N Engl J Med 376(13):1234–1244PubMedCrossRef

51.

Mehta SR, Wood DA, Storey RF et al (2019) Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 381(15):1411–1421PubMedCrossRef

52.

Bainey KR, Engstrøm T, Smits PC et al (2020) Complete vs culprit-lesion-only revascularization for ST-segment elevation myocardial infarction: a systematic review and meta-analysis. JAMA Cardiol 5(8):881–888PubMedCrossRef

53.

Denormandie P, Simon T, Cayla G et al (2021) Compared outcomes of ST-segment-elevation myocardial infarction patients with multivessel disease treated with primary percutaneous coronary intervention and preserved fractional flow reserve of nonculprit lesions treated conservatively and of those with low fractional flow reserve managed Invasively: insights from the FLOWER-MI trial. Circ Cardiovasc Interv 14(11):e11314PubMedCrossRef

54.

Wald DS, Hadyanto S, Bestwick JP (2020) Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary intervention in ST-elevation myocardial infarction? Eur Heart J Qual Care Clin Outcomes 6(3):186–192PubMedCrossRef

55.

Sardella G, Lucisano L, Garbo R et al (2016) Single-staged compared with multi-staged PCI in multivessel NSTEMI patients: the SMILE trial. J Am Coll Cardiol 67(3):264–272PubMedCrossRef

56.

Lee JM, Kim HK, Park KH et al (2023) Fractional flow reserve versus angiography-guided strategy in acute myocardial infarction with multivessel disease: a randomized trial. Eur Heart J 44(6):473–484PubMedCrossRef

57.

Adlam D, Alfonso F, Maas A et al (2018) European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection. Eur Heart J 39(36):3353–3368PubMedPubMedCentralCrossRef

58.

Pathik B, Raman B, Mohd Amin NH et al (2016) Troponin-positive chest pain with unobstructed coronary arteries: incremental diagnostic value of cardiovascular magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 17(10):1146–1152PubMedCrossRef

59.

McDonagh TA, Metra M, Adamo M et al (2023) Focused update of the 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J

60.

Elbadawi A, Elgendy IY, Mahmoud K et al (2019) Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction. JACC Cardiovasc Interv 12(18):1825–1836PubMedCrossRef

61.

Knuuti J, Wijns W, Saraste A et al (2020) 2019 ESC guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J 41(3):407–477PubMedCrossRef

62.

Mach F, Baigent C, Catapano AL et al (2019) 2019 ESC/EAS guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk: the task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and European Atherosclerosis Society (EAS). Eur Heart J 41(1):111–188CrossRef

63.

Nidorf SM, Fiolet ATL, Mosterd A et al (2020) Colchicine in patients with chronic coronary disease. N Engl J Med 383(19):1838–1847PubMedCrossRef

64.

Tardif JC, Kouz S, Waters DD et al (2019) Efficacy and safety of low-dose colchicine after myocardial infarction. N Engl J Med 381(26):2497–2505PubMedCrossRef

Titel: Management des akuten Koronarsyndroms
ESC-Leitlinie 2023
verfasst von: Maria Buske
Hans-Josef Feistritzer
Alexander Jobs
Prof. Dr. med. Holger Thiele
Publikationsdatum: 30.11.2023
Verlag: Springer Medizin
Erschienen in: Herz / Ausgabe 1/2024
Print ISSN: 0340-9937
Elektronische ISSN: 1615-6692
DOI: https://doi.org/10.1007/s00059-023-05222-1

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