The new ESC acute coronary syndrome guideline and its impact in the CPU and emergency department setting

The new guideline on acute coronary syndrome (ACS) of the European Society of Cardiology (ESC) replaces two separate guidelines on ST-elevation myocardial infarction (STEMI) and non-ST-elevation (NSTE) ACS. This change of paradigm reflects the experts view that the ACS is a continuum, starting with unstable angina and ending in cardiogenic shock or cardiac arrest due to severe myocardial ischemia. Secondary, partly non-atherosclerotic-caused myocardial infarctions (“type 2”) are not integrated in this concept. With respect to acute care in the setting of emergency medicine and the chest pain unit structures, the following new aspects have to be taken into account: 1. New procedural approach as “think A.C.S.” meaning “abnormal ECG,” “clinical context,” and “stable patient” 2. New recommendation regarding a holistic approach for frail patients 3. Revised recommendations regarding imaging and timing of invasive strategy in suspected NSTE-ACS 4. Revised recommendations for antiplatelet and anticoagulant therapy in STEMI 5. Revised recommendations for cardiac arrest and out-of-hospital cardiac arrest 6. Revised recommendations for in-hospital management (starting in the CPU/ED) and ACS comorbid conditions In summary, the changes are mostly gradual and are not based on extensive new evidence, but more on focused and healthcare process-related considerations.