Perspective:

The following are 10 points to remember from these European Society of Cardiology guidelines:

1. Acute coronary syndrome (ACS), a life-threatening manifestation of atherosclerosis, is usually precipitated by acute thrombosis induced by a ruptured or eroded atherosclerotic coronary plaque, with or without concomitant vasoconstriction, causing a sudden and critical reduction in blood flow.

2. Blood has to be drawn promptly for troponin (cardiac troponin T or I) measurement. The result should be available within 60 minutes. The test should be repeated 6-9 hours after initial assessment if the first measurement is not conclusive. Repeat testing after 12-24 hours is advised if the clinical condition is still suggestive of ACS.

3. Angiography should be performed urgently for diagnostic purposes in patients at high risk and in whom the differential diagnosis is unclear. Coronary computed tomography angiography should be considered as an alternative to invasive angiography to exclude ACS when there is a low to intermediate likelihood of coronary artery disease, and when troponin and electrocardiogram are inconclusive.

4. Quantitative assessment of risk is useful for clinical decision making. Based on direct comparisons, the GRACE risk score provides the most accurate stratification of risk both on admission and at discharge due to its good discriminative power.

5. Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all patients at moderate to high risk of ischemic events (e.g., elevated troponins), regardless of initial treatment strategy and including those pretreated with clopidogrel (which should be discontinued when ticagrelor is commenced).

6. Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended for P2Y12-inhibitor-naïve patients (especially diabetics) in whom coronary anatomy is known and who are proceeding to percutaneous coronary intervention (PCI), unless there is a high risk of life-threatening bleeding or other contraindications.

7. Clopidogrel (300 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel.

8. Fondaparinux (2.5 mg subcutaneously daily) is recommended as having the most favorable efficacy–safety profile with respect to anticoagulation. If the initial anticoagulant is fondaparinux, a single bolus of unfractionated heparin (85 IU/kg adapted to activated clotting time, or 60 IU in the case of concomitant use of glycoprotein IIb/IIIa receptor inhibitors) should be added at the time of PCI.

9. Urgent coronary angiography (<2 hours) is recommended in patients at very high ischemic risk (refractory angina, with associated heart failure, life-threatening ventricular arrhythmias, or hemodynamic instability).

10. Appropriate secondary prevention is of paramount importance since ischemic events continue to accrue at a high rate after the acute phase.