The following are key points to remember from the 2020 European Society of Cardiology (ESC) Guidelines for the Management of Acute Coronary Syndromes in Patients Presenting Without Persistent ST-Segment Elevation:

1. A high-sensitivity cardiac troponin assay is recommended in the evaluation of chest pain. In patients with suspected non–ST-segment elevation acute coronary syndrome (NSTE-ACS), a 0-hour/1-hour high-sensitivity cardiac troponin assay algorithm is recommended to decrease time to clinical decision making while providing high sensitivity and diagnostic accuracy (class I, level B).
2. Routine pretreatment with a P2Y12 receptor inhibitor is no longer recommended in patients with NSTE-ACS with unknown coronary anatomy and planned early invasive angiography (class III, level A).
3. A central theme of these guidelines is assessment of bleeding and ischemia risks. Patients with undefined coronary anatomy and a plan for early invasive management should not receive pretreatment with a P2Y12 receptor inhibitor because of the potential delay of care and increased bleeding if cardiac surgery is required.
4. In patients who proceed to percutaneous coronary intervention (PCI), prasugrel is the preferred P2Y12 receptor inhibitor over ticagrelor (class IIa, level B).
5. The recommendation for use of prasugrel over ticagrelor and delayed P2Y12 receptor inhibitor administration is potentially practice changing.
6. While the safety of delayed pretreatment has been identified in both registry and randomized clinical trial data, prasugrel is highly potent and should be avoided in patients aged >75 years and those with a history of cerebrovascular accident.
7. In patients with atrial fibrillation (AF) and NSTE-ACS taking an oral anticoagulant, triple antithrombotic therapy with aspirin, clopidogrel, and a direct oral anticoagulant should be administered for up to 1 week, with de-escalation to dual antithrombic therapy with clopidogrel and a direct oral anticoagulant (class I, level A).
8. The ESC guidelines emphasize the need for individualized ischemia risk assessment during therapy selection. The recommendations for patients with AF and NSTE-ACS strive to balance the risk of bleeding with triple antithrombotic therapy versus the risk of stent thrombosis with dual antithrombotic therapy.
9. Optimal timing of coronary angiography in patients with NSTE-ACS remains incompletely understood. Study designs incorporating important patient risk variables (such as persistent symptoms and extent of myocardial necrosis) with time intervals to invasive coronary angiography are lacking.
10. A comprehensive risk prediction model incorporating both bleeding and ischemia risk factors could help standardize decision making for both short- and long-term antithrombotic therapies.

Clinical Topics: Acute Coronary Syndromes, Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Anticoagulation Management and ACS, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Anticoagulants, Arrhythmias, Cardiac, Aspirin, Atrial Fibrillation, Cardiac Surgical Procedures, Chest Pain, Coronary Angiography, Fibrinolytic Agents, Geriatrics, Hemorrhage, Myocardial Infarction, Myocardial Ischemia, Percutaneous Coronary Intervention, Purinergic P2Y Receptor Antagonists, Risk Assessment, Risk Factors, Secondary Prevention, Stents, Stroke, Thrombosis, Troponin

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