Zusammenfassung
Die im August 2020 publizierten ECS(European Society of Cardiology)-Leitlinien zur Behandlung des akuten Koronarsyndroms ohne persistierende ST-Strecken-Hebungen (NSTE-ACS) ersetzt die zuletzt 2015 veröffentlichten Leitlinien zu diesem Thema. Diese aktualisierte Leitlinie bringt einige bedeutsame Änderungen für die klinische Praxis. Diese betreffen v. a. Diagnostik, Risikostratifizierung, antithrombotische Therapie, invasive oder nichtinvasive Koronardiagnostik sowie Langzeittherapie. Neue Abschnitte befassen sich mit der spontanen Koronararteriendissektion (SCAD), dem Myokardinfarkt mit nichtobstruktiven Koronararterien (MINOCA) sowie mit neu eingeführten Qualitätsindikatoren in der Therapie. Eine Betonung erfährt die Verwendung hochsensitiver kardialer Troponinassays (hs-cTn) in Verbindung mit Diagnosealgorithmen, wodurch eine zügige Triageentscheidung („rule-out“ = sicher kein NSTEMI oder „rule-in“ = NSTEMI wahrscheinlich) in der Notaufnahme oder Chest Pain Unit möglich ist. Bei der antithrombotischen Therapie wird nun eine stärkere Individualisierung des Therapiekonzepts, basierend auf dem Risiko für ischämische/thrombotische Ereignisse und Blutungskomplikationen, empfohlen. Bezüglich des Zeitpunkts der invasiven Koronarangiographie wurden einige neue Aspekte eingeführt. Grundsätzlich bleibt es aber bei der umgehenden Koronarangiographie für Patienten mit einem sehr hohen Risiko und bei einer frühen Koronarangiographie (innerhalb von 24 h) für Patienten mit einem hohen Risiko. Die frühere intermediäre Risikogruppe wurde gestrichen. Stattdessen wird nun betont, dass diese Patienten wie die mit einem niedrigen Risiko oder mit einem chronischen Koronarsyndrom behandelt werden sollten.
Abstract
The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndrome without persistent ST-segment elevation (NSTE-ACS) published in August 2020, replace the former NSTE-ACS guidelines published in 2015. These updated guidelines have some relevant changes for the clinical practice, which include the diagnostic work-up, risk stratification, antithrombotic therapy, invasive or noninvasive coronary diagnostics and also long-term treatment. New sections deal with spontaneous coronary artery dissection (SCAD), myocardial infarction with nonobstructive coronary arteries (MINOCA) and also newly introduced quality indicators for NSTE-ACS treatment. The diagnostic work-up using highly sensitive cardiac troponin (hs-cTn) assays is emphasized with the recommendation to use fast triage decisions that enable an early rule-in (no STEMI) or rule-out (NSTEMI probable) in the emergency room or chest pain unit. In antiplatelet therapy a greater individualization of the treatment concept is recommended based on the individual ischemic/thrombotic events and bleeding complications. Some new aspects were introduced for timing of invasive coronary angiography; however, principally the very high-risk group should still immediately undergo coronary angiography and the high-risk group should undergo an invasive angiography within 24 h. In risk stratification, the former intermediate risk group has been removed, instead it is now emphasized that low-risk patients should be treated similarly to patients with chronic coronary syndrome.
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Thiele, H., Jobs, A. ESC-Leitlinie 2020: akutes Koronarsyndrom ohne persistierende ST-Strecken-Hebungen. Herz 46, 3–13 (2021). https://doi.org/10.1007/s00059-020-05002-1
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DOI: https://doi.org/10.1007/s00059-020-05002-1