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Acute coronary syndromes: 2015 ESC Guidelines recommend radial approach for percutaneous coronary interventions


ESC Guidelines recommended for the radial approach over the femoral one for coronary angiography and percutaneous coronary intervention ( PCI ) in patients with acute coronary syndromes ( ACS ).
The ACS without persistent ST-segment elevation ( NSTE-ACS ) guidelines are published in European Heart Journal.

New data have shown that the radial approach is superior to the femoral not only in terms of vascular complications and major bleeding events but also in reducing all-cause mortality. It is recommended that Centres treating acute coronary syndromes patients implement a transition from transfemoral to transradial access.
However, proficiency in the femoral approach should be maintained, as this access is indispensable in a variety of procedures, including intra-aortic balloon counterpulsation implantation, structural heart disease interventions, and peripheral revascularization procedures.

A new, shorter algorithm for diagnosis in patients with suspected non-ST-elevation myocardial infarction ( NSTEMI ) is introduced.
When high-sensitivity troponin assays are available, blood tests can be done at presentation and after 1 hour instead of the current practice of 3 hours. Both algorithms are equally good and either can be used. The 1 hour protocol accelerates diagnosis and consequent treatment or rules out NSTEMI so patients can be discharged or investigated for other conditions. This should translate to shorter stays in the emergency department.

While the general recommendation of dual antiplatelet therapy ( DAPT ) for one year remains, a tailored duration ( i.e., shortened to 3-6 months or extended up to 30 months ) is now allowed in selected patients at high bleeding or ischaemic risk, respectively.
With improved drug-eluting stent technology, stent thrombosis rates have dropped dramatically and recent data suggests that shorter duration of DAPT in patients at high bleeding risk is safe and effective.
In addition, new data have shown that DAPT beyond one year is effective in reducing ischaemic events in selected patients at high ischaemic and low bleeding risk.

The most controversial area was the optimal time to give P2Y12 inhibitors to NSTE-ACS patients scheduled for invasive assessment.
The 2011 Guidelines recommended the antiplatelet drug be given as soon as a diagnosis was made, independently of when the patient would undergo coronary angiography ( pretreatment ). The first study designed to test the impact of P2Y12 inhibitor pretreatment in ACS showed that Prasugrel ( Effient ) pretreatment resulted in more bleeding events compared to giving the drug at the time of coronary angiography / percutaneous coronary intervention in the absence of a reduction in ischaemic events.

Prasugrel pretreatment is now contraindicated, which is a change of paradigm. In retrospect, researchers were over confident about the value of P2Y12 inhibitor pretreatment.
With respect to Ticagrelor and Clopidogrel, the optimal timing of drug administration in patients scheduled for an invasive strategy has not been properly studied, so researchers do not give any recommendation for or against pretreatment. This is a gap in evidence that requires further research.

Guidance on the minimum duration of cardiac rhythm monitoring ( none, less than 24 hours, more than 24 hours ) in patients with NSTE-ACS is given for the first time, depending on clinical presentation. Researchers give recommendations to streamline the stay of patients in monitored units. This may reduce length of stay in hospital and costs.

There is a new section on the complex issue of managing antiplatelet therapy in patients requiring chronic oral anticoagulation. Additional new sections concern the treatment of bleeding related to antithrombotic therapy, management of antiplatelet agents in patients requiring coronary bypass surgery, and NSTE-ACS patients with atrial fibrillation or undergoing noncardiac surgery. ( Xagena )

Source: European Society of Cardiology ( ESC ) Meeting, 2015

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