Acute coronary syndrome without persistent elevation of the ST segment: New recommendations

Abstract

Acute myocardial infarction without persistent ST-segment elevation is a serious medical problem that significantly increases cardiovascular mortality and morbidity. Therefore, timely accurate diagnosis is crucial for adequate treatment of these patients, better survival and improved quality of life. It is characterized by a clinical picture of acute chest discomfort that may occur in the form of typical anginal problems or as the equivalent of acute chest pain. Changes in the electrocardiogram are varied, from transient ST-segment elevation, persistent or transient ST-segment depression, T-wave inversion, flattened T-wave, or pseudonormalization of the T-wave, to normal electrocardiographic recording. The latest guidelines of the European Society of Cardiology advise determining the value of cardio-specific enzymes from the patient's blood, namely high-sensitivity cardiac troponin T or I immediately upon admission to the health institution and repeated one hour after admission (0h / 1h algorithm). Echocardiographic examination is recommended in all patients as a routine procedure before admission or during hospitalization. Coronary CT angiography for the anatomical evaluation of coronary heart disease is important in patients with a low to moderate probability of an acute coronary event. Drug treatment in these patients involves the use of dual antiplatelet therapy to determine the ischemic risk of the patient as well as the risk of bleeding. Pre-treatment with the use of primarily P2Y12 receptor inhibitors is not recommended in routine clinical practice. In patients who have undergone revascularization and stent implantation, dual antiplatelet therapy is recommended for 12 months, except in cases where there are contraindications or increased hemorrhagic risk. Patients who require long-term use of oral anticoagulant therapy after a short period of triple antiplatelet therapy up to 1 week after the acute event, continue dual antiplatelet therapy, using new anticoagulants at the recommended dose to prevent stroke and one oral antiplatelet drug. Invasive coronary angiography can be performed according to the patient's risk immediately after admission to a health institution (within 2 hours) in very high-risk patients or as an early treatment strategy, within 24 hours of admission in high-risk patients. To perform an invasive intervention, a radial approach is advised, as well as the implantation of drug-coated stents. In patients in whom it is not possible to perform myocardial revascularization by percutaneous coronary intervention, revascularization with coronary artery bypass grafts is recommended. In the long-term follow-up of these patients, after an acute coronary event, it is advisable to change life habits with pharmacological treatment, which reduces mortality and improves the quality of life.