| Recommendations | Classa | Levelb | Quiz Question | Alternative Answers |
|---|---|---|---|---|
| It is recommended to base the diagnosis and initial short-term risk stratification of ACS on a combination of clinical history, symptoms, vital signs, other physical findings, ECG, and hs-cTn.1,17,18 | I | B | Which is NOT a recommended basis for diagnosis and initial short-term risk stratification of ACS? | 1) Clinical history 2) hs-cTn 3) BMI* 4) Symptoms |
| Twelve-lead ECG recording and interpretation is recommended as soon as possible at the point of FMC, with a target of <10 min.5,19 | I | B | What is the target time for twelve-lead ECG recording at the point of FMC? | 1) 5 minutes 2) 15 minutes 3) <10 minutes* 4) 20 minutes |
| Continuous ECG monitoring and the availability of defibrillator capacity is recommended as soon as possible in all patients with suspected STEMI, in suspected ACS with other ECG changes or ongoing chest pain, and once the diagnosis of MI is made.20,21 | I | B | When is continuous ECG monitoring recommended? | 1) Only after diagnosis of MI* 2) For all patients with STEMI* 3) Only for patients with chest pain 4) Only in suspected ACS |
| The use of additional ECG leads (V3R, V4R, and V7–V9) is recommended in cases of inferior STEMI or if total vessel occlusion is suspected and standard leads are inconclusive.22–24 | I | B | When is the use of additional ECG leads like V3R, V4R recommended? | 1) For all patients 2) If total vessel occlusion is suspected* 3) For superior STEMI 4) Only when standard leads are conclusive |
| An additional 12-lead ECG is recommended in cases with recurrent symptoms or diagnostic uncertainty. | I | C | When is an additional 12-lead ECG recommended? | 1) For all patients post-surgery 2) With recurrent symptoms* 3) Only for patients above 60 years 4) For all patients with hypertension |
| It is recommended to measure cardiac troponins with high-sensitivity assays immediately after presentation and to obtain the results within 60 min of blood sampling.15,25–27 | I | B | When should cardiac troponins be measured with high-sensitivity assays? | 1) Before presentation 2) 24 hours after presentation 3) Immediately after presentation* 4) Only if the patient has chest pain |
| It is recommended to use an ESC algorithmic approach with serial hs-cTn measurements (0 h/1 h or 0 h/2 h) to rule in and rule out NSTEMI.28–44 | I | B | What approach is recommended to rule in and rule out NSTEMI? | 1) Use of a WHO algorithm 2) ESC algorithmic approach with hs-cTn measurements* 3) Only ECG monitoring 4) Blood pressure monitoring |
| Additional testing after 3 h is recommended if the first two hs-cTn measurements of the 0 h/1 h algorithm are inconclusive and no alternative diagnoses explaining the condition have been made.45,46 | I | B | When is additional testing after 3 h recommended? | 1) Always after 3 h 2) If first two hs-cTn measurements are conclusive 3) If the first two hs-cTn measurements are inconclusive* 4) Only if patient requests |
| The use of established risk scores (e.g. GRACE risk score) for prognosis estimation should be considered.47–49 | IIa | B | Which risk score should be considered for prognosis estimation in ACS? | 1) BMI score 2) Cholesterol score 3) GRACE risk score* 4) Blood pressure score |
| It is recommended that patients with suspected STEMI are immediately triaged for an emergency reperfusion strategy.50–52 | I | A | What is recommended for patients with suspected STEMI? | 1) Wait and watch 2) Immediate triage for an emergency reperfusion strategy* 3) Provide painkillers 4) Start with oral medication |
| Recommendation Table 2 — Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome | ||||
|---|---|---|---|---|
| Recommendations | Classa | Levelb | Quiz Question | Alternative Answers |
| Emergency TTE is recommended in patients with suspected ACS presenting with cardiogenic shock or suspected mechanical complications. | I | C | For which patients is Emergency TTE recommended? | 1) Patients with cardiogenic shock or suspected mechanical complications* 2) Patients without ECG changes 3) Patients with mild chest pain 4) Patients post-surgery |
| In patients with suspected ACS, non-elevated (or uncertain) hs-cTn levels, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered. | IIa | A | When should CCTA or a non-invasive stress imaging test be considered as part of the initial workup? | 1) Always, for all suspected ACS patients 2) When there’s no recurrence of pain and uncertain hs-cTn levels* 3) When ECG changes are prominent 4) Only when the patient requests |
| Emergency TTE should be considered at triage in cases of diagnostic uncertainty but this should not result in delays in transfer to the cardiac catheterization laboratory if there is suspicion of an acute coronary artery occlusion. | IIa | C | When should Emergency TTE be considered at triage? | 1) Always, for every patient 2) Only if the patient has chest pain 3) In cases of diagnostic uncertainty* 4) Only after ECG results are analyzed |
| Routine, early CCTA in patients with suspected ACS is not recommended. | III | B | Is routine, early CCTA recommended in patients with suspected ACS? | 1) Yes, always 2) Only in severe cases 3) No* 4) Yes, but only after ECG analysis |
Recommendation Table 3 — Recommendations for the initial management of patients with acute coronary syndrome
| Recommendations | Class^a | Level^b | Quiz Question | Alternatives |
|---|---|---|---|---|
| Hypoxia | When is oxygen recommended for ACS patients? | A) SaO2 <80% B) SaO2 <90%* C) SaO2 >90% D) Always | ||
| Oxygen is recommended in patients with hypoxaemia (SaO2 <90%). | I | C | ||
| Routine oxygen is not recommended in patients without hypoxaemia (SaO2 >90%).^148,172 | III | A | Which patients should not routinely receive oxygen? | A) SaO2 <80% B) SaO2 <90% C) SaO2 >90%* D) Always |
| Symptoms | What should be considered to relieve pain in ACS patients? | A) Intravenous opioids* B) Oral opioids C) Mild tranquilizer D) Beta-blockers | ||
| Intravenous opioids should be considered to relieve pain. | IIa | C | ||
| A mild tranquilizer should be considered in very anxious patients. | IIa | C | What should be considered for very anxious ACS patients? | A) Intravenous opioids B) Oral opioids C) Mild tranquilizer* D) Beta-blockers |
| Recommendations | Class^a | Level^b | Quiz Question | Alternatives |
|---|---|---|---|---|
| Intravenous beta-blockers | What is the primary drug to consider for ACS patients without contraindications at presentation? | A) Mild tranquilizer B) Intravenous opioids C) Intravenous beta-blockers (preferably metoprolol)* D) None of the above | ||
| Intravenous beta-blockers (preferably metoprolol) should be considered at the time of presentation in patients undergoing PPCI with no signs of acute heart failure, an SBP >120 mmHg, and no other contraindications.^163–167,169 | IIa | A | ||
| Pre-hospital logistics of care | In which scenario should a pre-hospital management plan be based on regional networks? | A) For all ACS patients B) For patients with a working diagnosis of STEMI* C) For patients undergoing PPCI D) None of the above | ||
| It is recommended that the pre-hospital management of patients with a working diagnosis of STEMI is based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make PPCI available to as many patients as possible.^145 | I | B | ||
| It is recommended that PPCI-capable centres deliver a 24/7 service and are able to perform PPCI without delay.^173,174 | I | B | What should PPCI-capable centers provide? | A) 24/5 service B) 24/7 service* C) PPCI with delay D) PPCI only on weekdays |
| It is recommended that patients transferred for PPCI bypass the emergency department and CCU/ICU and are transferred directly to the catheterization laboratory.^137,175–178 | I | B | Where should patients transferred for PPCI go directly? | A) ICU B) CCU C) Emergency Department D) Catheterization laboratory* |
| It is recommended that EMS transfer patients with suspected STEMI to a PCI-capable centre, bypassing non-PCI centres. | I | C | Where should EMS transfer patients with suspected STEMI? | A) Any hospital B) PCI-capable centre* C) Non-PCI centres D) CCU |
| It is recommended that ambulance teams are trained and equipped to identify ECG patterns suggestive of acute coronary occlusion and to administer initial therapy, including defibrillation, and fibrinolysis when applicable.^142 | I | C | What training should ambulance teams have? | A) ECG identification* B) Administering fibrinolysis without identification C) Basic first aid D) All of the above |
| It is recommended that all hospitals and EMS participating in the care of patients with suspected STEMI record and audit delay times and work together to achieve and maintain quality targets. | I | C | What should hospitals and EMS do for STEMI care? | A) Ignore delay times B) Record and audit delay times* C) Work in isolation D) None of the above |
Recommendation Table 4 — Recommendations for re-perfusion therapy and timing of invasive strategy
| Recommendations | Class^a | Level^b | Quiz Question | Alternatives |
|---|---|---|---|---|
| Recommendations for reperfusion therapy for patients with STEMI | ||||
| Reperfusion therapy is recommended in all patients with a working diagnosis of STEMI (persistent ST-segment elevation or equivalents^c) and symptoms of ischaemia of <12 h duration. | I | A | What is the recommended therapy for patients with a diagnosis of STEMI and symptoms of ischaemia <12 h? | A) No therapy B) Fibrinolysis C) Reperfusion therapy* D) PPCI only |
| A PPCI strategy is recommended over fibrinolysis if the anticipated time from diagnosis to PCI is <120 min. | I | A | What is preferred if the time from diagnosis to PCI is <120 min? | A) PPCI* B) Fibrinolysis C) No therapy D) Delayed PCI |
| If timely PPCI (<120 min) cannot be performed in patients with a working diagnosis of STEMI, fibrinolytic therapy is recommended within 12 h of symptom onset in patients without contraindications. | I | A | When is fibrinolytic therapy recommended for STEMI patients if PPCI cannot be timely performed? | A) Within 24h B) Within 12h* C) Immediately D) Not recommended |
| Rescue PCI is recommended for failed fibrinolysis (i.e. ST-segment resolution <50% within 60–90 min of fibrinolytic administration) or in the presence of haemodynamic or electrical instability, worsening ischaemia, or persistent chest pain. | I | A | When is Rescue PCI recommended? | A) For all fibrinolytic therapies B) For failed fibrinolysis* C) Only if ST-segment resolution is >50% D) Within the first 30 min |
| In patients with a working diagnosis of STEMI and a time from symptom onset >12 h, a PPCI strategy is recommended in the presence of ongoing symptoms suggestive of ischaemia, haemodynamic instability, or life-threatening arrhythmias. | I | C | For STEMI patients with symptom onset >12h and ongoing symptoms, what is recommended? | A) Fibrinolysis B) PPCI* C) No therapy D) Wait and see |
| A routine PPCI strategy should be considered in STEMI patients presenting late (12–48 h) after symptom onset. | IIa | B | What should be considered for STEMI patients presenting late (12-48h)? | A) Fibrinolysis B) PPCI* C) Immediate surgery D) No therapy |
| Routine PCI of an occluded IRA is not recommended in STEMI patients presenting >48 h after symptom onset and without persistent symptoms. | III | A | What is NOT recommended for STEMI patients presenting >48h without persistent symptoms? | A) Fibrinolysis B) PPCI C) Routine PCI of an occluded IRA* D) Immediate surgery |
Transfer/interventions after fibrinolysis
| Recommendations | Class^a | Level^b | Quiz Question | Alternatives |
|---|---|---|---|---|
| Transfer/interventions after fibrinolysis | ||||
| Transfer to a PCI-capable centre is recommended in all patients immediately after fibrinolysis. | I | A | After fibrinolysis, where is it recommended to transfer all patients? | A) To a nearby hospital B) Home C) To a PCI-capable centre* D) To a non-PCI capable centre |
| Emergency angiography and PCI of the IRA, if indicated are recommended in patients with new-onset or persistent heart failure/shock after fibrinolysis. | I | A | For which patients is emergency angiography and PCI of the IRA recommended after fibrinolysis? | A) All patients B) Patients with a cough C) Patients with new-onset or persistent heart failure/shock* D) None of the patients |
| Angiography and PCI of the IRA, if indicated, is recommended between 2 and 24 h after successful fibrinolysis. | I | A | When is angiography and PCI of the IRA recommended after successful fibrinolysis? | A) Immediately B) Between 2 and 24 h* C) After 48 h D) Within 1 h |
Recommendation Table 4 — Recommendations for re-perfusion therapy and timing of invasive strategy
| Recommendations | Class^a | Level^b | Quiz Question | Alternatives |
|---|---|---|---|---|
| Invasive strategy in NSTE-ACS | ||||
| An invasive strategy during hospital admission is recommended in NSTE-ACS patients with high-risk criteria or a high index of suspicion for unstable angina. | I | A | When is an invasive strategy recommended for NSTE-ACS patients during hospital admission? | A) With medium-risk criteria B) With low index of suspicion C) With high-risk criteria or high suspicion for unstable angina* D) None of the above |
| A selective invasive approach is recommended in patients without very high- or high-risk NSTE-ACS criteria and with a low index of suspicion for NSTE-ACS. | I | A | For which NSTE-ACS patients is a selective invasive approach recommended? | A) With very high-risk criteria B) With high-risk criteria C) Without very high- or high-risk criteria and with low suspicion* D) With ongoing myocardial ischaemia |
| An immediate invasive strategy is recommended in patients with a working diagnosis of NSTE-ACS and with at least one of the following very high-risk criteria (e.g., Haemodynamic instability). | I | C | When is an immediate invasive strategy recommended for NSTE-ACS patients? | A) For all NSTE-ACS patients B) Those with at least one very high-risk criteria* C) Only those with transient ST-segment elevation D) Those with a GRACE risk score <140 |
| An early invasive strategy within 24 h should be considered in patients with at least one of the following high-risk criteria like Confirmed diagnosis of NSTEMI based on current recommended ESC hs-cTn algorithms. | IIa | A | When should an early invasive strategy be considered for patients with high-risk criteria like a confirmed NSTEMI diagnosis? | A) Within 48 h B) Within 12 h C) Within 24 h* D) Immediately |
Note: The asterisk (*) indicates the correct answer.
Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome
| Recommendations | Class^a | Level^b | Question | Alternatives |
|---|---|---|---|---|
| Antiplatelet therapy | ||||
| Aspirin is recommended for all patients without contraindications at an initial oral LD of 150–300 mg (or 75–250 mg i.v.) and an MD of 75–100 mg o.d. for long-term treatment. | I | A | ||
| In all ACS patients, a P2Y_12 receptor inhibitor is recommended in addition to aspirin, given as an initial oral LD followed by an MD for 12 months unless there is HBR.^C | I | A | ||
| A proton pump inhibitor in combination with DAPT is recommended in patients at high risk of gastrointestinal bleeding. | I | A | ||
| Prasugrel is recommended in P2Y_12 receptor inhibitor-naïve patients proceeding to PCI (60 mg LD, 10 mg o.d. MD, 5 mg o.d. MD for patients aged ≥75 years or with a body weight <60 kg). | I | B | ||
| Ticagrelor is recommended irrespective of the treatment strategy (invasive or conservative) (180 mg LD, 90 mg b.i.d. MD). | I | B | ||
| Clopidogrel (300–600 mg LD, 75 mg o.d. MD) is recommended when prasugrel or ticagrelor are not available, cannot be tolerated, or are contraindicated. | I | C | ||
| If patients presenting with ACS stop DAPT to undergo CABG, it is recommended they resume DAPT after surgery for at least 12 months. | I | C | ||
| Prasugrel should be considered in preference to ticagrelor for ACS patients who proceed to PCI. | IIa | B | ||
| GP IIb/IIIa receptor antagonists should be considered if there is evidence of no-reflow or a thrombotic complication during PCI. | IIa | C | ||
| In P2Y_12 receptor inhibitor-naïve patients undergoing PCI, cangrelor may be considered. | IIb | A | ||
| In older ACS patients, especially if HBR^c, clopidogrel as the P2Y_12 receptor inhibitor may be considered. | IIb | B | ||
| Pre-treatment with a P2Y_12 receptor inhibitor may be considered in patients undergoing a primary PCI strategy. | IIb | B | ||
| Pre-treatment with a P2Y_12 receptor inhibitor may be considered in NSTE-ACS patients who are not expected to undergo an early invasive strategy (<24 h) and do not have HBR.^263 | IIb | C | ||
| Pre-treatment with a GP IIb/IIIa receptor antagonist is not recommended. | III | A | ||
| Routine pre-treatment with a P2Y_12 receptor inhibitor in NSTE-ACS patients in whom coronary anatomy is not known and early invasive management (<24 h) is planned is not recommended. | III | A |
Recommendation Table 5 — Recommendations for antiplatelet and anticoagulant therapy in acute coronary syndrome
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Anticoagulant therapy | ||||
| Parenteral anticoagulation is recommended for all patients with ACS at the time of diagnosis. | I | A | What is recommended for all patients with ACS at the time of diagnosis? | 1) Parenteral anticoagulation 2) UFH bolus 3) Intravenous enoxaparin 4) Discontinuation of parenteral anticoagulation |
| Routine use of a UFH bolus (weight-adjusted i.v. bolus during PCI of 70–100 IU/kg) is recommended in patients undergoing PCI. | I | C | What is recommended for patients undergoing PCI? | 1) Parenteral anticoagulation 2) UFH bolus 3) Intravenous enoxaparin 4) Discontinuation of parenteral anticoagulation |
| Intravenous enoxaparin at the time of PCI should be considered in patients pre-treated with subcutaneous enoxaparin. | IIa | B | What should be considered for patients pre-treated with subcutaneous enoxaparin at the time of PCI? | 1) Parenteral anticoagulation 2) UFH bolus 3) Intravenous enoxaparin 4) Discontinuation of parenteral anticoagulation |
| Discontinuation of parenteral anticoagulation should be considered immediately after an invasive procedure. | IIa | C | What should be considered immediately after an invasive procedure? | 1) Parenteral anticoagulation 2) UFH bolus 3) Intravenous enoxaparin 4) Discontinuation of parenteral anticoagulation |
| Patients with STEMI | ||||
| Enoxaparin should be considered as an alternative to UFH in patients with STEMI undergoing PPCI. | IIa | A | What should be considered as an alternative to UFH for STEMI patients undergoing PPCI? | 1) Enoxaparin 2) Bivalirudin 3) Fondaparinux 4) Parenteral anticoagulation |
| Bivalirudin with a full-dose post PCI infusion should be considered as an alternative to UFH in patients with STEMI undergoing PPCI. | IIa | A | Which medication, with a full-dose post PCI infusion, should be considered as an alternative to UFH for STEMI patients undergoing PPCI? | 1) Enoxaparin 2) Bivalirudin 3) Fondaparinux 4) Parenteral anticoagulation |
| Fondaparinux is not recommended in patients with STEMI undergoing PPCI. | III | B | Which medication is not recommended for STEMI patients undergoing PPCI? | 1) Enoxaparin 2) Bivalirudin 3) Fondaparinux 4) Parenteral anticoagulation |
| Patients with NSTE-ACS | ||||
| For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is not anticipated, fondaparinux is recommended. | I | B | What is recommended for NSTE-ACS patients when early invasive angiography is not anticipated? | 1) Enoxaparin 2) Bivalirudin 3) Fondaparinux 4) Parenteral anticoagulation |
| For patients with NSTE-ACS in whom early invasive angiography (i.e. within 24 h) is anticipated, enoxaparin should be considered as an alternative to UFH. | IIa | B | What should be considered as an alternative to UFH for NSTE-ACS patients when early invasive angiography is anticipated? | 1) Enoxaparin 2) Bivalirudin 3) Fondaparinux 4) Parenteral anticoagulation |
Combining antiplatelets and OAC
| Recommendation | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Default strategy for patients with atrial fibrillation and CHA₂DS₂-VASc score ≥1 in men and ≥2 in women after up to 1 week of triple antithrombotic therapy… | I | A | What is the recommended strategy after 1 week of triple antithrombotic therapy following the ACS event for specified patients? | A) Triple therapy for 12 months B) Dual therapy using NOAC and an oral antiplatelet agent for 12 months* C) Only NOAC for 12 months D) Only oral antiplatelet for 12 months |
| During PCI, a UFH bolus is recommended in any of the following circumstances… | I | C | When is a UFH bolus recommended during PCI? | A) If the patient is on VKA B) If INR is >2.5 C) If the patient is on NOAC or if INR is <2.5 in VKA-treated patients* D) If the patient is not on any medication |
| In patients with an indication for OAC with VKA in combination with aspirin and/or clopidogrel… | IIa | B | What should be the target INR for VKA-treated patients with an indication for OAC combined with aspirin/clopidogrel? | A) INR of 1.5–2.0 B) INR of 2.0–2.5 with a time in the therapeutic range >70%* C) INR of 2.5–3.0 D) INR of 3.0–3.5 |
| When rivaroxaban is used and concerns about HBR prevail over ischaemic stroke… | IIa | B | When rivaroxaban is used and concerns about HBR prevail over ischaemic stroke, which dosage should be preferred? | A) 10 mg o.d. B) 15 mg o.d.* C) 20 mg o.d. D) 25 mg o.d. |
| In patients at HBR, dabigatran 110 mg b.i.d. should be considered… | IIa | B | Which dose of dabigatran should be considered for patients at HBR to mitigate bleeding risk during concomitant SAPT or DAPT? | A) 100 mg b.i.d. B) 110 mg b.i.d.* C) 150 mg b.i.d. D) 200 mg b.i.d. |
| In patients requiring anticoagulation and treated medically… | IIa | B | What should patients requiring anticoagulation and treated medically consider for up to 1 year? | A) A double antiplatelet agent B) No anticoagulant C) A single antiplatelet agent in addition to an OAC* D) Only OAC |
| In patients treated with an OAC, aspirin plus clopidogrel for longer than 1 week… | IIa | C | What is the recommendation for patients treated with an OAC with a high ischaemic risk or other factors? | A) Aspirin plus clopidogrel for less than 1 week B) Aspirin plus clopidogrel for more than 1 week* C) No aspirin or clopidogrel D) Only clopidogrel |
| In patients requiring OAC, withdrawing antiplatelet therapy at 6 months… | IIb | B | When should patients requiring OAC consider withdrawing antiplatelet therapy? | A) After 1 year B) After 6 months* C) After 3 months D) Do not withdraw |
| The use of ticagrelor or prasugrel as part of triple antithrombotic therapy… | III | C | Which antithrombotic agents are not recommended as part of triple therapy? | A) Aspirin and clopidogrel B) Ticagrelor or prasugrel* C) VKA D) Dabigatran |
Note: Asterisks (*) denote the correct alternatives.
Table 6 — Recommendations for alternative antithrombotic therapy regimens
| Recommendation | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| In patients who are event-free after 3–6 months of DAPT and are not at high ischaemic risk, single antiplatelet therapy (preferably with a P2Y₁₂ receptor inhibitor) should be considered. | IIa | A | What should be considered for patients event-free after 3-6 months of DAPT not at high ischaemic risk? | A) Discontinuing antiplatelet therapy B) Single antiplatelet therapy with P2Y₁₂ receptor inhibitor* C) Double antiplatelet therapy D) No therapy |
| De-escalation of P2Y₁₂ receptor inhibitor treatment (e.g. switch from prasugrel/ticagrelor to clopidogrel) may be considered as an alternative DAPT strategy to reduce bleeding risk. | IIb | A | What alternative DAPT strategy is suggested to reduce bleeding risk? | A) Continuing with prasugrel/ticagrelor B) Switching to aspirin only C) Switching from prasugrel/ticagrelor to clopidogrel* D) Discontinuing all treatments |
| In HBR patients, aspirin or P2Y₁₂ receptor inhibitor monotherapy after 1 month of DAPT may be considered. | IIb | B | What is recommended for HBR patients after 1 month of DAPT? | A) Continuation of DAPT B) Switching to aspirin only or P2Y₁₂ receptor inhibitor monotherapy* C) No therapy D) Adding a second antithrombotic agent |
| De-escalation of antiplatelet therapy in the first 30 days after an ACS event is not recommended. | III | B | What is the recommendation on de-escalation of antiplatelet therapy in the first 30 days post ACS event? | A) It is recommended B) It is not recommended* C) It is based on individual case D) No specific recommendation |
| Discontinuation of antiplatelet treatment in patients treated with an OAC is recommended after 12 months. | I | B | When is it recommended to discontinue antiplatelet treatment for patients on OAC? | A) After 6 months B) After 18 months C) After 24 months D) After 12 months* |
| Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention should be considered in patients with high ischaemic risk and without HBR. | IIa | A | What is suggested for extended long-term secondary prevention in patients with high ischaemic risk and without HBR? | A) Adding a second antithrombotic agent to aspirin* B) Discontinuing aspirin C) Using aspirin alone D) Using anticoagulant only |
| Adding a second antithrombotic agent to aspirin for extended long-term secondary prevention may be considered in patients with moderate ischaemic risk and without HBR. | IIb | A | What might be considered for extended long-term secondary prevention in patients with moderate ischaemic risk without HBR? | A) Adding a second antithrombotic agent to aspirin* B) Using aspirin only C) Discontinuing aspirin D) Using anticoagulant only |
| P2Y₁₂ inhibitor monotherapy may be considered as an alternative to aspirin monotherapy for long-term treatment. | IIb | A | Which monotherapy might be considered as an alternative to aspirin for long-term treatment? | A) P2Y₁₂ inhibitor* B) VKA C) DAPT D) No therapy |
Note: Asterisks (*) denote the correct alternatives.
OHCA
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Cardiac arrest and OHCA | What is the recommendation for patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation? | A) Not recommended for any patient. B) Recommended for all patients. C) Recommended if there’s an ST-segment elevation. D) No specific recommendation. | ||
| A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST-segment elevation (or equivalents). | I | B | ||
| Routine immediate angiography after resuscitated cardiac arrest is not recommended in haemodynamically stable patients without persistent ST-segment elevation (or equivalents). | III | A | When is routine immediate angiography recommended after resuscitated cardiac arrest? | A) Not in haemodynamically stable patients without persistent ST-segment elevation. B) In all patients. C) Only in patients with persistent ST-segment elevation. D) No specific recommendation. |
| Temperature control | How should temperature be managed after cardiac arrest? | A) No control required. B) Only monitor if there are symptoms of fever. C) Continuous monitoring and active prevention of fever. D) Only in cases of extreme temperatures. | ||
| Temperature control (i.e. continuous monitoring of core temperature and active prevention of fever [i.e. >37.7°C]) is recommended after either out-of-hospital or in-hospital cardiac arrest for adults who remain unresponsive after return of spontaneous circulation. | I | B | ||
| Systems of care | How should patients with suspected ACS after resuscitated cardiac arrest be managed? | A) Regular hospital care. B) They should not be hospitalized. C) Directly to a hospital offering 24/7 PPCI via one specialized EMS. D) Depends on the location of the patient. | ||
| It is recommended that healthcare systems implement strategies to facilitate transfer of all patients in whom ACS is suspected after resuscitated cardiac arrest directly to a hospital offering 24/7 PPCI via one specialized EMS. | I | C | ||
| Transport of patients with OHCA to a cardiac arrest centre according to local protocols should be considered. | IIa | C | Where should patients with OHCA be transported? | A) Any nearby medical facility. B) A cardiac arrest centre according to local protocols. C) Directly to a specialized EMS. D) Stay at the location of the arrest. |
| Evaluation of neurological prognosis | When should the neurological prognosis be evaluated in comatose survivors after cardiac arrest? | A) Immediately upon hospital admission. B) Only if there are visible neurological symptoms. C) No earlier than 72 h after admission. D) Before hospital admission. | ||
| Evaluation of neurological prognosis (no earlier than 72 h after admission) is recommended in all comatose survivors after cardiac arrest. | I | C |
Note: Asterisks indicate the correct answer.
Cardiogen shock
Recommendation Table 9 — Recommendations for cardiogenic shock
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Immediate coronary angiography and PCI of the IRA (if indicated) is recommended in patients with CS complicating ACS. | I | B | What is the primary recommendation for CS patients with ACS complications? | 1) Delayed coronary angiography 2) MRI Scan 3) Immediate coronary angiography and PCI of the IRA 4) Avoid all procedures |
| Emergency CABG is recommended for ACS-related CS if PCI of the IRA is not feasible/unsuccessful. | I | B | What is recommended if PCI of the IRA is unsuccessful in ACS-related CS? | 1) Routine ECG 2) Emergency CABG 3) Wait and observe 4) Immediate coronary angiography |
| In cases of haemodynamic instability, emergency surgical/catheter-based repair of mechanical complications of ACS is recommended, based on Heart Team discussion. | I | C | When is emergency surgical/catheter-based repair recommended? | 1) Always 2) In cases of haemodynamic instability 3) Only with successful PCI 4) After CABG |
| Fibrinolysis should be considered in STEMI patients presenting with CS if a PPCI strategy is not available within 120 min from the time of STEMI diagnosis and mechanical complications have been ruled out. | IIa | C | When should fibrinolysis be considered in STEMI patients with CS? | 1) Always 2) Never 3) If PPCI strategy isn’t available within 120 min and no mechanical complications 4) Before any other treatment |
| In patients with ACS and severe/refractory CS, short-term mechanical circulatory support may be considered. | IIb | C | What might be considered for ACS patients with severe CS? | 1) Long-term mechanical support 2) Short-term mechanical circulatory support 3) Immediate CABG 4) Fibrinolysis |
| The routine use of an IABP in ACS patients with CS and without mechanical complications is not recommended. | III | B | What is the recommendation on the use of IABP in ACS patients with CS without mechanical complications? | 1) Always use IABP 2) Use IABP after CABG 3) Routine use of IABP is not recommended 4) Only use IABP with fibrinolysis |
Note: The asterisk denotes the correct alternative for each question.
Recommendation Table 10 — Recommendations for in-hospital management
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| It is recommended that all hospitals participating in the care of high-risk patients have an ICCU/CCU equipped to provide all required aspects of care, including treatment of ischaemia, severe heart failure, arrhythmias, and common comorbidities. | I | C | What should hospitals caring for high-risk patients be equipped with? | 1) Only basic cardiac care 2) ICCU/CCU with comprehensive care capabilities 3) Only an emergency room 4) Only outpatient services |
| It is recommended that high-risk patients (including all STEMI patients and very high-risk NSTE-ACS patients) have ECG monitoring for a minimum of 24 h. | I | C | How long should high-risk patients, including STEMI patients, be monitored via ECG? | 1) For 48 h 2) Only during surgery 3) For a minimum of 24 h 4) Until they feel better |
| It is recommended that high-risk patients with successful reperfusion therapy and an uncomplicated clinical course (including all STEMI patients and very high-risk NSTE-ACS patients) are kept in the CCU/ICCU for a minimum of 24 h whenever possible, after which they may be moved to a step-down monitored bed for an additional 24–48 h. | I | C | After successful reperfusion therapy, where should high-risk patients be kept? | 1) Directly in a regular room 2) In outpatient care 3) In the CCU/ICCU for at least 24 h, then a step-down monitored bed 4) Sent home immediately |
| Discharge of selected high-risk patients within 48–72 h should be considered if early rehabilitation and adequate follow-up are arranged. | IIa | A | When can selected high-risk patients be considered for discharge? | 1) Immediately after treatment 2) Only after a week 3) Within 48–72 h if early rehabilitation and follow-up are ensured 4) After one month |
| Same-day transfer in selected stable patients after successful and uneventful PCI should be considered. | IIa | C | When should selected stable patients be considered for same-day transfer after PCI? | 1) After a successful and uneventful PCI 2) Always, regardless of PCI results 3) Only after 48 h 4) If they report discomfort |
| Routine echocardiography is recommended during hospitalization to assess regional and global LV function, detect mechanical complications, and exclude LV thrombus. | I | C | Why is routine echocardiography recommended during hospitalization? | 1) Only for comfort 2) To assess LV function and detect complications 3) To plan for surgeries 4) For patient education |
| When echocardiography is suboptimal/inconclusive, CMR imaging may be considered. | IIb | C | What can be considered when echocardiography results are not clear? | 1) Immediate surgery 2) Discharge the patient 3) More physical exams 4) CMR imaging |
Note: The asterisk denotes the correct alternate
Recommendation Table 11 — Recommendations for technical aspects of invasive strategies
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Radial access is recommended as the standard approach, unless there are overriding procedural considerations. | I | A | Which access is recommended as the standard approach for invasive strategies? | 1) Radial access 2) Femoral access 3) Brachial access 4) Carotid access |
| PCI with stent deployment in the IRA during the index procedure is recommended in patients undergoing PPCI. | I | A | When is PCI with stent deployment in the IRA recommended? | 1) In all heart surgeries 2) During the index procedure for patients undergoing PPCI 3) Only if there are complications 4) After PPCI, in a separate procedure |
| Drug-eluting stents are recommended in preference to bare metal stents in all cases. | I | A | Which type of stents is recommended over bare metal stents? | 1) Drug-eluting stents 2) Biodegradable stents 3) Metallic stents 4) Plastic stents |
| In patients with spontaneous coronary artery dissection, PCI is recommended only for patients with symptoms and signs of ongoing myocardial ischaemia, a large area of myocardium in jeopardy, and reduced antegrade flow. | I | C | For which patients with spontaneous coronary artery dissection is PCI recommended? | 1) All patients, regardless of symptoms 2) Only those with symptoms of ongoing myocardial ischaemia, a jeopardized myocardium area, and reduced antegrade flow 3) Those without any symptoms 4) Only elderly patients |
| Intravascular imaging should be considered to guide PCI. | IIa | A | What should be considered to guide PCI? | 1) ECG results 2) Patient feedback 3) Intravascular imaging 4) External ultrasound |
| Coronary artery bypass grafting should be considered in patients with an occluded IRA when PPCI is not feasible/unsuccessful and there is a large area of myocardium in jeopardy. | IIa | C | When should coronary artery bypass grafting be considered? | 1) In patients with occluded IRA, when PPCI isn’t possible and there’s a jeopardized myocardium area 2) In all heart patients 3) Only in young patients 4) As an alternative to all other procedures |
| Intravascular imaging (preferably optical coherence tomography) may be considered in patients with ambiguous culprit lesions. | IIb | C | In which cases might intravascular imaging with optical coherence tomography be considered? | 1) In routine check-ups 2) When there’s an equipment malfunction 3) For patients with ambiguous culprit lesions 4) For all heart surgeries |
| The routine use of thrombus aspiration is not recommended. | III | A | What is the recommendation regarding the routine use of thrombus aspiration? | 1) It’s mandatory for all procedures 2) It should be used only in emergencies 3) It is not recommended routinely 4) It should be used in every other procedure |
Note: The asterisk denotes the correct alternative for each question.
Recommendation Table 7 — Recommendations for fibrinolytic therapy
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| When fibrinolysis is the reperfusion strategy, it is recommended to initiate this treatment as soon as possible after diagnosis in the pre-hospital setting (aim for target of <10 min to lytic bolus). | I | A | When should fibrinolysis be initiated if it’s the chosen reperfusion strategy? | 1) As soon as possible in the pre-hospital setting 2) Only in the hospital after other tests 3) Within 30 minutes of diagnosis 4) After patient stabilization |
| A fibrin-specific agent (i.e. tenecteplase, alteplase, or reteplase) is recommended. | I | B | Which agents are recommended as fibrin-specific for fibrinolysis? | 1) Tenecteplase, alteplase, or reteplase 2) Aspirin, clopidogrel, or ibuprofen 3) Metoprolol, amlodipine, or lisinopril 4) Warfarin, heparin, or rivaroxaban |
| A half-dose of tenecteplase should be considered in patients >75 years of age. | IIa | B | In which patients should a half-dose of tenecteplase be considered? | 1) In all patients regardless of age 2) In children and teenagers 3) In patients older than 75 years 4) In patients with a BMI above 30 |
| Aspirin and clopidogrel are recommended. | I | A | Which co-therapy drugs are recommended with fibrinolysis? | 1) Aspirin and clopidogrel 2) Ibuprofen and naproxen 3) Metoprolol and amlodipine 4) Warfarin and heparin |
| Anticoagulation is recommended in patients treated with fibrinolysis until revascularization (if performed) or for the duration of hospital stay (up to 8 days). | I | A | Until when is anticoagulation recommended in patients treated with fibrinolysis? | 1) Only for the first 24 hours 2) Until discharge, regardless of the number of days 3) Until revascularization or up to 8 days of hospital stay 4) For a month post-discharge |
| Enoxaparin i.v. followed by s.c. is recommended as the preferred anticoagulant. | I | A | Which is the preferred anticoagulant after fibrinolysis? | 1) Enoxaparin 2) Warfarin 3) Heparin 4) Rivaroxaban |
| When enoxaparin is not available, UFH is recommended as a weight-adjusted i.v. bolus, followed by s.c. | I | B | What’s the recommendation if enoxaparin isn’t available? | 1) Do not administer any anticoagulant 2) Use any available anticoagulant in any dosage 3) Use UFH as a weight-adjusted i.v. bolus, then s.c. 4) Only administer rivaroxaban |
| In patients treated with streptokinase, an i.v. bolus of fondaparinux followed by an s.c. dose 24 h later should be considered. | IIa | B | In patients treated with what agent should an i.v. bolus of fondaparinux be considered? | 1) Tenecteplase 2) Streptokinase 3) Enoxaparin 4) Reteplase |
Note: The asterisk denotes the correct alternative for each question.
Recommendation Table 12 — Recommendations for management of patients with multivessel disease
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| It is recommended to base the revascularization strategy (IRA PCI/PCI/CABG) on the patient’s clinical status and comorbidities, as well as their disease complexity, according to the principles of management of myocardial revascularization. | I | B | On what should the revascularization strategy be based? | 1) Patient’s clinical status, comorbidities, and disease complexity 2) Patient’s age and gender 3) Hospital’s available equipment 4) Doctor’s preference |
| IRA-only PCI during the index procedure is recommended. | I | B | Which procedure is recommended during the index for multivessel disease in ACS patients presenting in cardiogenic shock? | 1) IRA-only PCI 2) Only CABG 3) No intervention 4) All available procedures |
| Staged PCI of non-IRA should be considered. | IIa | C | What should be considered regarding the non-IRA during the index procedure? | 1) Immediate CABG 2) No intervention 3) Staged PCI 4) Medical management only |
| Complete revascularization is recommended either during the index PCI procedure or within 45 days. | I | A | When is complete revascularization recommended for hemodynamically stable STEMI patients undergoing PPCI? | 1) Only during the index PCI procedure 2) Within 3 days of the index procedure 3) Either during the index PCI procedure or within 45 days 4) Within 6 months of the index procedure |
| It is recommended that PCI of the non-IRA is based on angiographic severity. | I | B | On what basis should PCI of the non-IRA be considered? | 1) Patient’s comfort level 2) Angiographic severity 3) Patient’s age 4) Doctor’s preference |
| Invasive epicardial assessment of non-culprit segments of the IRA is not recommended during the index procedure. | III | C | What is NOT recommended regarding the IRA’s non-culprit segments during the index procedure? | 1) Invasive epicardial assessment 2) PCI 3) CABG 4) Medical management |
| In patients presenting with NSTE-ACS and MVD, complete revascularization should be considered, preferably during the index procedure. | IIa | C | When should complete revascularization be considered for patients with NSTE-ACS and MVD? | 1) Only post-discharge 2) Preferably during the index procedure 3) Within 3 days of the index procedure 4) After medical management has been tried |
| Functional invasive evaluation of non-IRA severity during the index procedure may be considered. | IIb | B | What might be considered regarding the non-IRA’s severity during the index procedure? | 1) Ignoring its severity 2) Only medical management 3) Functional invasive evaluation 4) Using non-invasive methods only |
Note: The asterisk denotes the correct alternative for each question.
Recommendation Table 13 — Recommendations for myocardial infarction with non-obstructive coronary arteries
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| In patients with a working diagnosis of MINOCA, CMR imaging is recommended after invasive angiography if the final diagnosis is not clear. | I | B | What imaging method is recommended for patients with a working diagnosis of MINOCA when the final diagnosis isn’t clear? | 1) CMR imaging after invasive angiography 2) CT scan before invasive angiography 3) Ultrasound imaging 4) Non-invasive angiography |
| Management of MINOCA according to the final established underlying diagnosis is recommended, consistent with the appropriate disease-specific guidelines. | I | B | How should MINOCA be managed? | 1) According to patient’s preferences 2) Solely based on symptoms 3) According to the final established underlying diagnosis using disease-specific guidelines 4) Using trial-and-error methods |
| In all patients with an initial working diagnosis of MINOCA, it is recommended to follow a diagnostic algorithm to determine the underlying final diagnosis. | I | C | What approach is recommended for patients with an initial working diagnosis of MINOCA to determine the underlying final diagnosis? | 1) Empirical treatment without further diagnosis 2) Referring to another specialist without following any algorithm 3) Following a diagnostic algorithm 4) Using patient-reported outcomes to decide the diagnosis |
Note: The asterisk denotes the correct alternative for each qu
Recommendation Table 14 — Recommendations for acute coronary syndrome complications
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| IABP should be considered in patients with haemodynamic instability/cardiogenic shock due to ACS-related mechanical complications. | IIa | C | When should IABP be considered in ACS-related complications? | 1) In patients with haemodynamic instability/cardiogenic shock 2) In all ACS patients 3) Only in ACS patients without mechanical complications 4) In patients with mild ACS symptoms |
| CMR imaging should be considered in patients with equivocal echocardiographic images or in cases of high clinical suspicion of LV thrombus. | IIa | C | When should CMR imaging be considered for potential LV thrombus? | 1) In cases with equivocal echocardiographic images or high clinical suspicion 2) In all ACS patients 3) Only when patient complains of pain 4) After confirming with CT scan |
| Oral anticoagulant therapy (VKA or NOAC) should be considered for 3–6 months in patients with confirmed LV thrombus. | IIa | C | How long should oral anticoagulant therapy be considered for patients with confirmed LV thrombus? | 1) For 1 month 2) For 6–12 months 3) For 3–6 months 4) For 12–24 months |
| Following an acute anterior MI, a contrast echocardiogram may be considered for the detection of LV thrombus if the apex is not well visualized on echocardiography. | IIb | C | When might a contrast echocardiogram be considered after an acute anterior MI? | 1) If the apex is not well visualized on echocardiography 2) Always after an anterior MI 3) If patient experiences chest pain 4) Based solely on doctor’s preference |
| Intravenous beta-blockers are recommended when rate control is needed in the absence of acute HF or hypotension. | I | C | When are intravenous beta-blockers recommended for rate control? | 1) In the absence of acute HF or hypotension 2) Only in the presence of acute HF 3) If patient has hypotension 4) Always, irrespective of HF or hypotension |
| Intravenous amiodarone is recommended when rate control is needed in the presence of acute HF and no hypotension. | I | C | Under what conditions is intravenous amiodarone recommended for rate control? | 1) Always for rate control 2) If patient has hypotension 3) In the presence of acute HF and no hypotension 4) Only in the absence of acute HF |
| Immediate electrical cardioversion is recommended in patients with ACS and haemodynamic instability and when adequate rate control cannot be achieved promptly with pharmacological agents. | I | C | When is immediate electrical cardioversion recommended? | 1) In ACS patients with haemodynamic instability & inadequate rate control via drugs 2) Always for ACS patients 3) Only when patient requests it 4) In the presence of acute HF |
| Intravenous amiodarone is recommended to facilitate electrical cardioversion and/or decrease risk for early recurrence of AF after electrical cardioversion in unstable patients with recent-onset AF. | IIa | C | Why is intravenous amiodarone recommended after electrical cardioversion in unstable patients with recent-onset AF? | 1) To facilitate cardioversion & decrease recurrence risk 2) To control blood pressure 3) As a prophylactic measure 4) To reduce pain |
| In patients with documented de novo AF during the acute phase of ACS, long-term oral anticoagulation should be considered depending on the CHA₂DS₂–VASc score, after taking the HAS-BLED score and the need for concomitant antiplatelet therapy into consideration. NOACs are the preferred drugs. | IIa | C | Which factors should be considered for long-term oral anticoagulation in de novo AF during the acute phase of ACS? | 1) Only the CHA₂DS₂–VASc score 2) Only the HAS-BLED score 3) CHA₂DS₂–VASc score, HAS-BLED score & need for concomitant antiplatelet therapy 4) Patient’s age & gender |
Note: The asterisk denotes the correct alternative
Recommendation Table 14 — Recommendations for acute coronary syndrome complications (Ventricular arrhythmias)
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| ICD therapy is recommended to reduce sudden cardiac death in patients with symptomatic HF (NYHA Class II–III) and LVEF ≤35% despite optimal medical therapy for >3 months and at least 6 weeks after MI who are expected to survive for at least 1 year with good functional status. | I | A | When is ICD therapy recommended for patients with symptomatic HF? | 1) With NYHA Class II–III, LVEF ≤35%, >3 months of therapy & at least 6 weeks post-MI with expected 1-year survival 2) Immediately after any MI 3) Only if patient is above 60 years old 4) Only with NYHA Class IV |
| Intravenous beta-blocker and/or amiodarone treatment is recommended for patients with polymorphic VT and/or VF unless contraindicated. | I | B | Which treatments are recommended for patients with polymorphic VT and/or VF? | 1) Intravenous beta-blocker and/or amiodarone 2) Oral calcium channel blockers 3) Regular physiotherapy sessions 4) Immediate ICD implantation |
| Prompt and complete revascularization is recommended to treat myocardial ischemia that may be present in patients with recurrent VT and/or VF. | I | C | How should myocardial ischemia in patients with recurrent VT and/or VF be treated? | 1) Prompt and complete revascularization 2) With long-term medication only 3) Immediate electrical cardioversion 4) Observation without intervention |
| Transvenous catheter pacing termination and/or overdrive pacing should be considered if VT cannot be controlled by repeated electrical cardioversion. | IIa | C | What should be considered if VT is uncontrolled by repeated electrical cardioversion? | 1) Transvenous catheter pacing termination and/or overdrive pacing 2) Intravenous diuretics 3) Administering oxygen therapy 4) Increasing the dosage of current medication |
| Radiofrequency catheter ablation at a specialized ablation center followed by ICD implantation should be considered in patients with recurrent VT, VF, or electrical storm despite complete revascularization and optimal medical therapy. | IIa | C | In which patients should radiofrequency catheter ablation followed by ICD implantation be considered? | 1) With recurrent VT, VF, or electrical storm despite complete revascularization and therapy 2) In all ACS patients 3) Only in patients with NYHA Class IV 4) Only in elderly patients |
| Treatment of recurrent VT with haemodynamic relevance (despite repeated electrical cardioversion) with lidocaine may be considered if beta-blockers, amiodarone, and overdrive stimulation are not effective/applicable. | IIb | C | What might be considered for recurrent VT with haemodynamic relevance not controlled by other measures? | 1) Treatment with lidocaine 2) Intravenous magnesium sulfate 3) Switching to a different beta-blocker 4) Immediate surgery |
| In patients with recurrent life-threatening ventricular arrhythmias, sedation or general anesthesia to reduce sympathetic drive may be considered. | IIb | C | What may be considered for patients with recurrent life-threatening ventricular arrhythmias? | 1) Sedation or general anesthesia to reduce sympathetic drive 2) Immediate pacemaker implantation 3) High doses of oral beta-blockers 4) Referral to a mental health professional |
| ICD implantation or the temporary use of a wearable cardioverter-defibrillator may be considered <40 days after MI in selected patients (incomplete revascularization, persisting LVEF dysfunction, occurrence of arrhythmias >48 h after STEMI onset, polytopic PVC or VT). | IIb | C | When might ICD implantation or the use of a wearable cardioverter-defibrillator be considered after an MI? | 1) Always within 10 days post-MI 2) Only if the patient experiences chest pain 3) <40 days post-MI in selected cases (incomplete revascularization, etc.) 4) Only if patient requests it |
Note: The asterisk denotes the correct alternative for e
Bradyarrhythmias Recommendations
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| In cases of sinus bradycardia with haemodynamic intolerance or high-degree AV block without stable escape rhythm: i.v. positive chronotropic medication (adrenaline, vasopressin, and/or atropine) is recommended. | I | C | What is recommended for sinus bradycardia with haemodynamic intolerance or high-degree AV block without stable escape rhythm? | 1) i.v. positive chronotropic medication (adrenaline, vasopressin, and/or atropine) 2) Immediate cardioversion 3) Radiofrequency ablation 4) Sedation |
| Temporary pacing is recommended in cases of failure to respond to atropine. | I | C | What is recommended if there is a failure to respond to atropine? | 1) Temporary pacing 2) Intravenous fluids 3) Beta-blocker therapy 4) Observation |
| Urgent angiography with a view to revascularization is recommended if the patient has not received previous reperfusion therapy. | I | C | What is recommended for a patient who hasn’t received previous reperfusion therapy? | 1) Urgent angiography with a view to revascularization 2) Immediate discharge 3) Commencement of oral anticoagulants 4) Stress test |
| Implantation of a permanent pacemaker is recommended when high-degree AV block does not resolve within a waiting period of at least 5 days after MI. | I | C | When is the implantation of a permanent pacemaker recommended in the context of a high-degree AV block post-MI? | 1) If it doesn’t resolve within at least 5 days 2) Immediately after MI 3) Only if there are recurrent arrhythmias 4) Only if the patient is symptomatic |
| In selected patients with high-degree AV block in the context of an anterior wall MI and acute HF, early device implantation (CRT-D/CRT-P) may be considered. | IIb | C | In which patients might early device implantation (CRT-D/CRT-P) be considered? | 1) Those with high-degree AV block, anterior wall MI, and acute HF 2) All MI patients irrespective of the location 3) Those with only a high-degree AV block 4) Only if the patient has a history of arrhythmias |
| Pacing is not recommended if high-degree AV block resolves after revascularization or spontaneously. | III | B | When is pacing not recommended in the context of a high-degree AV block? | 1) If it resolves after revascularization or spontaneously 2) If the patient is asymptomatic 3) Within 24 hours of detection 4) In older patients |
Note: The asterisk denotes the correct alternative
Recommendations for Acute Coronary Syndrome Comorbid Conditions
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Chronic kidney disease | ||||
| The use of low- or iso-osmolar contrast media (at the lowest possible volume) is recommended for invasive strategies. | I | A | Which type of contrast media is recommended for invasive strategies in patients with chronic kidney disease? | 1) Low- or iso-osmolar contrast media at the lowest possible volume 2) High-osmolar contrast media 3) Any contrast media in high volume 4) Non-ionic contrast media |
| It is recommended to assess kidney function using eGFR in all patients with ACS. | I | A | How should kidney function be assessed in patients with ACS? | 1) Using eGFR 2) Using serum creatinine levels 3) Urinalysis 4) Using creatinine clearance |
| It is recommended to apply the same diagnostic and therapeutic strategies in patients with CKD (dose adjustment may be necessary) as in patients with normal kidney function. | I | A | How should patients with CKD be managed compared to those with normal kidney function? | 1) Use the same diagnostic and therapeutic strategies with potential dose adjustments 2) Avoid all medications 3) Use only alternative therapies 4) Only focus on symptomatic relief |
| Hydration during and after angiography should be considered in patients at risk of contrast-induced nephropathy, especially in patients with acute kidney injury and/or CKD with eGFR <30 mL/min/1.73 m^2. | IIa | B | Who should be considered for hydration during and after angiography? | 1) Patients at risk of contrast-induced nephropathy, especially those with AKI or CKD with eGFR <30 mL/min/1.73 m^2 2) All patients undergoing angiography 3) Only patients with eGFR >60 mL/min/1.73 m^2 4) Patients without CKD |
| Diabetes | ||||
| It is recommended to base the choice of long-term glucose-lowering treatment on the presence of comorbidities, including heart failure, CKD, and obesity. | I | A | On what should the choice of long-term glucose-lowering treatment be based? | 1) Presence of comorbidities like heart failure, CKD, and obesity 2) Patient’s age 3) Duration of diabetes 4) Blood sugar levels alone |
| It is recommended to assess glycemic status at initial evaluation in all patients with ACS. | I | B | What should be assessed at the initial evaluation in all patients with ACS? | 1) Glycemic status 2) Lipid profile 3) Kidney function 4) Liver enzymes |
| It is recommended to frequently monitor blood glucose levels in patients with known diabetes mellitus or hyperglycemia (defined as glucose levels >11.1 mmol/L or >200 mg/dL). | I | C | Who should have frequent monitoring of blood glucose levels? | 1) Patients with known diabetes or hyperglycemia (glucose >11.1 mmol/L or >200 mg/dL) 2) All elderly patients 3) All patients with CKD 4) Patients with mild hyperglycemia |
| Glucose-lowering therapy should be considered in patients with ACS with persistent hyperglycemia, while episodes of hypoglycemia should be avoided. | I | C | When should glucose-lowering therapy be considered in patients with ACS? | 1) In cases of persistent hyperglycemia, avoiding hypoglycemia 2) Only if the patient is symptomatic 3) In all patients regardless of glycemic status 4) Only in patients without other comorbidities |
Note: The asterisk denotes the cor
Recommendations for Acute Coronary Syndrome Comorbid Conditions
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Older adults | ||||
| It is recommended to apply the same diagnostic and treatment strategies in older patients as in younger patients. | I | B | Should older patients be treated with the same diagnostic and treatment strategies as younger patients in ACS? | 1) Yes 2) No 3) Only if they have no comorbidities 4) Only for diagnostics |
| It is recommended to adapt the choice and dosage of thrombotic agent, as well as of secondary prevention medications, to renal function, co-medications, comorbidities, frailty, cognitive function, and specific contraindications. | I | B | What should the choice and dosage of thrombotic agent in older adults with ACS be based on? | 1) Renal function, co-medications, comorbidities, frailty, cognitive function, and specific contraindications 2) Age alone 3) Duration of ACS 4) Patient’s weight |
| For older patients with comorbidities, a holistic approach is recommended to individualize interventional and pharmacological treatments after careful evaluation of the risks and benefits. | I | B | How should older patients with comorbidities be treated for ACS? | 1) A holistic approach with individualized treatments after evaluating risks and benefits 2) Standard treatment 3) Minimal interventions 4) Only pharmacological treatments |
| Patients with cancer | ||||
| An invasive strategy is recommended in cancer patients presenting with high-risk ACS with expected survival ≥6 months. | I | A | In which cancer patients with ACS is an invasive strategy recommended? | 1) High-risk ACS patients with expected survival ≥6 months 2) All cancer patients irrespective of risk 3) Only those with metastatic cancer 4) Only if the patient is symptomatic |
| A temporary interruption of cancer therapy is recommended in patients in whom the cancer therapy is suspected to be a contributing cause of ACS. | IIa | B | When should a temporary interruption of cancer therapy be considered? | 1) When cancer therapy is suspected to be a contributing cause of ACS 2) In all patients undergoing treatment for ACS 3) Never 4) Only if the patient has side effects from the cancer therapy |
| A conservative non-invasive strategy should be considered in ACS patients with poor cancer prognosis (i.e., with expected survival <6 months) and/or very high bleeding risk. | IIa | B | Which ACS patients with cancer should be considered for a conservative non-invasive strategy? | 1) Those with poor prognosis (expected survival <6 months) and/or very high bleeding risk 2) All patients irrespective of prognosis 3) Only those with metastatic cancer 4) Those with expected survival >6 months |
| Aspirin is not recommended in cancer patients with a platelet count <100,000/µL. | III | C | In which cancer patients is aspirin not recommended? | 1) Those with a platelet count <100,000/µL 2) All patients 3) Those with a platelet count >300,000/µL 4) Only if they are symptomatic |
| Clopidogrel is not recommended in cancer patients with a platelet count <30,000/µL. | III | C | In which cancer patients is clopidogrel not recommended? | 1) Those with a platelet count <30,000/µL 2) All patients 3) Those with a platelet count >100,000/µL 4) Only if they are on other anticoagulants |
| In ACS patients with cancer and <50,000/µL platelet count, prasugrel or ticagrelor are not recommended. | III | C | Which medications are not recommended for ACS patients with cancer and <50,000/µL platelet count? | 1) Prasugrel or ticagrelor 2) Aspirin and clopidogrel 3) Beta-blockers 4) ACE inhibitors |
Note: The asterisk indicates the correct
Recommendations for Long-Term Management
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Cardiac rehabilitation | ||||
| It is recommended that all ACS patients participate in a medically supervised, structured, comprehensive, and multidisciplinary exercise-based cardiac rehabilitation programme. | I | A | Which ACS patients should participate in a cardiac rehabilitation programme? | 1) All ACS patients 2) Only those with severe ACS 3) Those below 50 years 4) Only if they have co-morbidities |
| Lifestyle management | ||||
| It is recommended that ACS patients adopt a healthy lifestyle, including: stopping smoking, healthy diet (Mediterranean style), alcohol restriction, regular aerobic physical activity and resistance exercise, reduced sedentary time. | I | B | Which of the following is recommended for ACS patients as a lifestyle change? | 1) All of the mentioned (stopping smoking, Mediterranean diet, etc.) 2) Only stopping smoking 3) Only alcohol restriction 4) Only exercise |
| In smokers, offering follow-up support, nicotine replacement therapy, varenicline or bupropion, individually or in combination, should be considered. | IIa | A | What support should be offered to smokers who are ACS patients? | 1) Follow-up support, nicotine replacement, varenicline or bupropion 2) Just counseling 3) Only nicotine replacement 4) No additional support |
| Pharmacological treatment | ||||
| Lipid-lowering therapy | ||||
| It is recommended that high-dose statin therapy is initiated or continued as early as possible, regardless of initial LDL-C values. | I | A | When should high-dose statin therapy be initiated for ACS patients? | 1) As early as possible 2) After 1 week of ACS diagnosis 3) Only if LDL-C is above a certain threshold 4) Only in recurrent ACS patients |
| It’s recommended to aim to achieve an LDL-C level of ≤1.4 mmol/L (≤55 mg/dL) and to reduce LDL-C by ≥50% from baseline. | I | A | What is the target LDL-C level for ACS patients under therapy? | 1) ≤1.4 mmol/L (≤55 mg/dL) and a reduction of ≥50% from baseline 2) ≤2.0 mmol/L (≤80 mg/dL) 3) No specific target, only monitor 4) Only based on patient’s age |
| If the LDL-C goal is not achieved despite maximally tolerated statin therapy after 4-6 weeks, the addition of ezetimibe is recommended. | IIb | B | What is recommended if the LDL-C goal isn’t achieved after 4-6 weeks of max statin therapy? | 1) Addition of ezetimibe 2) Increase the dose of statin 3) Switch to a different statin 4) Monitor for another 4-6 weeks |
| If the LDL-C goal is not achieved despite maximally tolerated statin therapy and ezetimibe after 4-6 weeks, the addition of a PCSK9 inhibitor is recommended. | IIb | B | If the LDL-C goal isn’t met even after adding ezetimibe to max statin therapy, what’s next? | 1) Addition of a PCSK9 inhibitor 2) Change the entire treatment regimen 3) Stop ezetimibe 4) Double the dose of statin |
| It’s recommended to intensify lipid-lowering therapy during the index ACS hospitalization for patients who were on lipid-lowering therapy before admission. | I | B | What should be done regarding lipid-lowering therapy during ACS hospitalization if a patient was already on such therapy? | 1) Intensify the lipid-lowering therapy 2) Continue with the same regimen 3) Stop lipid-lowering therapy 4) Only monitor LDL-C levels |
Note: The asterisk indicates the correct
Recommendations
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Beta-blockers | ||||
| Beta-blockers are recommended in ACS patients with LVEF ≤40% regardless of HF symptoms. | I | A | In which ACS patients are beta-blockers recommended? | 1) Those with LVEF ≤40%, regardless of HF symptoms 2) Only if they have HF symptoms 3) Those with LVEF >40% 4) Only if they don’t have any other medications |
| Routine beta-blockers for all ACS patients regardless of LVEF should be considered. | IIa | B | Should all ACS patients be considered for beta-blocker therapy? | 1) Yes, regardless of LVEF 2) No, only if they have a certain LVEF 3) Only if they have HF symptoms 4) Only in recurrent ACS patients |
| RAAS system inhibitors | ||||
| Angiotensin-converting enzyme (ACE) inhibitors are recommended in ACS patients with HF symptoms, LVEF ≤40%, diabetes, hypertension, and/or CKD. | I | A | For which patients are ACE inhibitors recommended in ACS? | 1) Those with HF symptoms, LVEF ≤40%, diabetes, hypertension, and/or CKD 2) Only if they have diabetes 3) Only with hypertension 4) All ACS patients |
| Mineralocorticoid receptor antagonists are recommended in ACS patients with LVEF ≤40% and HF or diabetes. | I | A | Who should be prescribed mineralocorticoid receptor antagonists in ACS? | 1) Those with LVEF ≤40% and HF or diabetes 2) Only with LVEF ≤30% 3) Only if they have CKD 4) All ACS patients regardless of conditions |
| Routine ACE inhibitors for all ACS patients regardless of LVEF should be considered. | IIa | B | Should all ACS patients be considered for ACE inhibitor therapy? | 1) Yes, regardless of LVEF 2) No, only if they have a certain LVEF 3) Only if they have diabetes 4) Only if they have HF symptoms |
| Adherence to medication | ||||
| A polypill should be considered as an option to improve adherence and outcomes in secondary prevention after ACS. | IIa | B | What can be considered to improve adherence and outcomes after ACS? | 1) A polypill 2) Regular counseling 3) Patient’s own choice of medication 4) No need for additional measures |
| Imaging | ||||
| In patients with pre-discharge LVEF ≤40%, a repeat evaluation of the LVEF 6-12 weeks after ACS (and after complete revascularization and the institution of optimal medical therapy) is recommended to assess the potential need for sudden cardiac death primary prevention ICD implantation. | I | A | When should ACS patients with pre-discharge LVEF ≤40% have a repeat LVEF evaluation? | 1) 6-12 weeks after ACS and after complete revascularization and optimal medical therapy 2) After 1 year 3) Only if they show symptoms 4) Within 1 month of discharge |
| Vaccination | ||||
| Influenza vaccination is recommended for all ACS patients. | I | A | Who should receive the influenza vaccine among ACS patients? | 1) All ACS patients 2) Only those with LVEF ≤40% 3) Only those with diabetes 4) Only if they have HF symptoms |
| Anti-inflammatory drugs | ||||
| Low-dose colchicine (0.5 mg once daily) may be considered, particularly if other risk factors are insufficiently controlled or recurrent cardiovascular events occur. | IIb | B | When can low-dose colchicine be considered for ACS patients? | 1) If other risk factors are uncontrolled or if recurrent cardiovascular events occur 2) For all ACS patients 3) Only those with inflammation 4) Only if they have arthritis |
Note: The asterisk indicates the correct alternative for each queue
Recommendations for patient perspectives in acute coronary syndrome care
| Recommendations | Class | Level | Question | Alternatives |
|---|---|---|---|---|
| Patient-centered care | ||||
| Patient-centered care is recommended by assessing and adhering to individual patient preferences, needs, and beliefs, ensuring that patient values are used to inform all clinical decisions. | I | B | How should patient values be incorporated in care? | 1) By using them to inform all clinical decisions 2) Only in the case of surgery 3) Only if the patient insists 4) When no other clinical guidelines are available |
| It is recommended to include ACS patients in decision-making (as much as their condition allows) and to inform them about the risk of adverse events, radiation exposure, and alternative options. Decision aids can be used to facilitate the discussion. | I | B | How should ACS patients be involved in their treatment decisions? | 1) By including them in decision-making and informing them about risks and options 2) Only if they ask questions 3) Only for minor decisions 4) If their family approves |
| It is recommended to assess symptoms using methods that help patients to describe their experience. | I | C | How should clinicians assess the symptoms of ACS patients? | 1) By using methods that help patients describe their experience 2) By only relying on medical tests 3) Based on a standard questionnaire 4) By comparing with previous patients’ experiences |
| Informed decision making | ||||
| Use of the ‘teach back’ technique for decision support during the securing of informed consent should be considered. | IIa | B | Which technique can be used to support decision making during the consent process? | 1) ‘Teach back’ technique 2) Role-playing 3) Providing pamphlets 4) Video demonstration |
| Patient education | ||||
| Patient discharge information should be provided in both written and verbal formats prior to discharge. Adequate patient education for patient discharge using the teach back technique and/or motivational interviewing, giving information in chunks, and checking for understanding should be considered. | IIa | B | How should patient discharge information be conveyed? | 1) Both written and verbal formats using the teach back technique or motivational interviewing 2) Only written 3) Only verbal 4) Via email after discharge |
| Mental well-being | ||||
| Assessment of mental well-being using a validated tool and onward psychological referral when appropriate should be considered. | IIa | B | How should mental well-being be assessed in ACS patients? | 1) Using a validated tool and referring for psychological help when needed 2) Through casual conversation 3) Only if the patient shows visible signs 4) After every few months routinely |
Note: The asterisk indicates the correct alternative for e
Table 6: Dose regimen of antiplatelet and anticoagulant drugs in acute coronary syndrome patients
| Drug | Dosing Regimen | |
|---|---|---|
| I. Antiplatelet drugs | ||
| Aspirin | LD of 150–300 mg orally or 75–250 mg i.v. if oral ingestion is not possible, followed by oral MD of 75–100 mg o.d; no specific dose adjustment in CKD patients. | |
| Clopidogrel | LD of 300–600 mg orally, followed by an MD of 75 mg o.d.; no specific dose adjustment in CKD patients. | |
| Prasugrel | LD of 60 mg orally, followed by an MD of 10 mg o.d. In patients with body weight <60 kg, an MD of 5 mg o.d. is recommended. In patients aged ≥75 years, prasugrel should be used with caution, but a MD of 5 mg o.d. should be used if treatment is deemed necessary. No specific dose adjustment in CKD patients. Prior stroke is a contraindication for prasugrel. | |
| Ticagrelor | LD of 180 mg orally, followed by an MD of 90 mg b.i.d.; no specific dose adjustment in CKD patients. | |
| Cangrelor | Bolus of 30 mcg/kg i.v. followed by 4 mcg/kg/min infusion for at least 2 h or the duration of the procedure (whichever is longer). | |
| II. GP IIb/IIIa receptor inhibitors (i.v.) | ||
| Eptifibatide | Double bolus of 180 mcg/kg i.v. (given at a 10-min interval) followed by an infusion of 2.0 mcg/kg/min for up to 18 h. | |
| For CrCl 30–50 ml/min: first LD, 180 mcg/kg i.v. bolus (max 22.6 mg); maintenance infusion, 1 mcg/kg/min (max 7.5 mg/h). Second LD (if PCI), 180 mcg/kg i.v. bolus (max 22.6 mg) should be administered 10 min after the first bolus. Contraindicated in patients with end-stage renal disease and with prior ICH, haemorrhagic stroke within 30 days, fibrolysis, or platelet count <100 000/mm³. | ||
| Tirofiban | Bolus of 25 mcg/kg i.v. over 3 min, followed by an infusion of 0.15 mcg/kg/min for up to 18 h. | |
| For CrCl <50 ml/min: LD, 25 mcg/kg i.v. over 5 min followed by a maintenance infusion of 0.075 mcg/kg/min continued for up to 18 h. Contraindicated in patients with prior ICH, ischaemic stroke within 30 days, fibrolysis, or platelet count <100 000/mm³. | ||
| III. Anticoagulants | ||
| UFH | Initial treatment: i.v. bolus 70–100 U/kg followed by i.v. infusion titrated to achieve an aPTT of 60–80 s. | |
| Enoxaparin | During PCI: 70–100 U/kg i.v. bolus or according to ACT in case of UFH pre-treatment. | |
| Initial treatment for treatment of ACS 1 mg/kg b.i.d. subcutaneously for a minimum of 2 days and continued until clinical stabilization. In patients whose CrCl is below 30 mL per minute (by Cockcroft–Gault equation), the enoxaparin dosage should be reduced to 1 mg per kg o.d. During PCI: For patients managed with PCI, the last dose of enoxaparin was given less than 8 h before balloon inflation, an i.v. bolus of 0.3 mg/kg enoxaparin sodium should be added. If the last s.c. administration was given more than 8 h before balloon inflation, an i.v. bolus of 0.3 mg/kg enoxaparin sodium should be administered. | ||
| Bivalirudin | During PPCI: 0.75 mg/kg i.v. bolus followed by i.v. infusion of 1.75 mg/kg/h for 4 h after the procedure. | |
| Fondaparinux | In patients whose CrCl is below 30 mL/min (by Cockcroft–Gault equation), maintenance infusion should be reduced to 1 mg/kg/h. | |
| Initial treatment: 2.5 mg/d subcutaneously. | ||
| During PCI: A single bolus of UFH is recommended. |
ACS, acute coronary syndrome; ACT, activated clotting time; aPTT, activated partial thromboplastin time; b.i.d., bis in die (twice a day); CKD, chronic kidney disease; CrCl, creatinine clearance; DDL, drug-drug interaction; ICH, intracranial haemorrhage; i.v., intravenous; LD, loading dose; MD, maintenance dose; o.d., once a day; PPCI, primary percutaneous coronary intervention; s.c., subcutaneous; UFH, unfractionated heparin.
Table 7: Suggested strategies to reduce bleeding risk related to percutaneous coronary intervention
- Anticoagulant doses adjusted to body weight and renal function, especially in women and older patients
- Radial artery approach as default vascular access
- Proton pump inhibitors in patients on dual antiplatelet therapy at higher-than-average risk of gastrointestinal bleeds (i.e. history of gastrointestinal ulcer/haemorrhage, anticoagulant therapy, chronic non-steroidal anti-inflammatory drug/corticosteroid use), or two or more of:
- (a) Age ≥65 years
- (b) Dyspepsia
- (c) Gastro-oesophageal reflux disease
- (d) Helicobacter pylori infection
- (e) Chronic alcohol use
- In patients on OAC:
- (a) PCI performed without interruption of VKAs or NOACs
- (b) In patients on VKAs, do not administer UFH if INR >2.5
- (c) In patients on NOACs, regardless of the timing of the last administration of NOACs, add low-dose parenteral anticoagulation (e.g. enoxaparin 0.5 mg/kg i.v. or UFH 60 IU/kg)
- Aspirin is indicated but avoid pre-treatment with P2Y₁₂ receptor inhibitors
- GP IIb/IIIa receptor inhibitors only for bailout or peri-procedural complications
Abbreviations:
GP, glycoprotein;
INR, international normalized ratio;
i.v., intravenous;
NOAC, non-vitamin K antagonist oral anticoagulant;
OAC, oral anticoagulation/anticoagulant;
PCI, percutaneous coronary intervention;
UFH, unfractionated heparin;
VKA, vitamin K antagonist.