Comments on the 2020 guidelines of the European Society of Cardiology (ESC) on management of acute coronary syndrome in patients without persistent ST-segment elevation

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, further management either invasively or noninvasively, and also long-term medical treatment. New sections deal with spontaneous coronary artery dissection (SCAD), myocardial infarction with non-obstructive coronary arteries (MINOCA) and also newly introduced quality indicators for NSTE-ACS treatment. The diagnostic work-up using highly -sensitive cardiac troponin (hs-cTn) is emphasized with the recommendation to use fast algorithms that enable an early rule-in or rule-out in the emergency room or chest pain unit. Regarding risk stratification, the former intermediate risk group has been removed and it has been emphasized that low-risk patients should be treated similarly to patients with chronic coronary syndrome. A greater individualization of the duration of antiplatelet therapy is recommended based on the individual ischemic and bleeding risks. Some changes have been introduced for timing of invasive coronary angiography; however, the very high-risk group should still immediately undergo invasive assessment and the high-risk group should undergo an invasive angiography within 24 h.