Definitions

The term non-ST-elevation myocardial infarction-acute coronary syndrome (non-STEMI-ACS) has been introduced for both NSTEMI and unstable angina pectoris because the differential diagnosis is dependent on biomarkers that may be detectable only after hours, whereas decisions on treatment are dependent on the clinical signs at presentation.

Chest pain units and decision rules for early discharge

• History, clinical examinations, biomarkers, ECG criteria and risk scores are unreliable for the identification of patients who may be safely discharged early.
• The role of chest pain observation units (CPUs) is to identify, by using repeated clinical examinations, ECG and biomarker testing, those patients who require admission for invasive procedures. This may include provocative testing and, in selected patients, imaging procedures as cardiac computed tomography, magnetic resonance imaging, etc.

Symptomatic treatment

• Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided.
• Nitrates should not be used for diagnostic purposes.
• Supplementary oxygen to be given only to those patients with hypoxaemia, breathlessness or pulmonary congestion. Hyperoxaemia may be harmful in uncomplicated infarction.

Causal treatment

• Guidelines for treatment with acetyl salicylic acid (ASA) have been made more liberal and it may now be given by bystanders with or without dispatchers assistance.
• Revised guidance for new antiplatelet and antithrombin treatment for patients with ST elevation myocardial infarction (STEMI) and non-STEMI-ACS based on therapeutic strategy.
• Gp IIb/IIIa inhibitors before angiography/percutaneous coronary intervention (PCI) are discouraged.

Reperfusion strategy in STEMI

• Primary PCI (PPCI) is the preferred reperfusion strategy provided it is performed in a timely manner by an experienced team.
• A nearby hospital may be bypassed by emergency medical services (EMS) provided PPCI can be achieved without too much delay.
• The acceptable delay between start of fibrinolysis and first balloon inflation varies widely between about 45 and 180 min depending on infarct localisation, age of the patient, and duration of symptoms.
• ‘Rescue PCI’ should be undertaken if fibrinolysis fails.
• The strategy of routine PCI immediately after fibrinolysis (‘facilitated PCI’) is discouraged.
• Patients with successful fibrinolysis but not in a PCI-capable hospital should be transferred for angiography and eventual PCI, performed optimally 6–24 h after fibrinolysis (the ‘pharmaco-invasive’ approach).
• Angiography and, if necessary, PCI may be reasonable in patients with return of spontaneous circulation (ROSC) after cardiac arrest and may be part of a standardised post-cardiac arrest protocol.
• To achieve these goals, the creation of networks including EMS, non-PCI capable hospitals and PCI hospitals is useful.

Primary and secondary prevention

• Recommendations for the use of beta-blockers are more restricted: there is no evidence for routine intravenous beta-blockers except in specific circumstances such as for the treatment of tachyarrhythmias. Otherwise, beta-blockers should be started in low doses only after the patient is stabilised.
• Guidelines on the use of prophylactic anti-arrhythmics angiotensin converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and statins are unchanged.