New guidelines on acute coronary syndromes have been published today by the European Society of Cardiology (ESC) in the European Heart Journal.

Prof Robert Byrne, Chair of Cardiovascular Research at RCSI School of Pharmacy and Biomolecular Sciences and Director of Cardiology at the Mater Private Hospital and the Cardiovascular Research Institute, Dublin, chaired the guidelines taskforce.

The heart requires a constant supply of blood to function normally. Blood flow can suddenly reduce or stop when a clot forms in an artery supplying the cardiac muscle, and this is known as acute coronary syndrome. Acute coronary syndromes encompass a spectrum of conditions, including unstable angina (when no irreversible cardiac muscle damage occurs) and myocardial infarction, also called heart attack (when there is irreversible loss of muscle). The new guidelines provide a comprehensive overview of the management of all of these conditions.

Detailed treatment advice

“Time is critical in acute coronary syndromes. When an artery supplying the heart with blood becomes blocked, the quicker we open the artery and restore flow, the less damage occurs to the heart muscle,” said Prof Byrne. “Chest pain that lasts for more than 15 minutes and/or recurs within one hour should alert the public to contact the emergency medical services immediately, day or night. Other symptoms include sweating, pain in the shoulder or arm, and indigestion.”

The guidelines provide detailed advice on treatment, which includes medications such as blood thinners. Most patients will have a coronary angiogram, which uses X-ray images to see the heart’s arteries. When an artery supplying the heart is completely blocked, the patient will receive emergency insertion of a stent or, where this is unavailable, an intravenous clot-dissolving drug. When there is no complete blockage, the treatment options are stent insertion, open-chest bypass surgery, or medical therapy alone.

Long-term changes

Long-term management is crucial after an acute coronary syndrome, as patients are at increased risk of a repeat event. The guidelines acknowledge this, outlining how patients should attend a cardiac rehabilitation programme, where they will be encouraged to adopt healthy lifestyle changes including increasing activity levels, eating a balanced diet, limiting alcohol and quitting smoking. “This will reduce the chances of recurrent events and improve quality of life,” said Prof Byrne. “Some patients who experience heart attacks are at risk of developing heart failure because of large damage to the heart muscle, and additional medications may be given to reduce this risk.”

Specific advice is given on the management of acute coronary syndromes in patients with cancer who have an elevated risk of acute coronary syndromes due to shared risk factors such as smoking, types of cancer, and treatment with chemotherapy and radiotherapy.

There is also a section on patient perspectives, recommending assessing and adhering to individual patient preferences, needs and beliefs, and ensuring that patient values are used to inform all clinical decisions.