(完整版)2020ESC｜非ST段抬高急性冠脉综合征指南要点及更新

1、（完整版）2020ESC |非ST段抬高急性冠脉综合征指南要点及更新2020 ESC Guidelin es for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevati onThe T3sk Force for the* managme-nt of acute coronary syndromes im patients presenting without ersistent ST-seg.-me nt elevation of the

2、European Society of Cardiology E$C)先介绍欧洲指南的一个特点，不同的推荐级别用不同的颜色：绿色是I类推荐，红色是III类，黄色是Ha ,橘色是lib。ClisslEvidence and/or general igrecmcnt chat a given treatment or procedure is beneficial, useful, cffecVYc.Is recommended or b inAT with OAC .rad diher tkgrc1or or prasugrd may be considered as *n ahcrntivc

3、loTAT uith an OAC, aspirin and ctopxlogrcl m patients with moderate ar high risk M sicntYhromkHk. inepeetive of lhe lype of sdent ud. ；懑馆“NSTE_ACS患者准备行PCI ,普拉格雷优先于替格瑞洛推荐(Ila ) oDiagnosis厂A an nttcnuitivc to the ESC Oh/I h algonthiiL lhe ESC Oh/? h algorithm wilh blood sunpling at Uh and 2 h con be u

4、sed, if an hs-cTn tut with validMod 0 h/2 h tlgonthm n avaibblc.For diagnostic purpahs. it is not recommended to routinely meadre additional bion&kers such m CK. CK-MB. h-FA BPt or copept in. in addition to hiYTib打；L 苕可以用0h/2h测定高敏肌钙蛋白作为Oh/1 h的替代方案（I）。（注解：也就是说胸痛患者鉴别如果刚入急诊室（Oh ）高敏肌钙蛋白阴性，可以在到急诊2h后复查看是不

5、是已经升高了。）如果为了诊断的目的，测定高敏肌钙蛋白后，不再建议另外测定CK、CK-MB、h-FABP、和肽素等其他指标（III） o危险分层Risk stratificationMeasuring HNP or NT-proBNPconcent rations should be comidered to gain pronoeciiciftformatioh.= 込碾鐸晨*测定BNP或NT-proBNP血浆水平可用于预后评估(Ila )。抗栓治疗Antithrombotic treatmentPrasugnrl should be pnrfcrrcd over tiragrrlor for

6、 NST&ACS patients u ho proceed to PCI.h mno( nazommended lo adminislcr rmiiinc pre-uruimcnl w ilh ji P2Y nircrfMar inhibitor la 产说in whom the rofiary anatomy u nu Icnciwn and grly invakiv manaefnent m plannedIn pAtienu with NSTE ACS whoaurmoi nndcto an early invassvc xiniicgy, prc-irwiimcnt with M P

7、2Yu nn;cpn inhibhm nuy be vonMdered depending on bleeding riskDe wuhriicn of P2Y旺 inhibitor(e.f. with a twitch from pruurel or licafelnr tocloptdofrvb may be considered m an allrmjilive DA.PT Klnilcjy. mporully for ACS patients deemed unwiublc for potent phtclrt inhibition. Dcblion nuy be done unjuu

8、lcd hued onclinical jtidgmcrrl. or guided by piwttr ld funclkm tafling. or CYP2C19 genotyping depending on the patient risk proHk und aYiibbility of rcxpccuvc assayk.In (MdiMtx with AF (CHA:DSrVASc ecote 21 in men and 2 in u omra). After a Rbort perwd of TAT Qup lo I mccIc from the acute cwniK DAT n

9、Dcommcndcd the dcUult Mntety tutnf a SOAC at rhe roeotn mended due for omkr prevemiCTi and ftingic oral antiplaiclct ifent (pnclcnbly ckipidogrrllDimMinnuuiMm of antiphlclcl iruimcrt in pmwnls outed wtth OAOt M nBcommcnded nflcr 12 numihi在冠脉解剖不清楚或计划早期侵入性处理前不推荐常规使用P2Y12 抑制剂（III ） O不能行早期侵入策略的NSTE_ACS患

10、者，使用P2Y12抑制剂前需评 估出血风险（lib ）。P2Y12抑制剂的降级治疗（比如将普拉格雷或替格瑞洛转换到氯毗格 雷）可以作为双抗血小板（DAPT ）的替代方案,尤其是高强度血小板抑 制不适合的ACS患者。降级治疗不需要基于临床的判断,但可以依据患 者危险因素通过血小板功能试验或CYP2C19基因型来进行指导（lib ）。房颤患者（CHADS2VASC男V ,女,可以短期三抗（急性发 作起至一周），默认预防卒中的NOAC标准剂量+氯毗格雷进行双抗（I ）。这类患者12个月后停抗血小板药物，仅抗凝治疗（I）。无论植入什么类型的支架，在支架内血栓形成中高危风险的患者，可以考虑抗凝+普拉格雷

11、或替格瑞洛的方案代替抗凝+阿司匹林+氯毗格雷的三抗方案(lib ) o侵入性治疗Invasive treatmentAd early invurve strategy wtlhin 34 b te rwonunondod inwtth any of the fbUowinf high Huk erhnu:皿2 0丽1讪 Oynanxk 144)A selectmc tnwMtrr ttmefy* aflet 4ppnpruic ivhembi icstinj k9 rukrxjl pcnbocal al Ob and 3 h t* nccommirndcd tfhscTn Ir&ts arr

12、avatht4cA rapid rulc oui and mkr*in protocol with blood Mmpling m Qh und 3 h should be eonsidmd if an hs cTn test with a validated 0 h/3 h algorithm i& iivariable.、厂M DCT Cototiary Nfigiography should be considered as an ullemativc ta invasive angiography to exclude ACS uhen there is a IourHmtcrmcdu

13、itc likelihood of CAD and when cardiac troponin andforECG an: inconclusive.CCTA u recommended 昭 m ahenwitivclo imruhre angiography to exclude ACS when then: h a low伽 inlrrmedilc hkrlihood of CAD and when cinfiac troponin and/or BCG ate nonml or inconckwvc.丿J丿Rhythm nvxnitonng up to 24 h or PCt (mtIK

14、k hevn* omc5 firrt) should be cowddcrrd in NS*niM I patkntx 24 h or IP PC| (whichever comes first) in rocommendcd in NSTRMI patients al low rak foe canduc nrhylhmmjLRhythm monitoring for 24 h isRhythm monitoring for 24 h should be considered in NSTEMI puticnl a! inlcrmediatc-to4ri.gh risk for cardia

15、c ntythmwi5.rcvommcfxfcd in NSTEMI piicnti* f incRMi&cd rHk fwjjr4快速排除的高敏肌钙蛋白Oh/3h方案从I类推荐降级到IIao心电图和肌钙蛋白不支持ACS的低中危患者，推荐冠脉CTA检查代替造影排除ACS从Ila升级到I类推荐。心律失常低危的NSTEMI患者建议心电监护至24小时或直至PCI , 心律失常中高危风险的NSTEMI患者需心电监护应 24小时，两者从Ila 升级至I类推荐。危险分层Risk assessmentU is recommended Io use cjUabluhed rude Acorw for pn)gnvin durmg POBiraJiradin may be comicfcd an alicmaiivc to HillAdding i second ajitilhromboiK icni lo axpirin (or ciicndcd krng-icrni secondary piwvntion should be conskkrcd inP2Yu mhibiioc adnunisirUMm in addirim lo aspirin beyond I year may be ccmukkrad after careful antrssmcni q hc ischicf