Is it a STEMI or Non -STEMI ? The apparently realistic, but dichotomous thinking about ACS among physicians is existing for quite a long time. However, since the underlying pathobiology being same , it is worth wondering whether the conventional bifurcation of ACS is fool -proof , when applied to management decisions. The rapidity and totality of plaque fissure, rupture ,eruption,or erosion and the subsequent response of the local hemorheological system, determine the ferocity of the event.
How to recognise all these deep intracellular events in bed side ? Unfortunately, still with a lot of gratitude, we have to rely on the humble ECG for early segregation of ACS ,initiation of treatment. (Truthfully, Waller, Einthoven and Lewis should still be celebrated as forefathers of ACS )
Though STEMI/NSTEMI show different faces of ACS, however, it makes little logic to have two big set of guidelines when a patient presents with ER with resting angina with variable ST/T changes* .(In the very early hours of ACS, ie just moments after biological trigger who can predict which patient will enter what path and evolve into STEMI or NSTEMI)
* Typically, predicting the ECG-plaque interplay in Wellens’s syndrome ,De-winter or for that matter , in any biphasic precardial T wave sydromes can stretch our coronary acumen to its limits.
Now, ESC 2023 task force hasrealised this .To bring bettter judgment with a open mind ,decided to merge STEMI/NSTEMI into a single guideline , of-couse a with different treatment flow paths for these two entites.
I could take three key messages from this new guidelines.
1.STEMI guidelines are largely unchanged. There is still a major role for fibrinolysis, if you realistically think, and decide, you can’t reperfuse in the cath lab within 120 minutes after arrival.(120 mts time clock should start, much earlier is different debate!)
2.In NSTEMI, there has been important downgrading in the urgency of intervention even in the high risk category (Early invasive <24 hrs from class 1 to 2A)
3. Aspirin and regular unfractioned Heparin continue to rule the ACS world in most situations across the entire spectrum of ACS, except during the short peri-procedural period ,we need the assistance of new powerful P2Y12 blockers like Prasugrel or Ticagrelol.
Prof. Robert Byrne, from Ireland, succinctly explains the new ACS guidelines
Final message
Knowledge must be allowed to evolve, without any conditions or denials. Backtracking is an essential expertise, which can be as important as looking forward.
Dr.S.Venkatesan MD 