[Management of acute coronary syndrome : ESC guidelines 2023]. / Management des akuten Koronarsyndroms : ESC-Leitlinie 2023.

The new guidelines of the European Society of Cardiology (ESC) on the management of acute coronary syndrome (ACS) in 2023 encompass updates for both the guidelines pertaining to ST elevation myocardial infarction (STEMI) and acute coronary syndrome without ST segment elevation (NSTE-ACS). The previously separated guidelines from 2017 and 2020 were therefore revised and summarized. These guidelines address various topics, including diagnostics, acute management, antithrombotic treatment, out-of-hospital cardiac arrest, cardiogenic shock, invasive strategies, and long-term treatment. The notable updates compared to earlier guidelines address the recommendation regarding the timing of invasive diagnostics in NSTE-ACS (Non-ST elevation acute coronary syndrome), the procedure of revascularization in multivessel coronary artery disease and alternative regimens for antithrombotic treatment in patients with a high risk of bleeding.

Reperfusion Injury: How Can We Reduce It by Pre-, Per-, and Postconditioning.

While early coronary reperfusion via primary percutaneous coronary intervention (pPCI) is established as the most efficacious therapy for minimizing infarct size (IS) in acute ST-elevation myocardial infarction (STEMI), the restoration of blood flow also introduces myocardial ischemia-reperfusion injury (IRI), leading to cardiomyocyte death. Among diverse methods, ischemic conditioning (IC), achieved through repetitive cycles of ischemia and reperfusion, has emerged as the most promising method to mitigate IRI. IC can be performed by applying the protective stimulus directly to the affected myocardium or indirectly to non-affected tissue, which is known as remote ischemic conditioning (RIC). In clinical practice, RIC is often applied by serial inflations and deflations of a blood pressure cuff on a limb. Despite encouraging preclinical studies, as well as clinical studies demonstrating reductions in enzymatic IS and myocardial injury on imaging, the observed impact on clinical outcome has been disappointing so far. Nevertheless, previous studies indicate a potential benefit of IC in high-risk STEMI patients. Additional research is needed to evaluate the impact of IC in such high-risk cohorts. The objective of this review is to summarize the pathophysiological background and preclinical and clinical data of IRI reduction by IC.