Summary: This paper critically examines the established 12-month dual antiplatelet therapy (DAPT) recommendation for acute coronary syndrome (ACS) patients, noting it as a Class I recommendation in American and European guidelines despite its origins in studies not designed to determine optimal duration. The authors highlight that subsequent research has questioned the universal 12-month regimen, suggesting shorter durations for high bleeding risk patients and longer durations for high ischemic risk patients. They point out that bleeding risk assessment, rather than ischemic risk, has become a key modifier for DAPT, and various de-escalation strategies have shown reduced bleeding without increasing ischemic events compared to 12-month DAPT. The paper concludes that the continued Class I recommendation for 12-month DAPT, despite a lack of prospective evidence, leads to potential overtreatment and calls for guideline updates to reflect current evidence on optimal DAPT duration.

Summary: This manuscript offers a North American viewpoint on the 2023 European Society of Cardiology (ESC) guidelines for managing acute coronary syndromes (ACS), which now consolidate previous separate documents for ST-segment elevation ACS (STE-ACS) and non-ST-segment elevation ACS (NSTE-ACS). The paper aims to highlight differences between the 2023 ESC guidelines and the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines, noting new and revised recommendations, and discussing future perspectives, although an in-depth comparison is stated to be beyond its scope, with key differences summarized in a table and evolution illustrated in a figure.

Summary: This paper reviews the 2023 European Society of Cardiology (ESC) Guidelines for the Management of Acute Coronary Syndromes (ACS), highlighting how US cardiology can learn from them, particularly noting the ESC's comprehensive approach covering unstable angina, NSTEMI, and STEMI in a single document, unlike prior US guidelines. It details the ESC's conceptual framework of 'think A.C.S.' (assessment, invasive management, antithrombotic therapy, revascularization, secondary prevention) and outlines initial assessment strategies including ECG, clinical context, and troponin trends. The guidelines stratify NSTE-ACS patients based on risk features to guide invasive management decisions, recommending early angiography for STEMI and high-risk NSTE-ACS, and within 24 hours for others without very high-risk features. It also elaborates on antithrombotic therapy, including dual antiplatelet therapy (DAPT) durations, de-escalation strategies, and considerations for patients requiring oral anticoagulation, alongside long-term management goals focusing on lifestyle, pharmacotherapy, and risk factor control.

Summary: This meta-analysis of seven randomized controlled trials involving 2997 patients investigated the optimal management strategy for older adults with Non-ST-elevation Acute Coronary Syndrome (NSTE-ACS). The findings indicate that an invasive strategy significantly reduces the risk of unplanned revascularization and myocardial infarction compared to a conservative approach. However, no significant differences were observed between the two strategies regarding major bleeding, all-cause mortality, composite major adverse events, or stroke.

Summary: This review examines updated evidence on invasive management strategies for older patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI), a common ACS diagnosis in this demographic. Despite advances, older patients experience poorer outcomes, necessitating specific evidence for this cohort. While ESC guidelines suggest considering invasive management holistically without age cut-offs, older patients are less likely to receive it due to limited trial representation. The paper highlights challenges in assessing risk in older adults due to frailty, cognitive impairment, and comorbidities. The SENIOR-RITA trial indicated that invasive management is safe and reduces non-fatal MI and revascularization in older NSTEMI patients, though not mortality, emphasizing the need for individualized risk assessment and shared decision-making.

Summary: This paper is a commentary on updated ESC guidelines for non-ST-segment elevation acute coronary syndromes (NST-ACS), praising their comprehensiveness in areas like elderly patient management and bleeding complications. However, the authors express confusion regarding the guidelines' recommendations on anticoagulation, noting that a table presents multiple regimens without clear direction.

Summary: This meta-analysis systematically searched for randomized controlled trials comparing early invasive versus conservative management strategies for patients aged 70 years or older presenting with acute coronary syndrome (ACS). The pooled analysis found no significant difference in all-cause death between the two strategies. However, an early invasive strategy was associated with a reduced risk of recurrent myocardial infarction and repeated coronary revascularization, but also an increased risk of major bleeding. The authors suggest that the competing risks associated with an early invasive strategy should be considered in shared decision-making for older ACS patients.

Summary: This randomized controlled trial, the After Eighty Study, investigated the long-term outcomes of invasive versus conservative treatment strategies in 457 patients aged 80 years or older with Non-ST-segment elevation acute coronary syndrome (NSTE-ACS). After a median follow-up of 5.3 years, the invasive strategy, involving early coronary angiography and potential revascularization, was found to be superior to the conservative strategy (optimal medical therapy alone) in reducing a composite endpoint of myocardial infarction, urgent revascularization, stroke, and death. The invasive approach demonstrated a significant gain in event-free survival at both 5 and 10 years, with results consistent across patient subgroups.

Summary: This review discusses the management of Non-ST-segment elevation acute coronary syndrome (NSTE-ACS), emphasizing a personalized approach that includes tailored antithrombotic therapies, timely invasive management, and consideration for vulnerable populations like the elderly and those with chronic kidney disease. It also highlights the importance of cardiac rehabilitation and cardiovascular risk factor management for secondary prevention.

Summary: This paper reviews selected important cardiology articles from 2023, covering topics such as semaglutide and bempedoic acid for cardiovascular outcomes, conservative versus invasive management in frail, older NSTEMI patients, expedited transfer for cardiac arrest secondary to NSTEMI, thrombolysis in elderly STEMI patients, guideline-directed medical therapy for heart failure, noninvasive testing for stable coronary artery disease, anticoagulation in device-detected atrial fibrillation, and transcatheter approaches for mitral and tricuspid regurgitation.