Robert P. Giugliano, MD, Brigham & Women’s Hospital, Boston, Massachusetts, USA, discussed the similarities and differences between the ACC/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) Guidelines.

“Overall,” said Dr. Giugliano, “the guidelines for patients with STEMI published by the ACC/AHA and the ESC are similar in terms of approach (ie, structure, rigor, and classification and level of evidence), the types of guidelines (eg, both full and focused updates), and the versions that are offered (eg, pocket, web, etc). The differences lie primarily in the areas of style, scope/timing, attitude, and belief.”

In a 2009 publication, Dr. Giugliano and Dr. Deepak Thomas compared the then-current guidelines for management of STEMI, as issued by the ACC/AHA [2007: Antman EM et al. J Am Col Cardiol 2008] and ESC [2008: Van de Werf F et al. Eur Heart J 2008; Thomas D & Giugliano RP. Am Heart J 2009]. Both guidelines contain key changes, and among them there was vigorous agreement in 4 areas:

• greater detail on the selection of a reperfusion strategy
• new data and recommendations on adjunctive anticoagulants
• caution regarding IV β-blockers
• more aggressive secondary risk management.

In this comparison, the authors found only very few differences in belief or attitude. Most of the differences were in style or possibly associated with the scope or timing of the review/release (Table 1).

Dr. Giugliano also summarized key changes from two newer AHA/ACC focused updates that introduced both new indications and changes to existing Class I recommendations: 

1. The 2009 Focused Updates: ACC/AHA Guidelines for the Management of Patients With STEMI; ACC/AHA/SCAI Guidelines on Percutaneous Coronary Intervention (PCI) [Kushner FG et al. J Am Coll Cardiol 2009] introduced 5 new Class I indications:

• Prasugrel ASAP as an alternative to clopidogrel in STEMI
• Dual antiplatelet therapy can now incorporate either clopidogrel or prasugrel along with aspirin in non-ST-elevation myocardial infarction (NSTEMI)
• Community-based STEMI systems
• Thienopyridine for ≥12 months after placement of a bare metal stent
• There are now specific contrast agents that are preferred for patients with chronic kidney disease who are not on dialysis.

2. The 2011 ACC/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/NSTEMI [Wright RS et al. J Am Coll Cardiol 2011] instituted five changes to the Class I recommendations:

• Added prasugrel as an alternative to clopidogrel
• Loading dose of clopidogrel now up to 600 mg
• Extension of thienopyridine therapy to at least 12 months whether patients are managed medically or invasively
• Deleted the prior recommendation for “aggressive” glycemic management
• New recommendations for avoiding contrast-induced nephropathy.

“Given the rapid pace of change, it is even more important to keep abreast of the guidelines,” said Dr. Giugliano.