Personalized Precision Medicine in Cardiology: A Step Forward

The 2020 European Society of Cardiology (ESC) guidelines for the management of non-ST-elevation acute coronary syndrome (ACS) have brought forth a new era of personalized precision medicine in the field of cardiology. These guidelines provide clinicians with a risk stratification framework to identify patients undergoing percutaneous coronary intervention (PCI) who are at low, moderate, and high risk for major adverse cardiovascular events (MACE). Notably, the guidelines not only aid in thrombotic risk categorization but also shed light on the bleeding risk associated with PCI in high-risk patients.

Thrombotic Risk Stratification using ESC Guidelines

The ESC guidelines propose specific criteria to identify patients at increased thrombotic risk who may benefit from an additional antithrombotic agent during PCI. The criteria encompass a range of clinical and angiographic features that contribute to the overall risk assessment. By evaluating these factors, clinicians can categorize patients into low, moderate, or high thrombotic risk groups, enabling tailored treatment decisions].

Assessing Bleeding Risk in High-Risk Patients

In a study presented at the Society for Cardiovascular Angiography and Interventions Scientific Sessions, it was revealed that high-risk patients identified by the ESC guidelines face a significantly greater bleeding risk at one year compared to moderate- and low-risk patients. The study, conducted by Dr. George Dangas and colleagues at the Icahn School of Medicine at Mount Sinai, highlights the importance of individualized cardiology care and the need to identify the right blood thinner therapy for high-risk patients.

Key Criteria for Thrombotic Risk Stratification

The criteria proposed by the ESC guidelines provide insights into the various risk factors associated with thrombotic events during PCI. High-risk patients exhibit one or more clinical features such as diabetes, prior myocardial infarction (MI), peripheral artery disease (PAD), chronic kidney disease, age less than 45 years, and multivessel coronary artery disease (CAD). Additionally, angiographic features, including multiple stents or lesions, total stent length more than 60 mm, left main PCI, chronic total occlusion, and bifurcation with two stents, contribute to the risk assessment.

Outcomes of Risk Stratification

The study conducted by Dangas and colleagues included 11,787 patients who underwent PCI at Mount Sinai Hospital between 2012 and 2019. The cohort was categorized into low-, moderate-, and high-thrombotic risk groups based on the ESC guidelines. The primary endpoint was a composite of 1-year MACE, including all-cause death, MI, and stroke. The results showed that high-risk patients had a significantly higher incidence of MACE compared to moderate- and low-risk patients. Furthermore, the risk for all-cause death and MI was also markedly elevated in high-risk patients. However, no significant difference was observed in the risk for stroke among the risk groups.

Implications for Personalized Treatment

The 2020 ESC guidelines provide clinicians with a valuable tool for risk stratification and personalized treatment decision-making in non-ST-elevation ACS patients undergoing PCI[^1^]. The ability to identify high-risk patients who may benefit from long-term treatment with multiple blood thinners is a significant step towards precision medicine in cardiology. By incorporating patient-specific risk factors, clinicians can optimize therapeutic strategies and enhance patient outcomes.

Limitations and Future Considerations

While the ESC guidelines offer valuable insights into risk stratification, there are certain limitations that should be acknowledged. The study did not account for procedural factors and did not include data on the duration or adherence of dual antiplatelet therapy (DAPT). Future research should focus on integrating procedural characteristics and assessing the impact of DAPT duration on patient outcomes.

Expert Perspectives on Risk Stratification

Dr. Jay Widmer emphasizes the forward-thinking approach of the ESC guidelines and highlights the importance of considering procedural factors and exploring better percutaneous coronary intervention techniques. Dr. Karim M. Al-Azizi underscores the need for individualized therapies and urges the integration of intravascular imaging and novel interventions to improve outcomes.


The 2020 ESC guidelines provide a robust risk stratification framework that aids in the personalized management of non-ST-elevation ACS patients undergoing PCI. By identifying patients at high thrombotic risk, clinicians can tailor treatment strategies to mitigate adverse events. The guidelines also shed light on the bleeding risk associated with PCI in high-risk patients, facilitating informed decision-making. As cardiology advances further into the realm of personalized precision medicine, the ESC guidelines serve as a vital tool in optimizing patient care and outcomes.