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Arrhythmias frequently accompany acute coronary syndromes (ACSs). Management of such patients might be a challenging issue for emergency physicians and cardiologists, and because knowledge and evidence on the topic are emerging and evolving (1). The recently published position paper by the European Heart Rhythm Association, Acute Cardiovascular Care Association, and European Association for Percutaneous Cardiovascular Interventions joint task force addresses this issue, providing an expert opinion on the topic, explaining and justifying comprehensive management approaches, and suggesting decision making and actions for cardiologists and specialists in relevant disciplines on how to manage and treat challenging cases of arrhythmias in patients with ACS (2-4). The document covers the following topics: how to determine patients at risk for arrhythmias, pharmacological (antiarrhythmic drug therapy), and nonpharmacological approaches (overdrive pacing, direct current cardioversion (DCC), and catheter ablation), which have become the preferred way of treating arrhythmia, how to treat tachyand bradyarrhythmias and atrial fibrillation (AF), and how to manage arrhythmias in special conditions: occurring during PCI, accompanying cardiogenic shock, and in patients with implanted ICD. The following distinctive message of the paper must be acknowledged; that is, management approaches of patients with ACS and patients with arrhythmias have shifted towards invasive management. The mainstay of treatment of all types of cardiac arrhythmias in patients with ACS is the achievement of complete revascularization and restoration of coronary flow and perfusionmeasures to treat underlying ischemia and infarction-which should be the first-line treatment in management of arrhythmias. Patients with ACS might present with a wide variety of cardiac arrhythmias, including sustained ventricular arrhythmias (VAs), AF, and bradyarrhythmias. It is outlined that patients with ACS presenting late from onset of symptoms or in whom complete revascularization was not achieved or having substrate for arrhythmia prior to ACS and those with complications should be considered at a high risk for cardiac arrhythmia development.

What we have learned from the ESC position paper on arrhythmias in acute coronary syndromes