Download - 2017 ESC Guidelines for the management of acute myocardial ... · What is new in 2017 Guidelines on AMI-STEMI 19 2012 CHANGE IN RECOMMENDATIONS 2017 Same dose i.V in all patients

2017ESCGuidelinesfortheManagementofAMI-STEMI(EuropeanHeartJournal2017-doi:10.1093/eurheartj/ehx095)www.escardio.org/guidelines

TheTaskForceforthemanagementofacutemyocardialinfarc6oninpa6entspresen6ngwithST-segmenteleva6onoftheEuropeanSocietyofCardiology

2017ESCGuidelinesforthemanagementofacutemyocardialinfarcNoninpaNentspresenNngwithST-segmentelevaNon

Chairpersons:BorjaIbanez(Spain),StefanJames(Sweden).Authors/TaskForceMembers:StefanAgewall(Norway),ManuelJ.Antunes(Portugal),ChiaraBucciarelli-Ducci(UK),HéctorBueno(Spain),AlidaL.P.Caforio(Italy),FilippoCrea(Italy),JohnA.Goudevenos(Greece),SigrunHalvorsen(Norway),GerhardHindricks(Germany),AdnanKastra6(Germany),MaSeJ.Lenzen(TheNetherlands),EvaPrescoT(Denmark),MarcoRoffi(Switzerland),MarcoValgimigli(Switzerland),ChristophVarenhorst(Sweden),PascalVranckx(Belgium),PetrWidimský(CzechRepublic).

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ESC

WG - Cardiovascular Pharmacotherapy

WG - Cardiovascular Surgery

EACVI - European Association of Cardiovascular Imaging

ACCA - Acute Cardiovascular Care Association

HFA - Heart Failure Association

EHRA - European Heart Rhythm Association

Council - Cardiovascular Nursing and Allied Professions

EAPCI - European Association of PCI

WG - Myocardial and Pericardial Diseases

WG - Thrombosis

EAPC -- European Association of Preventive cardiology

Council – for Cardiology practice

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-1224 comments and requests

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Task Force Members

2017ESCGuidelinesfortheManagementofAMI-STEMI(EuropeanHeartJournal2017-doi:10.1093/eurheartj/ehx095)www.escardio.org/guidelines

19 Authors ESC

www.escardio.org/guidelines 2017ESCGuidelinesfortheManagementofAMI-STEMI(EuropeanHeartJournal2017-doi:10.1093/eurheartj/ehx095)

Levelofevidence

3

21%

159 recommendations based on 477 references

A

B

C

3723%

4428%

7849%

A Dataderivedfrommul6plerandomizedclinicaltrialsormeta-analyses.

BDataderivedfromasinglerandomizedclinicaltrialorlargenon-randomizedstudies.

CConsensusofopinionoftheexpertsand/orsmallstudies,retrospec6vestudies,registries.


2017NEW/REVISEDCONCEPTS

STRATEGYSELECTIONANDTIMEDELAYS:• Cleardefini6onoffirstmedicalcontact(FMC).• Defini6onof“6me0”tochoosereperfusionstrategy(i.e.thestrategyclockstartsatthe6meof“STEMIdiagnosis”).

• Selec6onofPCIoverfibrinolysis:whenan6cipateddelayfrom“STEMIdiagnosis”towirecrossingis≤120min.• Maximumdelay6mefrom“STEMIdiagnosis”tobolusoffibrinolysisagentissetin10min.• “Door-to-Balloon”termeliminatedfromguidelines.

ELECTROCARDIOGRAMATPRESENTATION:• Lejandrightbundlebranchblockconsideredequalforrecommendingurgentangiographyifischaemicsymptoms.

TIMELIMITSFORROUTINEOPENINGOFANIRA:• 0-12h(ClassI);12-48h(ClassIIa);>48h(ClassIII).

MINOCAANDQUALITYINDICATORS:• Newchaptersdedicatedtothesetopics.

PATIENTSTAKINGANTICOAGULANTS:• Acuteandchronicmanagementpresented.

TIMETOANGIOGRAPHYAFTERFIBRINOLYSIS:• Timeframeissetin2-24hajersuccessfulfibrinolysis.

Whatisnewin2017GuidelinesonAMI-STEMI

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ModesofpaNentpresentaNon,componentsofischaemicNmeandflowchartforreperfusionstrategyselecNon

TotalischaemicNme

TotalischaemicNme

PaNentdelay EMSdelay

PaNentdelay

Systemdelay

Systemdelay

FMC:EMS<10’

STEMIdiagnosis

<10’

FMC:Non-PCIcentre

<10’

FMC:PCIcentre

PrimaryPCI

strategyReperfusion

(Wirecrossing)

Fibrinolysisstrategy

Reperfusion(Ly6cbolus)

PrimaryPCI

strategyReperfusion

(Wirecrossing)

<90’

<10’

<60’

STEMIdiagnosis

≤120min

>120min

TimetoPCI?

5

Term DefiniNonFMC The6mepointwhenthepa6entis

eitherini6allyassessedbyaphysician,paramedic,nurseorothertrainedEMSpersonnelwhocanobtainandinterprettheECG,anddeliverini6alinterven6ons(e.g.defibrilla6on).FMCcanbeeitherintheprehospitalseSngoruponpa6entarrivalatthehospital(e.g.emergencydepartment).



TotalischaemicNme

TotalischaemicNme


PaNentdelay

Systemdelay

Systemdelay

FMC:EMS<10’

STEMIdiagnosis

<10’

FMC:Non-PCIcentre

<10’

FMC:PCIcentre

PrimaryPCI

strategyReperfusion

(Wirecrossing)



PrimaryPCI

strategyReperfusion

(Wirecrossing)

<90’

<10’

<60’

STEMIdiagnosis

≤120min

>120min

TimetoPCI?

9

Term DefiniNonSTEMIdiagnosis

The6meatwhichtheECGofapa6entwithischaemicsymptomsisinterpretedaspresen6ngST-segmenteleva6onorequivalent.

Ambiguoustermsareeliminated:“Door-to-balloon”“Doortodoor”



TotalischaemicNme

TotalischaemicNme


PaNentdelay

Systemdelay

Systemdelay

FMC:EMS<10’

STEMIdiagnosis

<10’

FMC:Non-PCIcentre

<10’

FMC:PCIcentre

PrimaryPCI

strategyReperfusion

(Wirecrossing)



PrimaryPCI

strategyReperfusion

(Wirecrossing)

<90’

<10’

<60’

STEMIdiagnosis

≤120min

>120min

TimetoPCI?

10

Lejandrightbundlebranchblockareconsideredequalforrecommendingurgentangiographyifischaemic

symptoms.

AtypicalECGpresentaNons§  Bundlebranchblock,§  Ventricularpacing,§  Hyper-acuteTwaves,§  Isolateddepressioninanteriorleads,§  UniversalSTdepressionwithaVRelevaNonIn

Inthepresenceofsymptoms,aprimaryPCI

strategy(urgentangiographyandPCIif

indicated)shouldbefollowed.



TotalischaemicNme

TotalischaemicNme


PaNentdelay

Systemdelay

Systemdelay

FMC:EMS<10’

STEMIdiagnosis

<10’

FMC:Non-PCIcentre

<10’

FMC:PCIcentre

PrimaryPCI

strategyReperfusion

(Wirecrossing)



PrimaryPCI

strategyReperfusion

(Wirecrossing)

<90’

<10’

<60’

STEMIdiagnosis

≤120min

>120min

TimetoPCI?

11

IntheabsenceofST-segmentelevaNon Class Level

AprimaryPCIstrategyisindicatedinpa6entswithsuspectedongoingischaemicsymptomsif:‒  haemodynamicinstabilityorcardiogenicshock,‒  recurrentorongoingchestpainrefractorytomedicaltreatment,‒  life-threateningarrhythmiasorcardiacarrest,‒ mechanicalcomplica6onsofmyocardialinfarc6on,‒  acuteheartfailure,‒  recurrentdynamicST-segmentorT-wavechanges,par6cularlywithintermiTentST-segmenteleva6on.

I C


Reperfusionstrategiesintheinfarct-relatedarteryaccordingtoNmefromsymptomsonset

Early

pha

seofS

TEMI

3hours

Symptomsonset

0 PrimaryPCI

PrimaryPCI

Fibrinolysis(onlyifPCIcannotbeperformed

within120minfromSTEMIdiagnosis)

Fibrinolysis(onlyifPCIcannotbeperformed

within120minfromSTEMIdiagnosis)

I A I A

I AI A

12

12hours


Reperfusionstrategiesintheinfarct-relatedarteryaccordingtoNmefromsymptomsonset(con&nued)

EvolvedSTEM

I

48hours

Recent

STEM

I

I C

PrimaryPCI(ifsymptoms,

hemodynamicinstabilicy,orarrhythmias)

PrimaryPCI(asymptomaNcstablepaNents)

III ARouNnePCI(asymptomaNcstablepaNents)

IIa B

12hours

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CHANGEINRECOMMENDATIONS2012 2017

Same dose i.V in all patients Half dose i.V. in Pts ≥75 years STREAM

Oxygen when SaO2 <95% Oxygen when SaO2 <90% AVOID, DETO2X

Radial access

PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute

TOTAL, TASTE

MATRIX, HEAT-PPCI

ATOLL, Meta-analysis

Small trials & observational data

EXAMINATION,COMFORTABLE-AMI,NORSTENT

MATRIX

DES over BMS

Complete Revascularization

Thrombus Aspiration

Bivalirudin

Enoxaparin

Early Hospital Discharge

OXYGEN

TNK-tPA



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Valgimigli et al. Lancet 2015;385:2465-76



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Sabate et al. Lancet 2012;380:1482-90



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Engstrometal,Lancet2015



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Jollyetal,NEJM2015Frobertetal,NEJM2013



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Valgimiglietal,NEJM2015 Shazadetal,Lancet2014



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Silvainetal,BMJ2012



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA



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Radial access


TOTAL, TASTE

MATRIX, HEAT-PPCI




MATRIX

DES over BMS


Thrombus Aspiration

Bivalirudin

Enoxaparin


OXYGEN

TNK-tPA

Stubbetal,Circ2015



•  CangrelorifP2Y12inhibitorshavenotbeengiven.CHAMPION

•  SwitchtopotentP2Y12inhibitors48hoursajerfibrinolysis.Expertopinion

•  ExtendTicagrelorupto36monthsinhigh-riskpa6ents.PEGASUS-TIMI54

•  Useofpolypilltoincreaseadherence.FOCUS

2017NEWRECOMMENDATIONS•  Addi6onallipidloweringtherapyifLDL>1.8mmol/L(70mg/dL)despiteonmaximumtoleratedsta6ns.IMPROVE-IT,FOURIER

•  Completerevasculariza6onduringindexprimaryPCIinSTEMIpa6entsinshock.Expertopinion

IIIIIbIIaI

•  Rou6neuseofdeferredsten6ng.DANAMI3-DEFER

23









IIIIIbIIaI


24

BhaTetal,NEJM2013









IIIIIbIIaI


25

Bonacaetal,NEJM2015

www.escardio.org/guidelines 2017ESCGuidelinesfortheManagementofAMI-STEMI(EuropeanHeartJournal2017-doi:10.1093/eurheartj/ehx095)26

“Donotforget”intervenNonsinSTEMIpaNentsundergoingaprimaryPCIstrategy


DiagnosNctestflowchartinMINOCA

ACUTEINVESTIGATIONSUSPECTEDSTEMI

Coronarystenosis≥50% UrgentangiographyNoCoronarystenosis≥50%+Fulfilment

universalAMIcriteria

TreatasSTEMI MINOCAAcuteLVwallmoNonassessment(angiogram/echo)

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www.escardio.org/guidelinesFullTextESCPocketGuidelinesAppandmuchmore…

Ιωάννινα

Λευκάδα

Πρέβεζα

Άρτα

Κέρκυρα

Φιλιάτες

STEMI in NW Greece

Διάρκεια 12 µήνες

(1/10/05 – 31/9/06)

n: 359 (άνδρες

82%) Άφιξη από την έναρξη των συµπτωµάτων

<3 h 201(55%) 3-12 59

>12 99

Primary PCI Athens area

STEMI pPCI patients Time Delays

Thrombolysis 2011 2012 2015 Symptoms – FMC 136,91 min 125,5 min 136 min FMC – needle 62,17 min 65,5 min 36 min pPCI Symptoms – FMC 142,41 min 131,26min 125 min FMC – PCI center 129,11 min 119,21 min 78 min Door – Balloon 53,41 min 53,1 min 55 min FMC – Balloon 182,52 min 172,31 min 133 min

ESCPocketGuidelinesAppAny6me-Anywhere

• AllESCPocketGuidelines• Over140interacNvetools

- Algorithms- Calculators- Charts&Scores

• SummaryCards&EssenNalMessages

• Online&Offline

Learn more on the Guidelines area

HELIOS 2005-6 Eπαναιµάτωση σε STEMI

p PCI9%

Lysis50%

No Rx41%

Mε αιµοδ/εργ. Xωρίς

35% 65%

prPCI 24%

1% Θρ/λυση 43%

54% Kαµµιά 33%

45%

2017ESCGuidelinesforthemanagementofacutemyocardialinfarcNoninpaNentspresenNngwithST-segmentelevaNon

Ratio Total PCI/Primary PCI: 2007-2015

8,8%

10,2%

15,5%

23%

25%

20%


ClassesofrecommendaNons

9258%38

24%

138%

1610%

I IIa

IIb III

159 recommendations Classes DefiniNon Suggested

wording

ClassI Evidenceand/orgeneralagreementthatagiventreatmentorprocedureisbeneficial,useful,effec6ve.

Recommended/isindicated.

ClassIIa Weightofevidence/opinionisinfavourofusefulness/efficacy.

Shouldbeconsidered.

ClassIIb Usefulness/efficacyislesswellestablishedbyevidence/opinion.

Maybeconsidered.

ClassIII Evidenceorgeneralagreementthatthegiventreatmentorprocedureisnotuseful/effec6ve,andinsomecasesmaybeharmful.

Notrecommended.


2017NEW/REVISEDCONCEPTS

STRATEGYSELECTIONANDTIMEDELAYS:• Cleardefini6onoffirstmedicalcontact(FMC).• Defini6onof“6me0”tochoosereperfusionstrategy(i.e.thestrategyclockstartsatthe6meof“STEMIdiagnosis”).

• Selec6onofPCIoverfibrinolysis:whenan6cipateddelayfrom“STEMIdiagnosis”towirecrossingis≤120min.• Maximumdelay6mefrom“STEMIdiagnosis”tobolusoffibrinolysisagentissetin10min.• “Door-to-Balloon”termeliminatedfromguidelines.

ELECTROCARDIOGRAMATPRESENTATION:• Lejandrightbundlebranchblockconsideredequalforrecommendingurgentangiographyifischaemicsymptoms.

TIMELIMITSFORROUTINEOPENINGOFANIRA:• 0-12h(ClassI);12-48h(ClassIIa);>48h(ClassIII).

MINOCAANDQUALITYINDICATORS:• Newchaptersdedicatedtothesetopics.

PATIENTSTAKINGANTICOAGULANTS:• Acuteandchronicmanagementpresented.

TIMETOANGIOGRAPHYAFTERFIBRINOLYSIS:• Timeframeissetin2-24hajersuccessfulfibrinolysis.


41



TotalischaemicNme

TotalischaemicNme


PaNentdelay

Systemdelay

Systemdelay

FMC:EMS<10’

STEMIdiagnosis

<10’

FMC:Non-PCIcentre

<10’

FMC:PCIcentre

PrimaryPCI

strategyReperfusion

(Wirecrossing)



PrimaryPCI

strategyReperfusion

(Wirecrossing)

<90’

<10’

<60’

STEMIdiagnosis

≤120min

>120min

TimetoPCI?

42

www.escardio.org/guidelines 2017ESCGuidelinesfortheManagementofAMI-STEMI(EuropeanHeartJournal2017-doi:10.1093/eurheartj/ehx095)43

Reperfusionstrategiesintheinfarct-relatedarteryaccordingtoNmefromsymptomsonset