Acute coronary syndromes A European viewpoint. Felicita Andreotti, MD PhD FESC Catholic University Hospital Cardiovascular Diseases - Rome, IT

Transcription

1 Acute coronary syndromes A European viewpoint Felicita Andreotti, MD PhD FESC Catholic University Hospital Cardiovascular Diseases - Rome, IT

2 Potential conflicts of interest In the past 2 years Felicita Andreotti has received fees for lectures, advising or monitoring activities from Amgen, Bayer, Bristol-Myers Squibb / Pfizer, Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly Speaker

3 3 Eur Heart J 2016 Jan 14;37(3):

4 Initial assessment of patients with suspected acute coronary syndromes <10 min Emergency Echo in acute HF pts to assess LV and valve fx & exclude mechanical complications IC

5 What else is new 1 - High-sensitivity cardiac troponin diagnostic algorithm 2 - Revascularization Criteria mandating indication/timing of invasive strategy 3 - Antithrombotic treatment Timing of P2Y12 inhibitor for early invasive strategy (pretreatment) 4 - Antithrombotic treatment: With long-term oral anticoagulants 5 - Revascularization: Radial approach and DES 6 - Rhythm monitoring guide 7 - Antithrombotic treatment: Duration of dual antiplatelet therapy 8 - Section on elderly (web addenda) 9 - Secondary prevention: Lipid lowering beyond statins 10- «Questions and Answers» companion

6 Guidance on hs-ctn for suspected NSTEMI > obtain sensitive or high sensitivity (hs)-ctn <60 min... IA > use 0-3h protocol with hs-ctn... IB > use validated 0-1h hs-ctn algorithm and repeat at 3-6h if inconclusive or suggestive. IB Very Low or Low and No 0-1h High or 0-1h Predictive values for acute MI: negative >98% - positive 75-80%

7 0-1h rule-in and rule-out hs-ctn algorithms Cut-offs are assay specific

8 Invasive strategy and timing based on initial risk (2011: primary/ secondary high-risk criteria) <2h, IC Ongoing ischaemia Immediate action <24h, IA <72h, IA +, IA

9 P2Y12 inhibitor before early invasive strategy (2011: as soon as possible ) As the optimal timing of ticagrelor or clopidogrel administration in NSTE-ACS patients scheduled for an invasive strategy has not been adequately investigated, no recommendation for or against pretreatment with these agents can be formulated. In patients not scheduled for an invasive strategy, P2Y12 inhibitor recommended as soon as diagnosis established (and ticagrelor preferred over clopidogrel in absence of increased bleeding risk) Eur Heart J 2016 Jan 14;37(3):

10 Oral anticoagulation plus antiplatelet(s) Eur Heart J 2016 Jan 14;37(3):

11 Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification 11 IC IA IA IA (MDCT angio if ECG or ctn inconclusive, IIa A)

12 Radial approach It is recommended that centres treating ACS patients implement a transition from transfemoral to transradial access. Proficiency in the femoral approach should be maintained (e.g. for IABP insertion and structural as well as peripheral procedures) Eur Heart J 2016 Jan 14;37(3):

13 MATRIX Co-primary composite outcomes at 30 days 13 All-cause mortality, MI, stroke N=8404 NSTE-ACS + STEMI Radial vs. femoral All-cause mortality, MI, stroke, or BARC 3 or 5 bleeding Valgimigli M et al. Lancet. 2015;385: Speaker

14 Radial vs femoral meta-analysis RR (95% CI) P Non-CABG major bleeeds Death, MI, or stroke Death MI Stroke Valgimigli M et al. Lancet 2015;385:

15 Drug-eluting stents Eur Heart J 2016 Jan 14;37(3):

16 Antiplatelet therapy after stenting on OAC

17 Time from PCI/ACS NSTE-ACS patients with non-valvular atrial fibrillation Management strategy PCI Medically managed /CABG Bleeding risk Low to intermediate (e.g. HAS-BLED = 0 2) High (e.g. HAS-BLED 3) 0 4 weeks 6 months IIaC Triple therapy O A C Dual therapy b Triple or dual therapy a O A C Dual therapy b O C or A IIaC Dual therapy b O C or A 12 months O C or A Lifelong O Monotherapy c Oral anticoagulation O A ASA mg daily C (VKA or NOACs) Clopidogrel 75 mg daily Adapted from Lip et al. Eur Heart J 2014;35: a Dual therapy with oral anticoagulation and clopidogrel may be considered in selected patients (low ischaemic risk). IIb B b aspirin as an alternative to clopidogrel may be considered in patients on dual therapy (i.e., oral anticoagulation plus single antiplatelet); triple therapy may be considered up to 12 months in patients at very high risk for ischaemic events. c Dual therapy with oral anticoagulation and an antiplatelet agent (aspirin or clopidogrel) beyond one year may be considered in patients at very high risk of coronary events. In patients undergoing coronary stenting, dual antiplatelet therapy may be an alternative to triple or dual therapy if the CHA2DS2-VASc score is 1 (males) or 2 (females).

18 Guidance on rhythm monitoring Continuous monitoring up to diagnosis (Y/N) IC IIa C * IIa C IIb C in suspected spasm * H A E R S C Eur Heart J 2016 Jan 14;37(3):

19 Duration of dual antiplatelet therapy Eur Heart J 2016 Jan 14;37(3):

20 Elderly with NSTE-ACS was B 2 RCTs - TACTICS - Elderly Eur Heart J 2016 Jan 14;37(3):

21 Antithrombotic therapy in the elderly Major RCT testing drugs shown in figure Age-stratified ischaemic and bleeding event rates Expert position on treatment in the elderly Andreotti F et al. ESC Thrombosis WG. Eur Heart J 2015;doi: /eurheartj/ehv304 Eur Heart J 2016 Jan 14;37(3):

22 40 cases each No reference Link to the dedicated sections of the GL Help to implement GL in daily practice 22 European Heart Journal doi: /eurheartj/ehv409 European Heart Journal doi: /eurheartj/ehv407 European Heart Journal doi: /eurheartj/ehv408 Speaker

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24 ABSTRACT SUBMISSION Mid December 14 February 2016 CLINICAL CASE SUBMISSION Mid January 1 March 2016 HOT LINES SUBMISSION Mid March 1 May 2016 EARLY REGISTRATION Deadline: 31 May 2016 LATE REGISTRATION Deadline: 31 July