2017 ESC Guidelines for the management of acute myocardial infarcnon in panents presennng with ST-segment elevanon

Transcription

1 2017 ESC Guidelines for the management of acute myocardial infarcnon in panents presennng with ST-segment elevanon The Task Force for the management of acute myocardial infarc6on in pa6ents presen6ng with ST-segment eleva6on of the European Society of Cardiology Chairpersons: Borja Ibanez (Spain), Stefan James (Sweden). Authors/Task Force Members: Stefan Agewall (Norway), Manuel J. Antunes (Portugal), Chiara Bucciarelli-Ducci (UK), Héctor Bueno (Spain), Alida L. P. Caforio (Italy), Filippo Crea (Italy), John A. Goudevenos (Greece), Sigrun Halvorsen (Norway), Gerhard Hindricks (Germany), Adnan Kastra6 (Germany), MaSe J. Lenzen (The Netherlands), Eva PrescoT (Denmark), Marco Roffi (Switzerland), Marco Valgimigli (Switzerland), Christoph Varenhorst (Sweden), Pascal Vranckx (Belgium), Petr Widimský (Czech Republic) ESC Guidelines for the Management of AMI-STEMI (European Heart Journal doi: /eurheartj/ehx095) 1

2 Task Force Members ESC 19 Authors ESC 30 Reviewers comments and requests ACCA - Acute Cardiovascular Care Association EAPCI - European Association of PCI EAPC -- European Association of Preventive cardiology EHRA - European Heart Rhythm Association EACVI - European Association of Cardiovascular Imaging HFA - Heart Failure Association Council - Cardiovascular Nursing and Allied Professions Council for Cardiology practice WG - Myocardial and Pericardial Diseases WG - Thrombosis WG - Cardiovascular Pharmacotherapy WG - Cardiovascular Surgery ESC Guidelines for the Management of AMI-STEMI (European Heart Journal doi: /eurheartj/ehx095) 2

3 Level of evidence A B C 21% Data derived from mul6ple randomized clinical trials or meta-analyses. Data derived from a single randomized clinical trial or large non-randomized studies. Consensus of opinion of the experts and/ or small studies, retrospec6ve studies, registries. 159 recommendations based on 477 references C 78 49% 37 23% 44 28% B A 3

4 What is new in 2017 Guidelines on AMI-STEMI MINOCA AND QUALITY INDICATORS: New chapters dedicated to these topics NEW / REVISED CONCEPTS STRATEGY SELECTION AND TIME DELAYS: Clear defini6on of first medical contact (FMC). Defini6on of 6me 0 to choose reperfusion strategy (i.e. the strategy clock starts at the 6me of STEMI diagnosis ). Selec6on of PCI over fibrinolysis: when an6cipated delay from STEMI diagnosis to wire crossing is 120 min. Maximum delay 6me from STEMI diagnosis to bolus of fibrinolysis agent is set in 10 min. Door-to-Balloon term eliminated from guidelines. TIME LIMITS FOR ROUTINE OPENING OF AN IRA: 0-12h (Class I); 12-48h (Class IIa); >48h (Class III). ELECTROCARDIOGRAM AT PRESENTATION: Lej and right bundle branch block considered equal for recommending urgent angiography if ischaemic symptoms. TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS: Timeframe is set in 2-24h ajer successful fibrinolysis. PATIENTS TAKING ANTICOAGULANTS: Acute and chronic management presented. 4

5 Modes of panent presentanon, components of ischaemic Nme and flowchart for reperfusion strategy selecnon PaNent delay EMS delay Total ischaemic Nme System delay PaNent delay FMC: EMS <10 Term DefiniNon Primary <90 PCI strategy Reperfusion (Wire crossing) FMC 120 min The 6me point when the pa6ent is STEMI either ini6ally assessed by a diagnosis Time to PCI? physician, paramedic, nurse or other <10 trained EMS personnel Fibrinolysis <10 who can Reperfusion >120 min obtain strategy and interpret (Ly6c the bolus) ECG, and FMC: deliver ini6al interven6ons (e.g. Non-PCI centre defibrilla6on). FMC can be either in <10 the Primary prehospital <60 sesng PCI Reperfusion or upon strategy (Wire crossing) FMC: PCI centre STEMI pa6ent arrival at the hospital diagnosis (e.g. emergency department). System delay Total ischaemic Nme 5

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9 Modes of panent presentanon, components of ischaemic Nme and flowchart for reperfusion strategy selecnon PaNent delay PaNent delay EMS delay STEMI diagnosis Total ischaemic Nme System delay FMC: EMS <10 <10 Term STEMI diagnosis Time to PCI? 120 min DefiniNon The 6me Primary at which <90 PCI Reperfusion the ECG of a pa6ent strategy with ischaemic (Wire crossing) symptoms is interpreted as presen6ng STsegment eleva6on or equivalent. Ambiguous Fibrinolysis Reperfusion >120 min terms are strategy eliminated: (Ly6c bolus) FMC: Door-to-balloon Non-PCI centre Door to door <10 Primary <60 PCI Reperfusion strategy (Wire crossing) FMC: PCI centre STEMI diagnosis System delay Total ischaemic Nme <10 9

10 Modes of panent presentanon, components of ischaemic Nme and flowchart for reperfusion strategy selecnon Atypical ECG presentanons PaNent delay Bundle branch block, Ventricular pacing, EMS delay Hyper-acute T waves, STEMI diagnosis Isolated depression in anterior leads, Universal ST depression with avr elevanonin <10 FMC: In the presence of symptoms, a primary Non-PCI PCI centre Total ischaemic Lej and Nme right bundle branch block are considered equal System delay for recommending urgent angiography if ischaemic FMC: EMS symptoms. < min Primary <90 PCI Reperfusion strategy (Wire crossing) Time to PCI? >120 min Fibrinolysis strategy strategy (urgent angiography and PCI if <10 Primary PCI indicated) should be followed. strategy FMC: PCI centre STEMI diagnosis PaNent delay System delay Total ischaemic Nme Reperfusion (Ly6c bolus) Reperfusion (Wire crossing) <60 <10 10

11 Modes of panent presentanon, components of ischaemic Nme and flowchart for reperfusion strategy selecnon PaNent delay EMS delay Total ischaemic Nme System delay In the absence of ST-segment elevanon FMC: EMS Class Level Primary <10 <90 A primary PCI strategy is indicated in pa6ents with suspected ongoing 120 min PCI strategy ischaemic symptoms if: STEMI diagnosis Time haemodynamic instability or cardiogenic shock, to PCI? recurrent or ongoing chest pain refractory <10 to medical treatment, Fibrinolysis <10 >120 min life-threatening arrhythmias or cardiac strategy FMC: arrest, mechanical complica6ons of myocardial Non-PCI infarc6on, centre I C acute heart failure, <10 Primary <60 recurrent dynamic ST-segment or T-wave changes, par6cularly with PCI strategy intermitent ST-segment eleva6on. FMC: PCI centre STEMI diagnosis PaNent delay System delay Total ischaemic Nme Reperfusion (Wire crossing) Reperfusion (Ly6c bolus) Reperfusion (Wire crossing) 11

12 Reperfusion strategies in the infarct-related artery according to Nme from symptoms onset Early phase of STEMI Symptoms onset 0 3 hours 12 hours Primary PCI I A Primary PCI I A I A Fibrinolysis (only if PCI cannot be performed within120 min from STEMI diagnosis) I A Fibrinolysis (only if PCI cannot be performed within120 min from STEMI diagnosis) 12

13 Reperfusion strategies in the infarct-related artery according to Nme from symptoms onset (con&nued) Evolved STEMI Recent STEMI 12 hours 48 hours Primary PCI (if symptoms, hemodynamic instabilicy, or arrhythmias) I C Primary PCI (asymptomanc stable panents) IIa B RouNne PCI (asymptomanc stable panents) III A 13

14 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 14

15 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Valgimigli et al. Lancet 2015;385: Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 15

16 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Oxygen when SaO2 <95% Same dose i.v in all patients Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA EXAMINATION, COMFORTABLE-AMI, NORSTENT Sabate et al. Lancet 2012;380: PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM MATRIX 16

17 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Oxygen when SaO2 <95% Same dose i.v in all patients Radial access DES over BMS Complete Revascularization Engstrom et al, Lancet 2015 Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM MATRIX 17

18 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Frobert et al, NEJM 2013 Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Jolly et al, NEJM 2015 Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 18

19 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Oxygen when SaO2 <95% Same dose i.v in all patients Radial access DES over BMS Complete Revascularization Valgimigli et al, NEJM 2015 PRAMI, DANAMI-3-PRIMULTI, Shazad et al, Lancet 2014 CVLPRIT, Compare-Acute Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge OXYGEN TNK-tPA EXAMINATION, COMFORTABLE-AMI, NORSTENT TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM MATRIX 19

20 Silvain et al, BMJ 2012 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 20

21 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 21

22 Stubb et al, Circ 2015 What is new in 2017 Guidelines on AMI-STEMI 2012 CHANGE IN RECOMMENDATIONS 2017 Radial access DES over BMS Complete Revascularization Thrombus Aspiration Bivalirudin Enoxaparin Early Hospital Discharge MATRIX EXAMINATION, COMFORTABLE-AMI, NORSTENT PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute TOTAL, TASTE MATRIX, HEAT-PPCI ATOLL, Meta-analysis Small trials & observational data Oxygen when SaO2 <95% Same dose i.v in all patients OXYGEN TNK-tPA Oxygen when SaO2 <90% AVOID, DETO2X Half dose i.v. in Pts 75 years STREAM 22

23 What is new in 2017 Guidelines on AMI-STEMI Addi6onal lipid lowering therapy if LDL >1.8 mmol/l (70 mg/dl) despite on maximum tolerated sta6ns. IMPROVE-IT, FOURIER 2017 NEW RECOMMENDATIONS Complete revasculariza6on during index primary PCI in STEMI pa6ents in shock. Expert opinion Cangrelor if P2Y 12 inhibitors have not been given. CHAMPION Switch to potent P2Y 12 inhibitors 48 hours ajer fibrinolysis. Expert opinion Extend Ticagrelor up to 36 months in high-risk pa6ents. PEGASUS-TIMI 54 Use of polypill to increase adherence. FOCUS Rou6ne use of deferred sten6ng. DANAMI 3-DEFER I IIa IIb III 23

24 What is new in 2017 Guidelines on AMI-STEMI Addi6onal lipid lowering therapy if LDL >1.8 mmol/l (70 mg/dl) despite on maximum tolerated sta6ns. IMPROVE-IT, FOURIER 2017 NEW RECOMMENDATIONS Complete revasculariza6on during index primary PCI in STEMI pa6ents in shock. Expert opinion BhaT et al, NEJM 2013 Cangrelor if P2Y 12 inhibitors have not been given. CHAMPION Switch to potent P2Y 12 inhibitors 48 hours ajer fibrinolysis. Expert opinion Extend Ticagrelor up to 36 months in high-risk pa6ents. PEGASUS-TIMI 54 Use of polypill to increase adherence. FOCUS Rou6ne use of deferred sten6ng. DANAMI 3-DEFER I IIa IIb III 24

25 Bonaca et al, NEJM 2015 What is new in 2017 Guidelines on AMI-STEMI Addi6onal lipid lowering therapy if LDL >1.8 mmol/l (70 mg/dl) despite on maximum tolerated sta6ns. IMPROVE-IT, FOURIER 2017 NEW RECOMMENDATIONS Complete revasculariza6on during index primary PCI in STEMI pa6ents in shock. Expert opinion Cangrelor if P2Y 12 inhibitors have not been given. CHAMPION Switch to potent P2Y 12 inhibitors 48 hours ajer fibrinolysis. Expert opinion Extend Ticagrelor up to 36 months in high-risk pa6ents. PEGASUS-TIMI 54 Use of polypill to increase adherence. FOCUS Rou6ne use of deferred sten6ng. DANAMI 3-DEFER I IIa IIb III 25

26 Do not forget intervennons in STEMI panents undergoing a primary PCI strategy 26

27 DiagnosNc test flow chart in MINOCA SUSPECTED STEMI ACUTE INVESTIGATION Coronary stenosis 50% Urgent angiography No Coronary stenosis 50% + Fulfilment universal AMI criteria Treat as STEMI MINOCA Acute LV wall monon assessment (angiogram/echo) 27

28 Full Text ESC Pocket Guidelines App and much more

29 STEMI in NW Greece Διάρκεια 12 µήνες (1/10/05 31/9/06) Κέρκυρα Ιωάννινα n: 359 (άνδρες 82%) Φιλιάτες Άφιξη από την έναρξη των συµπτωµάτων Πρέβεζα Άρτα <3 h Λευκάδα

30 Primary PCI Athens area

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33 STEMI ppci patients Time Delays Thrombolysis 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

34 ESC Pocket Guidelines App Any6me - Anywhere All ESC Pocket Guidelines Over 140 interacnve tools - Algorithms - Calculators - Charts & Scores Summary Cards & EssenNal Messages Learn more on the Guidelines area Online & Offline

35 Lysis 50% HELIOS Eπαναιµάτωση σε STEMI No Rx 41% Mε αιµοδ/εργ. Xωρίς 35% 65% p PCI 9% prpci 24% 1% Θρ/λυση 43% 54% Kαµµιά 33% 45%

36 2017 ESC Guidelines for the management of acute myocardial infarcnon in panents presennng with ST-segment elevanon

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38 Ratio Total PCI/Primary PCI: ,8 % 10,2 % 15,5 % 23 % 25 % 20 %

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40 Class I Classes of recommendanons Classes DefiniNon Evidence and/or general agreement that a given treatment or procedure is beneficial, useful, effec6ve. Suggested wording Recommended/ is indicated. 159 recommendations IIb 13 8% III 16 10% Class IIa Weight of evidence/opinion is in favour of usefulness/efficacy. Should be considered. Class III Class IIb Usefulness/efficacy is less well established by evidence/opinion. Evidence or general agreement that the given treatment or procedure is not useful/effec6ve, and in some cases may be harmful. May be considered. Not recommended. IIa 38 24% 92 58% I

41 What is new in 2017 Guidelines on AMI-STEMI MINOCA AND QUALITY INDICATORS: New chapters dedicated to these topics NEW / REVISED CONCEPTS STRATEGY SELECTION AND TIME DELAYS: Clear defini6on of first medical contact (FMC). Defini6on of 6me 0 to choose reperfusion strategy (i.e. the strategy clock starts at the 6me of STEMI diagnosis ). Selec6on of PCI over fibrinolysis: when an6cipated delay from STEMI diagnosis to wire crossing is 120 min. Maximum delay 6me from STEMI diagnosis to bolus of fibrinolysis agent is set in 10 min. Door-to-Balloon term eliminated from guidelines. TIME LIMITS FOR ROUTINE OPENING OF AN IRA: 0-12h (Class I); 12-48h (Class IIa); >48h (Class III). ELECTROCARDIOGRAM AT PRESENTATION: Lej and right bundle branch block considered equal for recommending urgent angiography if ischaemic symptoms. TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS: Timeframe is set in 2-24h ajer successful fibrinolysis. PATIENTS TAKING ANTICOAGULANTS: Acute and chronic management presented. 41

42 Modes of panent presentanon, components of ischaemic Nme and flowchart for reperfusion strategy selecnon PaNent delay EMS delay Total ischaemic Nme System delay STEMI diagnosis FMC: EMS <10 <10 FMC: Non-PCI centre Time to PCI? 120 min >120 min Primary PCI strategy Fibrinolysis strategy <90 <10 Reperfusion (Wire crossing) Reperfusion (Ly6c bolus) PaNent delay <10 Primary PCI FMC: PCI centre STEMI strategy diagnosis System delay Total ischaemic Nme Reperfusion (Wire crossing) <60 42

43 Reperfusion strategies in the infarct-related artery according to Nme from symptoms onset 43