2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation 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 Kastrati (Germany), Mattie J. Lenzen (The Netherlands), Eva Prescott (Denmark), Marco Roffi (Switzerland), Marco Valgimigli (Switzerland), Christoph Varenhorst (Sweden), Pascal Vranckx (Belgium), Petr Widimský (Czech Republic). 1 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Task Force Members ESC v ACCA - Acute Cardiovascular Care Association 19 Authors v EAPCI - European Association of PCI EAPC -- European Association of Preventive cardiology ESC EHRA - European Heart Rhythm Association 30 Reviewers v EACVI - European Association of Cardiovascular Imaging v v HFA - Heart Failure Association -1224 comments v v v v v Council - Cardiovascular Nursing and Allied Professions and requests v v v v Council – for Cardiology practice v v v v WG - Myocardial and Pericardial Diseases v WG - Thrombosis v v v v v v WG - Cardiovascular Pharmacotherapy v v v WG - Cardiovascular Surgery v v v v 2 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Level of evidence 159 recommendations based on 477 references 21% A Data derived from multiple randomized 37 A clinical trials or meta-analyses. 23% 78 Data derived from a single randomized C B clinical trial or large non-randomized 49% studies. Consensus of opinion of the experts C and/or small studies, retrospective 44 studies, registries. 28% B 3 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
What is new in 2017 Guidelines on AMI-STEMI 2017 NEW / REVISED CONCEPTS MINOCA AND QUALITY INDICATORS: • New chapters dedicated to these topics. STRATEGY SELECTION AND TIME DELAYS: • Clear definition of first medical contact (FMC). • Definition of “time 0” to choose reperfusion strategy (i.e. the strategy clock starts at the time of “STEMI diagnosis”). • Selection of PCI over fibrinolysis : when anticipated delay from “STEMI diagnosis” to wire crossing is ≤120 min. • Maximum delay time 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: • Left 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 after successful fibrinolysis. PATIENTS TAKING ANTICOAGULANTS: • Acute and chronic management presented. 4 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection Total ischaemic time Patient delay EMS delay System delay Term Definition FMC: EMS Primary <90’ Reperfusion <10’ FMC The time point when the patient is PCI ≤120 min (Wire crossing) strategy either initially assessed by a STEMI diagnosis Time physician, paramedic, nurse or other to PCI? trained EMS personnel who can <10’ <10’ Fibrinolysis Reperfusion obtain and interpret the ECG, and >120 min strategy (Lytic bolus) FMC: deliver initial interventions (e.g. Non-PCI centre defibrillation). FMC can be either in the prehospital setting or upon Primary <60’ <10’ Reperfusion PCI patient arrival at the hospital (Wire crossing) strategy STEMI FMC: PCI centre (e.g. emergency department). diagnosis Patient delay System delay Total ischaemic time 5 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection Total ischaemic time Patient delay EMS delay System delay Term Definition FMC: EMS Primary STEMI The time at which the ECG of a <90’ Reperfusion <10’ PCI ≤120 min (Wire crossing) diagnosis patient with ischaemic symptoms is strategy STEMI interpreted as presenting ST- diagnosis Time to PCI? segment elevation or equivalent. <10’ <10’ Fibrinolysis Reperfusion Ambiguous terms are eliminated: >120 min strategy (Lytic bolus) FMC: “Door -to-balloon ” Non-PCI centre “Door to door” Primary <60’ <10’ Reperfusion PCI (Wire crossing) strategy STEMI FMC: PCI centre diagnosis Patient delay System delay Total ischaemic time 9 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Modes of patient presentation, components of ischaemic time and flowchart for reperfusion strategy selection Total ischaemic time Atypical ECG presentations Left and right bundle branch block are considered equal Patient delay EMS delay System delay for recommending urgent angiography if ischaemic Bundle branch block, symptoms. FMC: EMS Ventricular pacing, Primary <90’ Reperfusion <10’ PCI ≤120 min (Wire crossing) Hyper-acute T waves, strategy STEMI diagnosis Time Isolated depression in anterior leads, to PCI? <10’ <10’ Universal ST depression with aVR elevationIn Fibrinolysis Reperfusion >120 min strategy (Lytic bolus) FMC: In the presence of symptoms, a primary PCI Non-PCI centre strategy (urgent angiography and PCI if Primary <60’ <10’ Reperfusion PCI (Wire crossing) indicated) should be followed. strategy STEMI FMC: PCI centre diagnosis Patient delay System delay Total ischaemic time 10 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Reperfusion strategies in the infarct-related artery according to time from symptoms onset 0 Primary PCI Symptoms onset Early phase of STEMI I A I A Fibrinolysis (only if PCI cannot be performed within120 min from STEMI diagnosis) 3 hours Primary PCI I A I A Fibrinolysis (only if PCI cannot be performed within120 min from STEMI diagnosis) 12 hours 12 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
Reperfusion strategies in the infarct-related artery according to time from symptoms onset (continued) 12 hours Primary PCI Primary PCI (if symptoms, (asymptomatic Evolved STEMI hemodynamic instabilicy, stable patients) or arrhythmias) IIa B 48 hours I C Routine PCI (asymptomatic Recent III A STEMI stable patients) 13 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
What is new in 2017 Guidelines on AMI-STEMI CHANGE IN RECOMMENDATIONS 2012 2017 Radial access MATRIX DES over BMS EXAMINATION, COMFORTABLE-AMI, NORSTENT Complete Revascularization PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute Thrombus Aspiration TOTAL, TASTE Bivalirudin MATRIX, HEAT-PPCI Enoxaparin ATOLL, Meta-analysis Early Hospital Discharge Small trials & observational data Oxygen when SaO2 <90% OXYGEN Oxygen when SaO2 <95% AVOID, DETO2X Half dose i.V. in Pts ≥75 years TNK-tPA Same dose i.V in all patients STREAM 14 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
What is new in 2017 Guidelines on AMI-STEMI CHANGE IN RECOMMENDATIONS 2012 2017 Radial access MATRIX DES over BMS EXAMINATION, COMFORTABLE-AMI, Valgimigli et al. Lancet 2015;385:2465-76 NORSTENT Complete Revascularization PRAMI, DANAMI-3-PRIMULTI, CVLPRIT, Compare-Acute Thrombus Aspiration TOTAL, TASTE Bivalirudin MATRIX, HEAT-PPCI Enoxaparin ATOLL, Meta-analysis Early Hospital Discharge Small trials & observational data Oxygen when SaO2 <90% OXYGEN Oxygen when SaO2 <95% AVOID, DETO2X Half dose i.V. in Pts ≥75 years TNK-tPA Same dose i.V in all patients STREAM 15 www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
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