JOURNAL TRANSCRIPT
1
European Heart Journal 2015 doi: 10.1093/eurheartj/ehv320
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Clinical implications of high-sensivity troponin assays
European Heart Journal 2015 doi: 10.1093/eurheartj/ehv320
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Conditions other than Type I acute myocardial infraction associated with cardiac troponin elevation
4
Initial assessment of patients with suspected acute coronary syndromes
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0h/3h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays
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0h/1h rule-in and rule-out algorithms using highsensitivity cardiac troponin assays
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Recommendations for diagnosis, risk stratification, imaging, and rhythm monitoring in patients with suspected NSTE-ACS
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Recommendations for anti-ischaemic drugs in the acute phase of NSTE-ACS
Recommendations for platelet inhibition in NSTE-ACS Classa
Levelb
I
A
I
A
I
B
I
B
I
B
P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES implantation may be considered in patients deemed at high bleeding risk.
IIb
A
It is not recommended to administer prasugrel in patients in whom coronary anatomy is not known.
III
B
GPIIb/IIIa inhibitors during PCI should be considered for bailout situations or thrombotic complications.
IIa
C
Cangrelor may be considered in P2Y12 inhibitor-naïve patients undergoing PCI.
IIb
A
It is not recommended to administer GPIIb/IIIa inhibitors in patients in whom coronary anatomy is not known.
III
A
Recommendations
Oral antiplatelet therapy Aspirin is recommended for all patients without contra-indications at an initial oral loading dosec of 150–300 mg (in aspirin-naïve patients) and a maintenance dose of 75–100 mg daily long-term regardless of treatment strategy. A P2Y12 inhibitor is recommended, in addition to aspirin, for 12 months unless there are contraindications such as excessive risk of bleeds. • Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended, in the absence of contraindicationsd, for all patients at moderate- to high-risk of ischaemic events (e.g. elevated cardiac troponins), regardless of initial treatment strategy and including those pretreated with clopidogrel (which should be discontinued when ticagrelor is started). • Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended in patients who are proceeding to PCI if no contraindication.d • Clopidogrel (300–600 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation.
Intravenous antiplatelet therapy
Targets for antithrombotic drugs Anticoagulant drugs
Antiplatelet drugs
Tissue Factor
Aspirin
Rivaroxaban Plasma clotting cascade
LMWH UFH
Antithrombin
Fondaparinux
ADP TXA2
Prothrombin
Conformational activation of GPIIb/IIIa
Factor Xa
Thrombin
Cangrelor Clopidogrel Prasudrel Ticagrelor
GPIIb/IIIa Inhibitors
Bivalirudin Vorapaxar PAR-1 receptor Soluble mediators (ADP, TXA2, Ca++, serotonin)
Fibrinogen
GPIIb/IIIa receptor Collagen Clot-bound thrombin/factor Xa
Fibrin
GPIIb/IIIa inhibitors
Major Bleeding
Navarese et al, BMJ 2015;350:h1618
Timing of P2Y12 Inhibitor Initiation • 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. Based on the ACCOAST results, pretreatment with prasugrel is not recommended.
Recommendations for platelet inhibition in NSTE-ACS (continued) Recommendations
Classa
Levelb
IIb
A
I
B
IIa
C
IIb
C
Long-term P2Y12 inhibition P2Y12 inhibitor administration in addition to aspirin beyond 1 year may be considered after careful assessment of the ischaemic and bleeding risks of the patient. General recommendations
A proton pump inhibitor in combination with DAPT is recommended in patients at higher than average risk of gastrointestinal bleeds (i.e. with a history of gastrointestinal ulcer/haemorrhage, anticoagulant therapy, chronic NSAID/corticosteroid use or two or more among age ≥65 years, dyspepsia, gastro-oesophageal reflux disease, Helicobacter pylori infection, and chronic alcohol use). In patients on P2Y12 inhibitors who need to undergo non-emergency major non-cardiac surgerye, postponing surgery for at least 5 days after cessation of ticagrelor or clopidogrel, and for 7 days for prasugrel, should be considered if clinically feasible and unless the patient is at high risk of ischaemic events,. In case of a non-cardiac surgical procedure that cannot be postponed or a bleeding complication, discontinuation of the P2Y12 inhibitor may be considered after a minimum of 1 and 3 months from PCI with BMS and new-generation DES, respectively.
Navarese et al, BMJ 2015;350:h1618
Recommendations for anticoagulation in NSTE-ACS Classa
Levelb
at the time of diagnosis according to both ischaemic and
I
B
Fondaparinux (2.5 mg s.c. daily) is recommended as having the most favourable efficacy–safety profile regardless of the management strategy.
I
B
Bivalirudin (0.75 mg/kg i.v. bolus, followed by 1.75 mg/kg/hour for up to 4 hours after the procedure) is recommended as alternative to UFH plus GPIIb/IIIa inhibitors during PCI.
I
A
I
B
In patients on fondaparinux (2.5 mg s.c. daily.) undergoing PCI, a single i.v. bolus of UFH (70–85 IU/kg, or 50–60 IU/kg in the case of concomitant use of GPIIb/IIIa inhibitors) is recommended during the procedure.
I
B
Enoxaparin (1 mg/kg s.c. twice daily) or UFH are recommended when fondaparinux is not available.
I
B
Enoxaparin should be considered as anticoagulant for PCI in patients pretreated with s.c. enoxaparin.
IIa
B
Additional ACT-guided i.v. boluses of UFH may be considered following initial UFH treatment.
IIb
B
Discontinuation of anticoagulation should be considered after PCI, unless otherwise indicated.
IIa
C
Crossover between UFH and LMWH is not recommended.
III
B
In NSTEMI patients with no prior stroke/TIA and at high ischaemic risk as well as low bleeding risk receiving aspirin and clopidogrel, low-dose rivaroxaban (2.5 mg twice daily for approximately one year) may be considered after discontinuation of parenteral anticoagulation.
IIb
B
Recommendations Parenteral anticoagulation is recommended bleeding risks.
UFH 70–100 IU/kg i.v. (50–70 IU/kg if concomitant with GPIIb/IIIa inhibitors) is recommended in patients undergoing PCI who did not receive any anticoagulant.
NSTE-ACS patients with non-valvular atrial fibrillation
Management strategy
PCI
Bleeding risk
High Low to intermediate (eg HAS-BLED=0-2) (eg HAS-BLED3)
Medically managed/CABG
0
Triple or dual therapy
Triple therapy
4 weeks
O A C
O A C 6 months
Time from PCI/ACS
Dual therapy
O C or A
12 months Lifelong
Dual therapy
Dual therapy
O C or A
O C or A
O Monotherapy O
Oral anticoagulation (VKA or NOACs)
A
Aspirin 75-100 mg daily
C
Clopidogrel 75 mg daily
Recommendations for long-term management post NSTE-ACS Recommendations (for the recommendations on Classa Levelb antithrombotic treatment see sections 5.2.9 and 5.3.3).d It is recommended to advise all patients on life style changes (including smoking cessation, regular physical activity and a healthy diet).
I
A
It is recommended to start high-intensity statin therapy as early as possible, unless contraindicated, and maintain it long-term.
I
A
An ACE inhibitor is recommended in patients with LVEF ≤40%, or heart failure, hypertension or diabetes, unless contraindicated. An ARB provides an alternative, particularly if ACE inhibitors are not tolerated.
I
A
Beta-blocker therapy is recommended in patients with LVEF ≤40%, unless contra-indicated.
I
A
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Selection of non-STelevation acute coronary syndromes (NSTE-ACS) treatment strategy and timing according to initial risk stratification
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Recommendations for invasive coronary angiography and revascularization in NSTE-ACS
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Recommendations for diabetic patients presenting with NSTE-ACS
Options for Revascularisation 1.
Acute coronary syndromes: Early revascularization (as in non DM).
2.
Stable coronary artery disease : CABG preferred option if myocardial area at risk is large. PCI with DES may be performed for symptom control in single and two-vessel disease.
Myocardial revascularisation vs. medical therapy in people with diabetes Event free survival in the BARI 2 D study – CABG stratum
Event free survival (%)
100
80
Revascularisation 78% Medical therapy 70%
60
p = 0.01
40
Compared to medical treatment alone prompt revascularisation decreased major CV events in the CABG stratum
20
0 0
1
3 2 Follow up (years)
4
5
BARI 2D Study group New Engl J Med 2009; 360: 2503
CABG vs. PCI in people with diabetes The FREEDOM trial Primary Outcome
Death 60
p=0.005 by log rank test 5-year event rate 26.6 vs.18.7%
50 40
PCI
30
7.9%
20
CABG
10
Death from any cause (%)
Death, myocardial infarction, or stroke (%)
60
p=0.049 by log rank test 5-year event rate 16.3 vs.10.9%
50 40 30
PCI
20
5.4%
10
CABG 0
0 0
1
2
3
4
5
Years since randomization
Farkouh et al New Engl J Med 2012; 367: 2375
0
1
2
3
4
Years since randomization
5
Revascularisation in people with diabetes Recommendations
Class
Level
Optimal medical treatment should be considered as preferred treatment in patients with stable CAD and DM unless there are large areas of ischaemia or significant left main or proximal LAD lesion.
IIa
B
CABG is recommended in patients with DM and multivessel or complex (SYNTAX Score >22) CAD to improve survival free from major cardiovascular events.
I
A
PCI for symptom control may be considered as an alternative to CABG in patients with DM and less complex multivessel CAD (SYNTAX score ≤22) in need of revascularization.
IIb
B
Primary PCI is recommended over fibrinolysis in DM patients presenting with STEMI if performed within recommended time limits.
I
B
In DM patients subjected to PCI, DES rather than BMS are recommended to reduce risk of target vessel revascularization.
I
A
Renal function should be carefully monitored after coronary angiography/PCI in all patients on metformin.
I
C
If renal function deteriorates in patients on metformin undergoing coronary angiography/PCI it is recommended to withhold treatment for 48 h or until renal function has returned to its initial level.
I
C
Recommendations for long-term management post NSTE-ACS (continued) Recommendations (for the recommendations antithrombotic treatment see sections 5.2.9 and 5.3.3).d
on Classa
Mineralocorticoid receptor antagonists, preferably eplerenone, are recommended in patients with LVEF ≤35% and either heart failure or diabetes after NSTE-ACS but no significant renal dysfunction or hyperkalaemia.c A diastolic blood pressure goal of