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Acute coronary syndromes
A European viewpoint
Felicita Andreotti, MD PhD FESC
Catholic University Hospital
Cardiovascular Diseases - Rome, IT
Potential conflicts of interest
Speaker
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
www.escardio.org
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Eur Heart J 2016 Jan 14;37(3):267-315
www.escardio.org
Initial assessment of patients with suspected acute coronary syndromes
Emergency Echo in acute HF pts
to assess LV and valve fx & excludemechanical complications IC
<10 min
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
Guidance on hs-cTn for suspected NSTEMI
Very LowLowand
No 0-1h or
Highor
0-1h
> 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
Predictive values for acute MI: negative >98% - positive 75-80%
0-1h rule-in and rule-out hs-cTn algorithms
Cut-offs are assay specific
Eur Heart J 2016 Jan 14;37(3):267-315
Invasive strategy and timing based on initial risk
(2011: primary/secondary high-risk criteria)
Ongoing ischaemia
Immediate action
<2h, IC
<24h, IA
<72h, IA
+, IA
P2Y12 inhibitor before early invasive strategy
• 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 ticagrelorpreferred over clopidogrel in absence of increased bleeding risk)
(2011: ‘as soon as possible’)
Eur Heart J 2016 Jan 14;37(3):267-315
Oral anticoagulation plus antiplatelet(s)
Eur Heart J 2016 Jan 14;37(3):267-315
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Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification
IC IA IAIA
(MDCT angioif ECG or cTn
inconclusive, IIa A)
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):267-315
www.escardio.org
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MATRIXCo-primary compositeoutcomes at 30 days
Speaker
• N=8404• NSTE-ACS + STEMI• Radial vs. femoral
Valgimigli M et al.Lancet. 2015;385:2465-76
All-cause mortality, MI, stroke
All-cause mortality, MI, stroke, or BARC 3 or 5 bleeding
Radial vs femoral meta-analysis
Non-CABG major bleeeds
Death, MI, or stroke
Death
MI
Stroke
PRR (95% CI)
Valgimigli M et al. Lancet 2015;385:2465-76
Drug-eluting stents
Eur Heart J 2016 Jan 14;37(3):267-315
Antiplatelet therapy after stenting on OAC
Adapted from Lip et al. Eur Heart J 2014;35:3155–3179.aDual therapy with oral anticoagulation and clopidogrel may be considered in selected patients (low ischaemic risk).baspirin 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.cDual 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).
NSTE-ACS patients with non-valvular atrial fibrillation
Tripletherapy
O A C
Triple or dual therapya
O A C
O A COral anticoagulation(VKA or NOACs)
ASA 75–100 mg daily Clopidogrel 75 mg daily
Tim
e f
rom
PC
I/A
CS
Lifelong
12 months
6 months
4 weeks
0
Dual therapyb
Dual therapyb
MonotherapycO
High(e.g. HAS-BLED ≥ 3)
Low to intermediate(e.g. HAS-BLED = 0–2)
PCI Medically managed /CABG
Dual therapyb
O C or A
Bleeding risk
O C or A
O C or A
Management strategy
IIaC IIaC
IIb B
Eur Heart J 2016 Jan 14;37(3):267-315
Guidance on rhythm monitoring
H A E R S C
*
*
IIa C
IIa C
Continuous monitoring up to diagnosis (Y/N) IC
IIb C in suspected spasm
†
†
Duration of dual antiplatelet therapy
Eur Heart J 2016 Jan 14;37(3):267-315
Eur Heart J 2016 Jan 14;37(3):267-315
†
†
Elderly with NSTE-ACS
was B
2 RCTs
- TACTICS
- Elderly
†
†
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:10.1093/eurheartj/ehv304
Eur Heart J 2016 Jan 14;37(3):267-315
www.escardio.org
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Speaker
European Heart Journaldoi:10.1093/eurheartj/ehv409
European Heart Journaldoi:10.1093/eurheartj/ehv407
European Heart Journaldoi:10.1093/eurheartj/ehv408
Help to implementGL in daily practice
• 40 cases each• No reference• Link to the dedicated
sections of the GL
www.escardio.org
ABSTRACT SUBMISSION
Mid December – 14 February 2016
EARLY REGISTRATION
Deadline: 31 May 2016
HOT LINES SUBMISSION
Mid March – 1 May 2016
CLINICAL CASE SUBMISSION
Mid January – 1 March 2016
LATE REGISTRATION
Deadline: 31 July 2016
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