diercks acs lecture 9.17

7/21/2019 Diercks ACS Lecture 9.17

http://slidepdf.com/reader/full/diercks-acs-lecture-917 1/19

Management of Patients withACS: Differences between ESC

and AHADeborah B. Diercks, MD

Professor of Emergency Medicine

University of California, Davis Medical CenterSacramento, CA



Objectives

• Review how sets of guidelines are created

• Discuss STEMI guidelines

• Review NSTE-ACS differences



How the guidelines are created• ESC

– Experts in the field – Comprehensive review

of published literature

– Critical reviewassessing risk andbenefit

– Level of evidence andstrength of evidenceare graded

– All have provideddisclosure

• AHA/ACC

– Experts selected withaddition of appropriateadditional specialties

– Formal literature

review – Level of evidence and

strength are graded

– All have provideddisclosure

– 1 ED physiciansupported by ACEP



How data driven are theseguidelines

• Data from all ACC/AHA practice guidelines issued from 1984 toSeptember 2008 were abstracted by personnel in the ACC Science

and Quality Division.• Fifty-three guidelines on 22 topics, including a total of 7196

recommendations, were abstracted.• The number of recommendations and the distribution of classes of

recommendation (I, II, and III) and levels of evidence (A, B, and C)

were determined.• Considering the 16 current guidelines reporting levels of evidence,

– 314 recommendations of 2711 total are classified as level of evidence A(median, 11%)

– 1246 (median, 48%) are level of evidence C.

– 245 of 1305 class I recommendations have level of evidence A (median,19%).

JAMA. 2009 Feb 25;301(8):831-41



Joint projects• Classification of Myocardial Infarction by Type:

1 Spontaneous MI related to ischemia due to a primary coronaryevent, such as plaque erosion and/or rupture, fissuring, or dissection2 MI secondary to ischemia due to an imbalance of O2 supply anddemand, as from coronary spasm or embolism, anemia,arrhythmias, hypertension, or hypotension

3 Sudden unexpected cardiac death, including cardiac arrest, oftenwith symptoms suggesting ischemia with new ST-segmentelevation; new left bundle branch block; or pathologic orangiographic evidence of fresh coronary thrombus—in the absenceof reliable biomarker findings4a MI associated with PCI

4b MI associated with documented in-stent thrombosis5 MI associated with CABG surgery

Circulation 2007;116:2634-2653



Differences are largely systemdriven

• Prehospital

• Resource Allocation

• Percutaneous Coronary Intervention

Capable



STEMI differences

• Overall minimal difference in treatment

– Some on timing: B-blockers

– Reperfusion therapy

• Variation in time door to balloonrecommendation

– (DB)-(DN)>60 minutes

– < 3 hours of symptoms all equal – Acceptable door to balloon time

European Heart Journal 2008;29:2909-2945

Circulation 2008; 117:296–329



Controversial study

• ESC has taken an individual approach

• Current guidelines base decisions of a PCItime <2 hours

– Systematic review that reported PCI delay<35 minutes was threshold of increased risk

– Retrospective review of NRMI data: DB-DN

threshold varies based on age and location ofthe infarct.


Eur Heart J. 2006 Apr;27(7):779-88Circulation 2006;114:2019-2025



NSTE-ACS differences

• Hospital Resources

– Observation Unit

– Strategy

• Invasive vs Conservative

• Urgent vs Early vs Conservative

– Biomarker

• Multi-marker

• Single marker


JACC 2007;50:e2-e157



Time to InterventionBoth guidelines are risk based

• ESC

• Urgent (2-15%) – Refractory angina

– Dynamic ST deviation

– Heart failure

– Arrhythmia

– Hemodynamic instability

• Early (<72 hours)

– Intermediate to high riskfeatures

• Conservative

• AHA

• Invasive strategy – Same as urgent

– Low EF

– Positive NI test

– Previous PCI or CABG

• Conservative

European Heart Journal 2007;28:1598-

1660

JACC 2007;50:e2-e157



Controversial study-ICTUS

• ICTUS

– Early invasive strategy (within 48 hours) wasassociated with an increased risk of MI

• 15.0 vs 10.0%

• RR 1.5 (95 % CI 1.1-2.10)

– No difference

N Engl J Med. 2005 Sep 15;353(11):1095-104



Assessment of Bleeding

• Higher focus of bleeding assessment

– Independent predictors identified by risk

• Age

• Female

• History of bleeding

• History of renal insufficiency




Observation Unit

• ACC/AHA

– Observation units

• Critical pathway based units with protocols todetermine if a patient has ACS

• Appropriate patients – Patients wieht possible ACS that is sl atypical and is pain

free now with nl or unchanged ECG and normalbiomarkers

– Patients with possible or definite based on symptomswith non-diagostic ECG and negative biomakers

JACC 2007;50:e2-e157



Biomarkers• Differences in strategy

• ESC – Single troponin > 12 hours after symptoms

– Serial troponin at presentation and 6-12 hours after

• ACC/AHA

– If neg biomarkers within 6 hours of symptoms repeat markersshould be measured 8-12 hrs after symptom onset. (LOE I)

– It is reasonable remeasure markers at 6-8 hours intervals (LOEIIa)

– If present within 6 hours it is reasonable to add an early marker,delta 2 hours CK-MB and delta troponin can be measures,evaluation of myoglobin,CK-MB mass, and troponin can bemeasured at 0 and 90 minutes. (LOE IIb)

European Heart Journal 2007;28:1598-

1660JACC 2007;50:e2-e157



More alike than different• Key components of acute care

– Risk stratification

• History

• ECG

• Biomarkers

• Non-invasive studies

– Treatment



Little guidance for EDphysicians

• Despite extrapolation

– Do these guidelines address our EM practicalissues?

• Admit all

• Serial markers prior to admission



ILCOR• More involvement of ED physicians from

Canada and US• Addressing time frames in the pre-hospital

setting and ED



Solution• Take advantage of anything you can

– If information changes to educate EDphysicians we need to get information into ourliterature

– To get information into our literature we needto be involved with the process



Conclusion• Consistent therapeutic recommendations

• Variations largely based on resources

• Both lack emergency medicine

representation

diercks acs lecture 9.17

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