ESC Congress 2017 In Review – Focus on CAD&ACS - 4

Main Session

2017 ESC Clinical Practice Guidelines for the Management of STEMI
Written by Toni Rizzo

A goal of the 2017 update of the European Society of
Cardiology (ESC) Clinical Practice Guidelines for the management of acute myocardial infarction (AMI)-STEMI [Ibanez
B et al. Eur Heart J. 2017] was to align the recommendations
with the other ESC guidelines and consensus documents,
including the simultaneously published update on dual antiplatelet therapy (DAPT) [Valgimigli M et al. Eur Heart J. 2017].
In a session on 27 August 2017 that presented an overview of the new AMI-STEMI guidelines, Stefan James, MD,
Uppsala University, Uppsala, explained that the ESC Task
Force attempted to make the guidelines more user-friend-

ly by highlighting the changes from the 2012 guidelines in
flowcharts and tables. The charts in Figure 1 summarise the
revised and new recommendations in the current update.
Acute Cardiac Care in Stable and Unstable STEMI
Pascal Vranckx, MD, PhD, Cardiovascular Research
Centre, Hasselt, Belgium, discussed the changes in the
updated guidelines on caring for patients in the acute
phase of MI, from symptom recognition to emergency
medical services (EMS) and emergency department
evaluation and treatment.

Figure 1. Changes in the 2017 ESC STEMI Guidelines

Change in Recommendations
2012

New Recommendations 2017

2017
Radial Access
MATRIX

DES Over BMS
EXAMINATION
COMFORTABLE-AMI, NORSTENT

Complete Revascularisation
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
Sa02 < 95%

AVOID
DETO2X

Oxygen when
Sa02 < 90%

2017 New / Revised Concepts
MINOCA and Qualtity Indicators:
*	 New	chapters	dedicated	to	these	topics

* Additional lipid lowering therapy if
LDL / 1.8 mmol/L (70 mg/dL) despite
on maximum tolerated statins
- IMPROVE-IT, FOURIER

* Complete revascularisation during
index primary PCI in STEMI patients
in shock
- Expert opinion

* Cangrelor if P2Y12 inhibitors have not
been given
- CHAMPION
* Switch to potent P2Y12 inhibitors 48
hours after fibrinolysis
- Expert opinion
* Extend ticagrelor up to 36 months in
high-risk patients
- PEGASUS-TIMI 54
* Use polypill to increase adherence
- FOCUS
* Routine use of deferred stenting
- DANAMI 3-DEFER

Dose i.V. TNK-tPA STREAM
Dose i.V. TNK-tPA
same in all patients
half in Pts ≥ 75 years

I

IIa

IIb

III

Strategy Selection and Time Delays:
*	 Clear	definition	of	first	medical	contact	
*	 Definition	of	"time	0"	to	choose	reperfusion	
strategy (ie, 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

BMS, bare-metal stent; DES, drug-eluting stent; IRA, infarct-related artery; LDL, low-density lipoprotein; MINOCA, myocardial infarction with nonobstructive
coronary arteries; PCI, percutaneous coronary intervention; SaO2, arterial oxygen saturation; STEMI, ST-segment elevation myocardial infarction; TNK-tPA,
tenecteplase tissue plasminogen activator.
Reprinted from Ibanez B, James S et al. 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 (ESC).
Eur Heart J 2017; doi:10.1093/eurheartj/ehx419. By permission of Oxford University Press on behalf of the European Society of Cardiology.

4

October 2017

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