ESC Congress 2017 In Review – Focus on CAD&ACS - 5

ESC Congress 2017

In Review

CAD & ACS

For the first time, the first medical contact (FMC)
is clearly defined in the guidelines, as the first contact
with a physician, paramedic, nurse, or other trained EMS
personnel who can obtain and interpret the electrocardiogram (ECG) and deliver initial interventions.
The guidelines on imaging and stress testing include
recommendations for emergency echocardiography for
certain presentations but should not delay angiography
unless the diagnosis is uncertain (Table 1) and provide recommendations following primary PCI and post discharge.
Table 1. Indications for Imaging and Stress Testing in Patients With STEMI
Recommendations

Class

Level

At presentation

The maximum target times according to reperfusion
strategy in patients presenting via EMS or in a non-PCI
centre are shown in Figure 2.
New recommendations have been added to the
guideline for management of cardiogenic shock, including the concept of the Heart Team (Table 2).
Table 2. Management of Cardiogenic Shock in STEMI
Recommendations

Class

Level

Immediate PCI is indicated for patients with cardiogenic
shock if coronary anatomy is suitable. If coronary anatomy
is not suitable for PCI, or PCI has failed, emergency CABG
is recommended.

Invasive blood pressure monitoring with an arterial line
is recommended.

Immediate Doppler echocardiography is indicated to assess
ventricular and valvular functions, loading conditions, and
to detect mechanical complications.

Emergency echocardiography is indicated in patients
with cardiogenic shock and/or haemodynamic instability
or suspected mechanical complications without delaying
angiography.

I
NEW

Emergency echocardiography before coronary angiography
should be considered if the diagnosis is uncertain.

IIa
IC➞ IIa

It is indicated that mechanical complications are treated
as early as possible after discussion by the Heart Team.

C
NEW

III
NEW

Oxygen/mechanical respiratory support is indicated
according to bloodgases.

III

IIa

C
NEW!

IIa

C
NEW

lntra-aortic balloon pumping should be considered in
patients with haemodynamic instability/cardiogenic shock
due to mechanical complications.

IIa

C
NEW

Haemodynamic assessment with pulmonary artery
catheter may be considered for confirming diagnosis or
guiding therapy.

IIb

Ultrafiltration may be considered for patients with
refractory congestion, who failed to respond to diureticbased strategies.

IIb

B
IIa ➞ IIb

Inotropic/vasopressor agents may be considered for
haemodynamic stabilisation.

IIb

C
IIa ➞ IIb

Short-term mechanical support may be considered in
patients in refractory shock.

IIb

Routine intra-aortic balloon pumping is not indicated.

III

B
IIb ➞ III

Routine echocardiography that delays emergency
angiography is not recommended.
Coronary CT angiography is not recommended.
CT, computed tomography.

Adapted 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.

Figure 2. Maximum Target Times According to Reperfusion Strategy
in Patients Presenting via EMS or in a non-PCI Centre
Strategy
clock

ECG:
STEMI
diagnosis
Alert & transfer
to PCI centre

Time to PCI
≤ 120 min

> 120 min

Primary PCI
strategy

Fibrinolysis
strategy
Bolus of
fibrinolytic

10 min.

Wire crossing
(reperfusion)

Rescue
PCI

Meet reperfusion
criteria?

≥ 120 min

90 min.

60-90 min

Transfer to
PCI centre

Yes

2 hours
24 hours

Routine PCI
strategy

ECG, electrocardiogram; PCI, percutaneous coronary intervention; STEMI, STsegment elevation myocardial infarction.
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.

Strategy should be guided as in other STEMI patients
if time from STEMI diagnosis to wire crossing is
> 120 min -> immediate fibrinolysis & transfer to PCI
centre. Urgent angiography upon arrival regardless of
time from lytics.

CABG, coronary artery bypass graft surgery; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.
Adapted 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.

β-blockers are now recommended for first-line rate
control for atrial fibrillation, with amiodarone as second
choice.
For patients presenting with ventricular arrhythmias
and conduction disturbances, one new recommendation
has been added recommending radiofrequency catheter ablation at a specialised ablation centre.

Official Peer-Reviewed Highlights From ESC Congress 2017

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