ESC Congress 2017 In Review – Focus on CAD&ACS - 6

Main Session

Primary PCI and Fibrinolysis Procedures
A key change in the guidelines for the timing of primary
PCI and fibrinolysis is the start of the "strategy clock"
at the time of STEMI diagnosis rather than FMC. Sigrun
Halvorsen, MD, PhD, University of Oslo, Oslo, Norway,
discussed the importance of time targets in the management of patients with STEMI.
Primary PCI is the preferred reperfusion strategy in
patients presenting within 12 hours of symptom onset, if
it can be performed within 120 minutes of STEMI diagnosis. Fibrinolytic therapy is recommended if this time
target cannot be met.
The 120-minute cut-off was kept based on the available
evidence, but Prof Halvorsen cautioned that no specific
study has addressed the time at which the benefits of priTable 3. Indications and Procedural Aspects of the Primary PCI Strategy
Recommendations

Class

Level

Stenting is recommended (over balloon angioplasty) for
primary PCI.

Stenting with new-generation DES is recommended over
BMS for primary PCI.

Radial access is recommended over femoral access if
performed by an experienced radial operator.

Routine use of thrombus aspiration is not recommended.

III

Routine use of deferred stenting is not recommended.

III

Prophylactic treatment with antiarrhythmic drugs to prevent AF is not indicated.

III

Routine revascularisation of non-IRA lesions should be
considered in STEMI patients with multivessel disease
before hospital discharge.

IIa

Non-IRA PCI during the index procedure should be considered in patients with cardiogenic shock.

IIa

Indications
In the absence of ST-segment elevation, a primary PCI
strategy is indicated in patients with suspected ongoing
ischaemic symptoms suggestive of MI and if at least one
of the following criteria is present:
* Haemodynamic instability or cardiogenic shock
* Recurrent or ongoing chest pain refractory to medical
treatment
* Life-threatening arrhythmias or cardiac arrest
* Mechanical complications of MI
* Acute heart failure
* Recurrent dynamic ST-segment or T-wave changes,
particularly with intermittent ST-segment elevation
IRA technique

Non-IRA strategy

CABG, coronary artery bypass graft surgery; DES, drug-eluting stent; IRA, infarct-related artery; 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.

October 2017

mary PCI are lost. For patients presenting within 12 to 48
hours, routine primary PCI should be considered; it should
only be recommended if ongoing symptoms suggestive of
ischaemia, haemodynamic instability, or life-threatening
arrhythmias are present. Routine PCI is not indicated if
more than 48 hours have passed.
The recommendations on the indications and procedural aspects of primary PCI are shown in Table 3.
An important addition to the antithrombotic therapy
options in patients undergoing primary PCI is the addition of cangrelor (IIb, A). Based on the CHAMPION studies, cangrelor may now be considered for patients who
have not received P2Y12 receptor inhibitors [Steg G et al.
Lancet. 2013].
Longer Term Therapies After STEMI
Eva Prescott, MD, DMSc, Bispebjerg University Hospital,
Copenhagen, Denmark, briefly reviewed the recommendations for hospital stay and lifestyle interventions. For
behavioural aspects, a new recommendation that use of
the polypill and combination therapy to increase adherence to drug therapy may be considered has been added.
The recommendation on calcium antagonists has been
omitted from the recommendations for routine medical
therapies in the acute, subacute, and long-term phases.
The goal for lipid-lowering therapy has been updated to
an LDL-C goal of < 70 mg/dL or a reduction of ≥ 50%, if
baseline is 70 to 135 mg/dL. Based on the IMPROVE-IT
and FOURIER trials, further lipid-lowering therapy should
be considered in patients with LDL-C ≥ 70 mg/dL despite
a maximally tolerated statin dose who remain at high risk
[Cannon CP et al. N Engl J Med. 2015; Sabatine MS et al.
N Engl J Med. 2017].
Table 4 summarises the recommendations on maintenance antithrombotic therapy. Details of the changes
are included in the 2017 focused update on dual antiplatelet therapy [Valgimigli M et al. Eur Heart J. 2017].
MI With Nonobstructive Coronary Arteries
The ESC 2017 AMI-STEMI guidelines include a new chapter addressing MI with nonobstructive coronary arteries
(MINOCA), which was summarised by Stefan Agewall,
MD, PhD, University of Oslo, Oslo, Norway. According to
a recently published ESC working group position paper
on MINOCA [Agewall S et al. Eur Heart J. 2017], the diagnosis is made immediately upon coronary angiography
in a patient meeting the criteria for AMI: universal AMI
criteria; nonobstructive coronary arteries on angiography, defined as no coronary artery stenosis ≥ 50%
in any potential infarct-related artery; and no clinically
overt specific cause for the acute presentation.
MINOCA is estimated to occur in 1-13% of patients with
AMI. It is a heterogeneous condition, with several potential

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