ESC Congress 2017 In Review – Focus on CAD&ACS - 7

ESC Congress 2017

In Review

CAD & ACS

Figure 3. Diagnostic Test Flowchart for MINOCA

Table 4. Maintenance Antithrombotic Strategy After STEMI
Recommendations
Antiplatelet therapy with low-dose aspirin (75-100 mg) is
indicated.

Class
I

Level
A

DAPT in the form of aspirin plus ticagrelor or prasugrel
(or clopidogrel if ticagrelor or prasugrel are not available
or are contraindicated), is recommended for 12 months
after PCI, unless there are contraindications such as excessive risk of bleeding.

A PPI in combination with DAPT is recommended in patients
at high risk of gastrointestinal bleeding.

In patients with an indication for oral anticoagulation, oral
anticoagulants are indicated in addition to antiplatelet therapy.

In patients who are at high risk of severe bleeding complications, discontinuation of P2Y12 inhibitor therapy after
6 months should be considered.

SUSPECTED STEMI
ACUTE INVESTIGATION
Coronary stenosis ≥50%

Urgent angiography

Treat as STEMI

MINOCA

No coronary stenosis
≥50% + fulfillment
universal AMI criteria

Acute LV wall motion assessment (angiogram / echo)

SUSPECTED DIAGNOSIS AND FURTHER DIAGNOSTIC TESTS

IIa

In STEMI patients with stent implantation and an indication
for oral anticoagulation, triple therapy should be considered
for 1-6 months (according to a balance between the
estimated risk of recurrent coronary events and bleeding).

IIa

DAPT for 12 months in patients who did not undergo PCI
should be considered unless there are contraindications
such as excessive risk of bleeding.

IIa

In patients with LV thrombus, anticoagulation should be administered for up to 6 months guided by repeated imaging.

IIa

In high ischaemic-risk patients who have tolerated DAPT
without a bleeding complication, treatment with DAPT in the
form of ticagrelor 60 mg BID on top of aspirin for longer than
12 months may be considered for up to 3 years.

IIb

In low bleeding-risk patients who receive aspirin and
clopidogrel, low-dose rivaroxaban (2.5 mg BID) may be
considered.

IIb

The use of ticagrelor or prasugrel is not recommended as
part of triple antithrombotic therapy with aspirin and oral
anticoagulation.

III

AMI, acute myocardial infarction; CAD, coronary artery disease; DAPT, dual antiplatelet therapy; LV, left ventricular; PCI, percutaneous coronary intervention;
PPI, proton pump inhibitor; STEMI, ST-segment 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.

etiologic diagnoses, and failure to identify the underlying cause might result in inadequate or inappropriate
therapy. Possible causes include coronary endothelial
dysfunction, such as microvascular spasm or myocardial
disorders without obvious coronary artery involvement
[Agewall S et al. Eur Heart J. 2017].
The updated AMI-STEMI guidelines include a diagnostic test flow chart for MINOCA (Figure 3).
Prof Agewall concluded that MINOCA is a working
diagnosis and should lead the treating physician to
investigate underlying causes. CMR might be considered a standard examination when the underlying cause
is not identified.

Non-invasive
Myocarditis

Coronary
(epicardial/
microvascular)

Myocardial disease

Pulmonary
embolism

Oxygen supply/
demand ImbalanceType 2 MI

Invasive

TTE Echo
(pericardial effusion)
CMR
(myocarditis, pericarditis)

Endomyocardial Biospy
(myocarditis)

TTE Echo (regional walll mation
abnormalities, embolic source)
CMR (small infarction)
TOE/Bubble Contrast Echo
(patent foramen ovale, atrial
septal defect)

IVUS/OCT
TTE
Echo (regional walll mation
(plaque disruption/dissection)
abnormalities,
embolic source)
IVUS/OCT
CMR
(small infarction)
(spasm)
TOE/Bubble
Contrast Echo
IVUS/OCT
(patent
foramen ovale, atrial
(microvascular
septal
defect) dysfunction)

TTE Echo
CMR
(Takutsubo, others)
D-dimer (pulmonary embolism)
CT scan (pulmonary embolism)
Thrombopilia screen
Blood test,
Extracardiac Investigation

CMR, cardiac magnetic resonance; IVUS, intravascular ultrasound; LV,
left ventricular; MINOCA, myocardial infarction with nonobstructed
coronary arteries; STEMI, ST-segment elevation myocardial infarction; TOE,
transoesophageal ultrasound; TTE, transthoracic echocardiography.
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.

Quality Indicators in STEMI
Héctor Bueno, MD, PhD, University Hospital, Madrid,
Spain, discussed the new chapter on quality indicators
in the 2017 AMI-STEMI guidelines. The new recommendations for quality indicators were added to ensure that
every patient with STEMI receives the best possible
care according to accepted standards and has the best
possible outcomes. The proposed quality indicators are
shown in Table 5.
The quality indicators chosen for the guideline were
validated in the MINAP-UK and FAST-MI studies [Bebb O
et al. Eur Heart J. 2017; Schiele F et al. Circ Cardiovasc
Qual Outcomes. 2017]. Prof Bueno concluded that the
new quality indicators will help institutions assess
the quality of care and improve the quality of care in
patients with STEMI.

Official Peer-Reviewed Highlights From ESC Congress 2017

Table of Contents for the Digital Edition of ESC Congress 2017 In Review – Focus on CAD&ACS