ESC Congress 2017 In Review -- Main Edition - 4

Main Session

Overview of the 2017 ESC Clinical
Practice Guidelines
Written by Toni Rizzo

The European Society of Cardiology (ESC) unveiled
4 new guideline updates developed by expert task
forces and peer-reviewers, covering acute myocardial
infarction in patients with ST-segment elevation
(AMI-STEMI), peripheral arterial disease (PAD),
dual antiplatelet therapy (DAPT), and valvular heart
disease (VHD). These guidelines summarise the
available evidence on the topics, providing a valuable
clinical decision-making tool for practicing clinicians.
Management of AMI in Patients With STEMI
The 2017 ESC Guidelines for the Management of AMI in
Patients Presenting With ST-Segment Elevation [Ibanez
B et al. Eur Heart J. 2017] were developed by the ESC
Task Force led by Stefan James, MD, Uppsala University,
Uppsala, Sweden, and Borja Ibanez, MD, PhD, University
Hospital Fundación Jiménez Díaz, Madrid, Spain. Levels
of recommendations have been changed for several
management options, including radial access, drugeluting stent over bare-metal stent, complete revascularisation, thrombus aspiration, bivalirudin and enoxaparin therapy, early hospital discharge, and the use of
tenecteplase tissue plasminogen activator.
The updated guidelines include a number of new
and revised concepts since the previous version was
published in 2012 (Figure 1). For example, important
changes have been made in the definition of "time 0"
to choose a reperfusion strategy. Ambiguous terms
such as "door-to-balloon" and "door-to-door" have

Figure 1. AMI-STEMI: New and Revised Concepts
MINOCA and Quality Indicators:
* New chapters dedicated to these topics
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 to 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)
Electrocardiogram at Presentation:
* Left and right bundle branch block considered equal for
recommending urgent angiography if ischaemic symptoms
Time to Angiography after Fibrinolysis:
* Recommended between 2-24h after successful fibrinolysis
Patients Taking Anticoagulants:
* Acute and chronic management presented
IRA, infarct-related artery; MINOCA, myocardial infarction with nonobstructive
coronary arteries; PCI, percutaneous coronary intervention; STEMI, ST-segment
elevation myocardial infarction.
Reprinted from Ibanez B and James S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2017. doi:10.1093/eurheartj/ehx393. By permission of Oxford
University Press on behalf of the European Society of Cardiology.

Figure 2. Flowchart for Reperfusion Strategy in Patients With STEMI

Patient delay

Total ischaemic time
System delay

EMS delay

FMC: EMS
< 10'
STEMI
diagnosis

≤ 120 min

Primary < 90' Reperfusion
PCI
(Wire crossing)
strategy

Time to PCI?

< 10'

≤ 120 min

Fibrinolysis < 10' Reperfusion
strategy
(Lytic bolus)

FMC: Non-PCI centre
< 10'
FMC: PCI centre
Patient delay

STEMI
diagnosis

Primary < 60' Reperfusion
PCI
(Wire crossing)
strategy

System delay
Total ischaemic time

EMS, emergency medical system; FMC, first medical contact; PCI, percutaneous coronary intervention; STEMI, ST-segment elevation myocardial infarction.
Reprinted from Ibanez B and James S et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment
elevation. Eur Heart J. 2017. doi:10.1093/eurheartj/ehx393. By permission of Oxford University Press on behalf of the European Society of Cardiology.

October 2017

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