ESC Congress 2017 In Review -- Main Edition - 5

ESC Congress 2017

been eliminated. Time 0 is the time of STEMI diagnosis,
defined as the time at which the electrocardiogram of
a patient with ischaemic symptoms is interpreted as
presenting ST-segment elevation or the equivalent.
A new flowchart outlines the criteria for selection of
reperfusion strategy (Figure 2).
The selection of reperfusion strategy is based on
the estimated time from STEMI diagnosis to percutaneous coronary intervention (PCI)-mediated reperfusion. Fibrinolysis should be initiated as soon as possible,
preferably in the prehospital setting. Patients receiving
primary fibrinolysis should be transferred immediately
after to a PCI centre. The 2017 ESC Pocket Guidelines
(offline and online app) include interactive tools for calculating antithrombotic agent doses.
Long-term maintenance therapies should include
antiplatelet and lipid-lowering therapy for all patients
with STEMI. Most patients should receive ß-blockers
and angiotensin-converting enzyme (ACE) inhibitors or
angiotensin receptor blockers (ARB). Mineralocorticoid
receptor antagonists (MRA) are recommended for patients
with left ventricular dysfunction and heart failure (HF)
after STEMI. The recommendations for routine lipid
lowering therapy, ß-blockers, ACE inhibitors, ARBs, and
MRAs are shown in Table 1.

In Review

The new guidelines also contain revised recommendations for management of STEMI patients with acute HF,
cardiogenic shock, and atrial fibrillation (AF). A flowchart
on MI with nonobstructive coronary arteries focuses on
determining aetiology rather than specific treatments.
Diagnosis and Treatment of PADs
The 2017 ESC Guidelines on the Diagnosis and Treatment
of Peripheral Arterial Diseases, in collaboration with
the European Society for Vascular Surgery (ESVS) were
updated from the 2011 version [Aboyans V et al. Eur Heart
J. 2017]. These guidelines address atherosclerotic disease
of all the arteries except the coronary arteries and the
aorta. ESC Task Force Chairperson, Victor Aboyans, MD,
PhD, Dupuytren University, Limoges, France, and co-Chairperson, Jean-Baptiste Ricco, MD, University of Poitiers,
Poitiers, France, presented an overview of the recommendations for lower-extremity artery disease (LEAD), renal
artery disease (RAD), and cerebrovascular PADs.
Management of patients with PADs involves addressing general cardiac risk and prevention and related
symptoms at the specific site. The guidelines recommend a multidisciplinary approach with a Vascular Team
at all centres.

Table 1. Recommendations for Routine Therapies in the Acute, Subacute, and Long-term Phases of STEMI
Recommendations

Class

Level

Lipid-lowering therapy
It is recommended to start high-intensity statin therapy as early as possible, unless contraindicated, and maintain it long-term.

A LDL-C goal of 70 mg/dL or a reduction of at least 50% if the baseline LDL-C is between 70 and 135 mg/dL is recommended.

It is recommended to obtain a lipid profile in all STEMI patients as soon as possible after presentation.

IIa

Intravenous ß-blockers should be considered at the time of presentation in patients undergoing primary PCI without contraindications, with no signs of acute HF, and with an SBP > 120 mm Hg.

IIa

Intravenous ß-blockers must be avoided in patients with hypotension, acute HF, or AV block or severe bradycardia.

III

Oral treatment with ß-blockers is indicated in patients with HF and/or LVEF ≤40% unless contraindicated.

IIa

ACE inhibitors are recommended, starting within the first 24 hours of STEMI in patients with evidence of HF, LV systolic dysfunction,
diabetes, or an anterior infarct.

An ARB, preferably valsartan, is an alternative to ACE inhibitors in patients with HF or LV systolic dysfunction, particularly those
who are intolerant of ACE inhibitors.

IIa

In patients with LDL-C ≥ 70 mg/dL despite a maximally tolerated statin dose who remain at high risk, further therapy to reduce
LDL-C should be considered.
ß-blockers

Routine oral treatment with ß-blockers should be considered during hospital stay and continued thereafter in all patients without
contraindications.
ACE inhibitors and ARBs: LVEF ≤40% and/or HF

ACE inhibitors should be considered in all patients in the absence of contraindications.
MRAs: LVEF ≤40% and HF
MRAs are recommended in patients with an LVEF ≤40% and HF or diabetes, who are already receiving an ACE inhibitor and a
ß -blocker, provided there is no renal failure or hyperkalaemia.

AV, atrioventricular; ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker; HF, heart failure; LDL-C, low-density lipoprotein cholesterol; LV, left
ventricular; LVEF, left ventricular ejection fraction; MRA, mineralocorticoid receptor antagonist; PCI, percutaneous coronary intervention; SBP, systolic blood pressure; 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.

Official Peer-Reviewed Highlights From ESC Congress 2017

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