Saturday, September 23, 2017

ESC 2017th guidelines updates on STEMI

The following are key points to remember about the 2017 European Society of Cardiology (ESC) Guidelines for the Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation:

  1. Despite the decline in acute and long-term death associated with ST-segment elevation myocardial infarction (STEMI), in parallel with the widespread use of reperfusion, mortality remains substantial. The in-hospital mortality rates of unselected patients with STEMI in national European registries vary between 4–12%.
  2. Women tend to receive reperfusion therapy and other evidence-based treatments less frequently and/or in a delayed way than men. It is important to highlight that women and men receive equal benefit from a reperfusion and other STEMI-related therapies, and so both genders must be managed equally.
  3. In some cases, patients may have coronary artery occlusion/global ischemia in the absence of characteristic ST-elevation (e.g., bundle branch block, ventricular pacing, hyperacute T waves, isolated ST-depression in anterior leads, and/or universal ST-depression with ST-elevation in aVR). In patients with the mentioned electrocardiographic (ECG) changes and clinical presentation compatible with ongoing myocardial ischemia, a primary percutaneous coronary intervention (PCI) strategy (i.e., urgent angiography and PCI if indicated) should be followed. 
  4. STEMI patients should undergo a primary PCI strategy unless the anticipated absolute time from STEMI diagnosis to PCI-mediated reperfusion is >120 minutes, when fibrinolysis should be initiated immediately (i.e., within 10 minutes of STEMI diagnosis).
  5. Patients with ST-elevation on post-resuscitation ECG should undergo a primary PCI strategy. In cases without ST-segment elevation on post-resuscitation ECG, but with a high suspicion of ongoing myocardial ischemia, urgent angiography should be done within 2 hours after a quick evaluation to exclude noncoronary causes. In all cases, the decision to perform urgent coronary angiography should take into account factors associated with poor neurological outcome. 
  6. Routine radial access and routine drug-eluting stent implant is the standard of care during primary PCI. Routine thrombus aspiration or deferred stenting are contraindicated. 
  7. Treatment of severe stenosis (evaluated either by angiography or fractional flow reserve) should be considered before hospital discharge (either immediately during the index PCI or staged at a later time). In cardiogenic shock, non–infarct-related artery PCI should be considered during the index procedure. 
  8. Patients taking oral anticoagulants with renal insufficiency and/or the elderly represent a challenge in terms of optimal antithrombotic therapy. Special attention should be paid to dose adjustment of some pharmacological strategies in these subsets.

  9. A sizeable proportion of STEMI patients do not present significant coronary artery stenosis on urgent angiography. It is important to perform additional diagnostic tests in these patients to identify the etiology and tailor appropriate therapy, which may be different from typical STEMI.
  10. In some cases, there is a gap between optimal guideline-based treatment and actual care of STEMI patients. In order to reduce this gap, it is important to measure established quality indicators to audit practice and improve outcomes in real life. The use of well-defined and validated quality indicators to measure and improve STEMI care is recommended.