Percutaneous coronary intervention or as pretreatment at the time of diagnosis in patients with myocardial infarction without ST elevation. OASIS-6 The Safety and Efficacy of Fondaparinux versus Control Therapy in Patients with ST-Segment Elevation Acute Myocardial Infarction.
Preamble
TICO Ticagrelor Monotherapy at 3 Months in Patients Treated with a New Generation Sirolimus Stent for Acute Coronary Syndrome TIMI Thrombolysis in Myocardial Infarction TLR Targeted Lesion Revascularization. TROPICAL-ACS testing of responsiveness to platelet inhibition in chronic antiplatelet treatment of acute coronary syndromes.
Introduction
- Definitions | Acute coronary syndromes and myocardial
- Epidemiology of acute coronary syndromes
- Number and breakdown of classes of recommendations
- What is new
Patients with ST-elevation myocardial infarction (STEMI) require primary percutaneous coronary intervention (PPCI) (or fibrinolysis if PPCI within 120 min is not possible); patients with non-ST-elevation ACS (NSTE-ACS) with very high-risk features require immediate angiography ± PCI if indicated; Patients with NSTE-ACS and high-risk features should undergo inpatient angiography (angiography within 24 hours should be considered). Intravascular imaging (preferably optical coherence tomography) may be considered in patients with equivocal culprit lesions.
Triage and diagnosis
- Clinical presentation and physical examination
- Clinical presentation
- History taking and physical examination
- Diagnostic tools | Electrocardiogram
- Acute coronary syndrome with persistent ST-segment
- Acute coronary syndrome without persistent ST-
- Diagnostic tools | Biomarkers
- High-sensitivity cardiac troponins
- Central laboratory vs. point of care
- Confounders of cardiac troponin concentration
- Rapid ‘rule-in’ and ‘rule-out’ algorithms
- Other biomarkers
- Diagnostic tools | Non-invasive imaging
- Echocardiography
- Computed tomography
- Cardiac magnetic resonance imaging with or without
- Differential diagnosis for acute chest pain
Patients with acute chest pain (or pain equivalent chest signs/symptoms) and persistent ST-segment elevation (or ST-segment elevation equivalents) on ECG (working diagnosis: ST-segment elevation MI: STEMI). Recommendation Table 2 – Recommendations for non-invasive imaging in the initial assessment of patients with suspected acute coronary syndrome.
Initial measures for patients presenting with suspected acute
Pre-hospital logistics of care
- Time to treatment
- Healthcare systems and system delays
- Emergency medical services
- General practitioners
- Organization of ST-elevation myocardial infarction
Various cardiac and non-cardiac conditions that can mimic ACS should be considered in the differential diagnosis of acute chest pain as part of the clinical assessment. It is recommended that the EMS should transport patients with a working diagnosis of STEMI to hospitals with a 24/7 service for PCI, bypassing non-PCI-eligible hospitals.144 Further information on this topic is provided in the Supplementary data online .
Emergency care
- Initial diagnosis and monitoring
- Acute pharmacotherapy
- Oxygen
- Nitrates
- Pain relief
- Intravenous beta-blockers
In some countries, primary care physicians (general practitioners) play an important role in the early care of patients with suspected ACS and may provide FMC. It is recommended that a regional reperfusion strategy be established to maximize the efficiency of care for patients with a functional diagnosis of STEMI.143 Optimal treatment of patients with a functional diagnosis of STEMI must be based on the establishment of networks between hospitals with different levels. provision of clinical services (the 'hub and spoke' model) connected by a priority and efficient ambulance service.
Acute-phase management of patients with acute coronary
- Selection of invasive strategy and reperfusion therapy
- Acute coronary syndrome managed with invasive strategy
- Primary percutaneous coronary intervention strategy for
- Immediate invasive strategy for non-ST elevation acute
- Routine vs. selective invasive strategy
- Summary of invasive strategies for patients with non-ST
- Fibrinolysis and pharmaco-invasive strategy in patients with
- Benefit and indication of fibrinolysis
- Patients not undergoing reperfusion
- Patients who are not candidates for invasive coronary
- Patients with coronary artery disease not amenable to
An invasive strategy during hospitalization is recommended in patients with NSTE-ACS with high-risk criteria or a high index of suspicion for UA. Fibrinolysis and pharmaco-invasive strategy in patients with ST-elevation strategy in patients with ST-elevation myocardial infarction.
Antithrombotic therapy
- Antiplatelet therapy in the acute phase
- Oral antiplatelet therapy
- Timing of loading dose of oral antiplatelet therapy
- Intravenous antiplatelet drugs
- Anticoagulant treatment in the acute phase
- Anticoagulation in patients with ST-elevation myocardial
- Anticoagulation in patients with non-ST-elevation acute
- Maintenance antithrombotic therapy after revascularization
- Shortening dual antiplatelet therapy
- De-escalation from potent P2Y 12 inhibitor to clopidogrel 37
- Long-term treatment
- Prolonging antithrombotic therapy beyond 12 months
- Antiplatelet therapy in patients requiring oral anticoagulation 41
- Patients requiring vitamin K antagonists or undergoing
- Antithrombotic therapy as an adjunct to fibrinolysis
- Antithrombotic therapy in patients not undergoing
Alternatives to UFH that should be considered in patients with STEMI undergoing PPCI include enoxaparin (LMWH) and bivalirudin (a direct thrombin inhibitor). In patients who were previously treated with
Acute coronary syndrome with unstable presentation
Out-of-hospital cardiac arrest in acute coronary syndrome
- Systems of care
Management of patients with ROSC without evidence of ST elevation should be individualized based on hemodynamic and neurologic status. Based on data from the COACT and TOMAHAWK trials, it seems reasonable to delay ICA in hemodynamically stable patients with OHCA resuscitation without ST elevation or equivalent.
Cardiogenic shock complicating acute coronary syndrome
Initial evaluation in the ED or cardiac intensive care unit (ICCU) should focus on ruling out noncoronary causes (cerebrovascular events, respiratory failure, noncardiogenic shock, PE, or intoxication). In the presence of CS due to AMI-related mechanical complications, surgical or percutaneous treatment may also be indicated and the strategy should be decided based on discussion between members of the Heart Team.
Management of acute coronary syndrome during hospitalization
Coronary care unit/intensive cardiac care unit
- Monitoring
- Ambulation
- Length of stay in the intensive cardiac care unit
In the IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial, intra-aortic balloon pump (IABP) use was not associated with lower 30-day mortality.399 Therefore, in the absence of mechanical complications, the routine was the use of an IABP is not recommended for CS complicating AMI. The role of mechanical circulatory devices (veno-arterial extracorporeal membrane oxygenation [VA-ECMO], microaxial pump) in the AMI setting is not well established and large-scale randomized trials are warranted. Therapy of Cardiogenic Shock Trial randomized 122 patients (51% with STEMI) with rapidly deteriorating or severe CS to either immediate implementation of VA-ECMO or an initially conservative strategy (allowing for downstream use of VA-ECMO).402 The immediate implementation of VA-ECMO. implementation of VA-ECMO did not lead to improved clinical outcomes.402 However, the interpretation of this trial is challenging due to the ~40% crossover rate to VA-ECMO in the conservative arm, the inclusion of heterogeneous phenotypes of CS, and inclusion of crossover in the combined primary endpoint.
In-hospital care
- Length of hospital stay
- Risk assessment
- Clinical risk assessment
- Imaging risk assessment
- Biomarkers for risk assessment
- Bleeding risk assessment
- Integrating ischaemic and bleeding risks
Length of stay in the cardiac intensive care unit Optimal length of stay in ICCU and hospital should be individual- The optimal length of stay in ICCU and hospital should be individualized according to the clinical situation of the patient, taking into account their background. cardiac risk and comorbidities, baseline mental/functional status, and social support.410,411 It is noteworthy that most in-hospital adverse events occur early after admission and initiation of treatment.
Technical aspects of invasive strategies
Percutaneous coronary intervention
- Vascular access
- Intravascular imaging/physiology of the infarct-related
- Intravascular imaging
- Intravascular physiology
- Timing of revascularization with percutaneous coronary
- Balloons and stents
- Embolic protection and microvascular salvage strategies
- Thrombus aspiration
- Interventions to protect the microcirculation
Intracoronary physiology is increasingly used in patients with ACS to assess the haemodynamic significance of intermediate severity non-IRA stenoses (see section 10). However, PCI of the IRA should not be postponed based on invasive epicardial functional assessment in patients with ACS.
Coronary artery bypass grafting
- Indication and timing of coronary artery bypass grafting in
- Technical considerations specific to acute coronary
In the small, prospective, randomized, single-center REVELATION (REVascularization With PaclitaxEL-Coated Balloon Angioplasty Versus Drug-Eluting Stenting in Acute Myocardial InfarcTION) trial, thrombus aspiration was associated with fewer cardiovascular deaths and more strokes or transient ischemic attacks in a subgroup of patients with a high thrombus burden (TIMI thrombus level 3).475 However, in the TOTAL subanalysis (trial of routine aspiration ThrOmbectomy with PCI vs.
Spontaneous coronary artery dissection
- Intravascular imaging
- Revascularization
A strategy of drug-eluting balloon (DCB) angioplasty without stenting has also been proposed for patients with NSTE-ACS. PCI alone in patients with STEMI), routine thrombus aspiration did not improve outcomes at 1 year and was also associated with an increased rate of stroke in patients with a high thrombotic burden.476.
Management of patients with multivessel disease
Management of multivessel disease in acute coronary
PRIMULTI (Third Danish Study of Optimal Acute Treatment of Patients with ST-Elevation Myocardial Infarction - Primary PCI in Multivessel Disease), COMPARE-ACUT (Comparison. Complete revascularization was also associated with a reduced composite of CV death or new MI, porting complete revascularization in patients with STEMI and MVD.512.
Timing of non-infarct-related artery revascularization in
- Patients presenting with ST-elevation myocardial
- Patients presenting with non-ST-elevation acute
Between FFR-guided revascularization versus conventional strategy in acute STEMI patients with MVD) and COMPLETE (Complete versus .. only Revascularization to treat multivessel disease after early PCI for STEMI) (further details on these trials are provided in the supplementary data online ).508–511. In a systematic review of 10 randomized trials including 7030 patients with STEMI and MVD, complete revascularization was associated with reduced CV mortality compared with PCI with IRA alone.512 All-cause mortality was comparable in the two groups.
Evaluation of non-infarct-related artery stenosis severity
Hybrid revascularization
Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, et al. trial of preventive angioplasty in myocardial infarction. Bueno H, Betriu A, Heras M, Alonso JJ, Cequier A, Garcia EJ, et al. fibrinolysis in very old patients with acute myocardial infarction: TRIANA.
Myocardial infarction with non-obstructive coronary arteries
Special situations
Type 2 myocardial infarction and acute myocardial injury
These include type 2 MI and myocardial injury as defined by the fourth universal definition of MI.1 Type 2 MI is ischemic myocardial injury in the context of a mismatch between oxygen supply and oxygen demand not associated with acute coronary atherothrombosis. Despite some common risk factors, the pathophysiology of type 2 MI differs from that of type 1 MI.
Complications
- Heart failure
- Mechanical complications
- Left ventricular thrombus
- Post-acute coronary syndrome pericarditis
- Arrhythmias
- Atrial fibrillation
- Ventricular arrhythmias
- Bleeding
- Management of bleeding
IABP should be considered in patients with hemodynamic instability/cardiogenic shock due to ACS-related mechanical complications. Oral anticoagulation therapy (VKA or NOAC) should be considered for 3-6 months in patients with confirmed LV thrombus.603.
Comorbid conditions
- Patients at high bleeding risk and with blood disorders
- Chronic kidney disease
- Diabetes mellitus
- Older adults with frailty and multimorbidity
- The older person
- Frailty and multimorbidity
- Pregnancy
- Drug abuse
- Patients with cancer
- Coronavirus disease (COVID-19)
Patients with active cancer with ACS tend to be older, with a greater number of comorbidities and more extensive CAD. The diagnosis of ACS in patients with cancer should be based on the same principles as in patients without cancer.
Long-term treatment
Cardiac rehabilitation
- Comprehensive cardiac rehabilitation
- Digital health
- Adherence and persistence
In addition to alternatives to CR, there is also a need for stronger endorsement of CR by physicians, cardiologists and healthcare professionals.732,733 It is also important to initiate and establish a strong partnership between patients and healthcare professionals as early as possible. 732–734. Polypills, which include guideline-recommended treatments for secondary prevention, have been shown to increase medication adherence in post-ACS patients and may improve therapeutic goals.750-752 The Secondary Prevention of Cardiovascular Disease in the Elderly (SECURE) study is the only RCT study testing the impact of a polypill-based strategy (containing aspirin, ramipril and atorvastatin) vs.
Lifestyle management
- Tobacco
- Nutrition and alcohol
- Physical activity and exercise
- Psychological considerations
- Resumption of activities
Based on extensive data from the general population, sedentary behavior, defined as time spent sitting or lying down with low energy expenditure while awake, is an independent risk factor for all-cause mortality.776,777 According to World Health Organization recommendations, adults with chronic conditions should limit the amount of sedentary time and replace it with physical activity of any intensity (including light intensity).646,778 General recommendations for physical activity include a combination of regular aerobic physical activity and strength exercises throughout the week, which also shapes the basis of recommendations for patients after ACS.646,778 However, it is important to recognize that daily physical activity does not replace participation in exercise-based CR. Psychological and pharmacological interventions may have a beneficial effect and should be considered in ACS patients with depression, anxiety and stress.781 It is recommended that all patients have their mental well-being assessed using validated instruments before discharge, with further psychological referral if appropriate.782 For further details, please refer to the 2021 ESC Guidelines for the Prevention of Cardiovascular Diseases.646.
Pharmacological treatment
- Antithrombotic therapy
- Lipid-lowering therapy
- Beta-blockers
- Nitrates and calcium channel blockers
- Renin–angiotensin–aldosterone system inhibitors
- Medications for diabetes
- Sodium–glucose co-transporter 2 inhibitors
- Glucagon-like peptide-1 receptor agonists
- Proton pump inhibitors
- Vaccination
- Anti-inflammatory drugs
- Hormone replacement therapy
Patients with heart disease are at double risk for anxiety and mood disorders. BETAMI (treatment with BE inhibitors after acute myocardial infarction in patients without reduced left ventricular systolic function), 10,000 patients with acute coronary syndrome with LVEF >40%; and DANBLOCK (Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction), 3570 ACS patients with LVEF >.
Patient perspectives
- Patient-centred care
- Shared decision-making
- Informed consent
- Research participation and consent in the acute setting
- Patient satisfaction and expectations
- Patient-reported outcome measures and patient-reported
- Preparation for discharge
If an abbreviated informed consent procedure was used, it is important that there is contact with the patient and/or. Expectations of ACS patients are summarized in Figure 20, and additional information can be found in online supplementary data, Table S19.
Key messages
A PPCI strategy is recommended in patients with resuscitated cardiac arrest and an ECG with persistent ST elevation (or equivalents), while routine immediate angiography is not recommended in patients with an ECG without persistent ST elevation (or equivalents). For patients with MVD presenting with CS, only IRA-PCI during the index procedure is recommended.
Gaps in evidence
Patients with an IRA not suitable for stent implantation were randomized to drug-eluting balloon treatment or usual care to evaluate clinical outcomes. Observational data are needed in patients with ACS to evaluate the actual impact of social determinants of health on clinical outcomes.
Sex differences
Ticagrelor is recommended regardless of treatment strategy (invasive or conservative) (180 mg LD, 90 mg twice daily MD). In patients treated with fibrinolysis, anticoagulation is recommended until revascularization (if performed) or during hospital stay (up to 8 days).
Supplementary data
The ESC understands the need to measure and report the quality and outcomes of CV care and has developed methods for developing the ESC QIs for the quantification of CVD care and outcomes.925 To date, the ESC has developed QI suites developed for a number of cardiovascular diseases in parallel with the writing of the ESC Clinical Practice Guidelines. The ESC aims to harmonize its QIs for different CV conditions and integrate them with ESC registries.935,936 This integrative approach provides 'real' data on the patterns and outcomes of CVD care across Europe.
Data availability statement
Quality indicators are tools that can be used to evaluate the quality of care, including structures, processes, and outcomes of care.925 They can also serve as a mechanism to improve adherence to guideline recommendations through associated quality improvement initiatives and benchmarking of care. providers.926,927 The role of QI in improving CVD care and outcomes is increasingly recognized by health authorities, professional organizations, payers, and the public.925. Previous QIs for the management of AMI have been tested in a number of large registries.928–933 A systematic review of these studies has shown that there is room for improvement in terms of the level of achievement of QIs.934.
Author information
Appendix
Algeria: Algerian Society of Cardiology, Mohammed El Amine Bouzid; Armenia: Armenian Society of Cardiologists, Hamlet Hayrapetyan; Austria: Austrian Society of Cardiology, Bernhard Metzler; Belgium: Belgian Society of Cardiology, Patrizio Lancellotti;. Bosnia and Herzegovina: Association of Cardiologists of Bosnia and Herzegovina, Mugdim Bajrić; Bulgaria: Bulgarian Society of Cardiology, Kiril Karamfiloff; Cyprus: Cyprus Society of Cardiology, Andreas Mitsis; Czech Republic: Czech Society of Cardiology, Petr Ostadal;.
