Acute coronary syndromes

A European viewpoint

Felicita Andreotti, MD PhD FESC

Catholic University Hospital

Cardiovascular Diseases - Rome, IT

Potential conflicts of interest

Speaker

In the past 2 years Felicita Andreotti has received fees

for lectures, advising or monitoring activities from

Amgen, Bayer, Bristol-Myers Squibb / Pfizer,

Boehringer Ingelheim, Daiichi Sankyo, Eli Lilly

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Eur Heart J 2016 Jan 14;37(3):267-315

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Initial assessment of patients with suspected acute coronary syndromes

Emergency Echo in acute HF pts

to assess LV and valve fx & excludemechanical complications IC

<10 min

What else is new

1 - High-sensitivity cardiac troponin diagnostic algorithm

2 - Revascularization

• Criteria mandating indication/timing of invasive strategy

3 - Antithrombotic treatment

• Timing of P2Y12 inhibitor for early invasive strategy (pretreatment)

4 - Antithrombotic treatment: With long-term oral anticoagulants

5 - Revascularization: Radial approach and DES

6 - Rhythm monitoring guide

7 - Antithrombotic treatment: Duration of dual antiplatelet therapy

8 - Section on elderly (web addenda)

9 - Secondary prevention: Lipid lowering beyond statins

10- «Questions and Answers» companion

Guidance on hs-cTn for suspected NSTEMI

Very LowLowand

No 0-1h or

Highor

0-1h

> obtain sensitive or high sensitivity (hs)-cTn <60 min .... IA

> use 0-3h protocol with hs-cTn ………………………………..……. IB> use validated 0-1h hs-cTn algorithm and repeat at

3-6h if inconclusive or suggestive …………………………………. IB

Predictive values for acute MI: negative >98% - positive 75-80%

0-1h rule-in and rule-out hs-cTn algorithms

Cut-offs are assay specific

Eur Heart J 2016 Jan 14;37(3):267-315

Invasive strategy and timing based on initial risk

(2011: primary/secondary high-risk criteria)

Ongoing ischaemia

Immediate action

<2h, IC

<24h, IA

<72h, IA

+, IA

P2Y12 inhibitor before early invasive strategy

• As the optimal timing of ticagrelor or clopidogrel administration in NSTE-ACS patients scheduled for an invasive strategy has not been adequately investigated, no recommendation for or against pretreatment with these agents can be formulated.

• In patients not scheduled for an invasive strategy, P2Y12 inhibitor recommended as soon as diagnosis established (and ticagrelorpreferred over clopidogrel in absence of increased bleeding risk)

(2011: ‘as soon as possible’)

Eur Heart J 2016 Jan 14;37(3):267-315

Oral anticoagulation plus antiplatelet(s)

Eur Heart J 2016 Jan 14;37(3):267-315

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Selection of NSTE-ACS treatment strategy and timing according to initial risk stratification

IC IA IAIA

(MDCT angioif ECG or cTn

inconclusive, IIa A)

Radial approach

• It is recommended that centres treating ACS patients implement a transition from transfemoral to transradial access.

• Proficiency in the femoral approach should be maintained (e.g. for IABP insertion and structural as well as peripheral procedures)

Eur Heart J 2016 Jan 14;37(3):267-315

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MATRIXCo-primary compositeoutcomes at 30 days

Speaker

• N=8404• NSTE-ACS + STEMI• Radial vs. femoral

Valgimigli M et al.Lancet. 2015;385:2465-76

All-cause mortality, MI, stroke

All-cause mortality, MI, stroke, or BARC 3 or 5 bleeding

Radial vs femoral meta-analysis

Non-CABG major bleeeds

Death, MI, or stroke

Death

MI

Stroke

PRR (95% CI)

Valgimigli M et al. Lancet 2015;385:2465-76

Drug-eluting stents

Eur Heart J 2016 Jan 14;37(3):267-315

Antiplatelet therapy after stenting on OAC

Adapted from Lip et al. Eur Heart J 2014;35:3155–3179.aDual therapy with oral anticoagulation and clopidogrel may be considered in selected patients (low ischaemic risk).baspirin as an alternative to clopidogrel may be considered in patients on dual therapy (i.e., oral anticoagulation plus single antiplatelet); triple

therapy may be considered up to 12 months in patients at very high risk for ischaemic events.cDual therapy with oral anticoagulation and an antiplatelet agent (aspirin or clopidogrel) beyond one year may be considered in patients at very

high risk of coronary events. In patients undergoing coronary stenting, dual antiplatelet therapy may be an alternative to triple or dual therapy if the

CHA2DS2-VASc score is 1 (males) or 2 (females).

NSTE-ACS patients with non-valvular atrial fibrillation

Tripletherapy

O A C

Triple or dual therapya

O A C

O A COral anticoagulation(VKA or NOACs)

ASA 75–100 mg daily Clopidogrel 75 mg daily

Tim

e f

rom

PC

I/A

CS

Lifelong

12 months

6 months

4 weeks

0

Dual therapyb

Dual therapyb

MonotherapycO

High(e.g. HAS-BLED ≥ 3)

Low to intermediate(e.g. HAS-BLED = 0–2)

PCI Medically managed /CABG

Dual therapyb

O C or A

Bleeding risk

O C or A

O C or A

Management strategy

IIaC IIaC

IIb B

Eur Heart J 2016 Jan 14;37(3):267-315

Guidance on rhythm monitoring

H A E R S C

*

*

IIa C

IIa C

Continuous monitoring up to diagnosis (Y/N) IC

IIb C in suspected spasm

†

†

Duration of dual antiplatelet therapy

Eur Heart J 2016 Jan 14;37(3):267-315

Eur Heart J 2016 Jan 14;37(3):267-315

†

†

Elderly with NSTE-ACS

was B

2 RCTs

- TACTICS

- Elderly

†

†

Antithrombotic therapy in the elderly

Major RCT testing drugs

shown in figure

Age-stratified ischaemic and

bleeding event rates

Expert position on treatment

in the elderly

Andreotti F et al. ESC Thrombosis WG.

Eur Heart J 2015;doi:10.1093/eurheartj/ehv304

Eur Heart J 2016 Jan 14;37(3):267-315

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Speaker

European Heart Journaldoi:10.1093/eurheartj/ehv409

European Heart Journaldoi:10.1093/eurheartj/ehv407

European Heart Journaldoi:10.1093/eurheartj/ehv408

Help to implementGL in daily practice

• 40 cases each• No reference• Link to the dedicated

sections of the GL

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ABSTRACT SUBMISSION

Mid December – 14 February 2016

EARLY REGISTRATION

Deadline: 31 May 2016

HOT LINES SUBMISSION

Mid March – 1 May 2016

CLINICAL CASE SUBMISSION

Mid January – 1 March 2016

LATE REGISTRATION

Deadline: 31 July 2016