scholarly journals Diagnosis and Management of Acute Coronary Syndrome: What is New and Why? Insight From the 2020 European Society of Cardiology Guidelines

2020 ◽  
Vol 9 (11) ◽  
pp. 3474
Author(s):  
Paul Guedeney ◽  
Jean-Philippe Collet
Keyword(s):  
Acute Coronary Syndrome ◽  
European Society ◽  
Bleeding Risk ◽  
St Segment Elevation ◽  
P2y12 Inhibitors ◽  
Diagnosis And Management ◽  
Coronary Syndrome ◽  
St Segment ◽  
European Society Of Cardiology ◽  
Rule Out

The management of acute coronary syndrome (ACS) has been at the center of an impressive amount of research leading to a significant improvement in outcomes over the last 50 years. The 2020 European Society of Cardiology (ESC) Guidelines for the management of patients presenting without persistent ST-segment elevation myocardial infarction have incorporated the most recent breakthroughs and updates from large randomized controlled trials (RCT) on the diagnosis and management of this disease. The purpose of the present review is to describe the main novelties and the rationale behind these recommendations. Hence, we describe the accumulating evidence against P2Y12 receptors inhibitors pretreatment prior to coronary angiography, the preference for prasugrel as leading P2Y12 inhibitors in the setting of ACS, and the numerous available antithrombotic regimens based on various durations of dual or triple antithrombotic therapy, according to the patient ischemic and bleeding risk profiles. We also detail the recently implemented 0 h/1 h and 0 h/2 h rule in, rule out algorithms and the growing role of computed coronary tomography angiography to rule out ACS in patients at low-to-moderate risk.

Use of Glycoprotein IIb/IIIa Inhibitors in the Modern Era of Acute Coronary Syndrome Management: A Survey of Cardiovascular Clinical Pharmacists

2019 ◽  
pp. 089719001987238
Author(s):  
Craig J. Beavers ◽  
Douglas L. Jennings
Keyword(s):  
Acute Coronary Syndrome ◽  
Heart Association ◽  
Research Network ◽  
St Segment Elevation ◽  
P2y12 Inhibitors ◽  
Clinical Pharmacists ◽  
Coronary Syndrome ◽  
St Segment ◽  
Myocardial Infraction

Evidence for the use of glycoprotein IIb/IIIa inhibitors (GPIs) in the management of acute coronary syndrome (ACS) is from the era of either limited utilization of P2Y12 inhibitors or prior the introduction of more potent P2Y12 inhibitors. This leads to divergent opinions regarding the role of these agents in contemporary practice. This study sought the opinion of cardiovascular clinical pharmacists regarding the role of GPIs in the modern of ACS management. A 13-question survey was created and distributed from June 2018 to July 2018 via the American College of Clinical Pharmacy’s Cardiology Practice and Research Network e-mail listserv. The survey consisted of questions regarding the ideal use of GPIs in ACS management, preferred agent selection, and rational for selection. All results were analyzed with descriptive statistics. There were a total 69 responses of 1175 (response rate 5.9%). The majority felt there was still a role for GPI in accordance to the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for ST-segment elevation myocardial infarction (65.2%), with eptifibatide being preferred (55.1%). For non-ST-segment myocardial infraction (NSTEMI), only 49.3% felt role of GPI was in line with the ACC/AHA guidelines, but a notable number of respondents felt GPIs were only indicated in NSTEMI patients for bailout or thrombotic complications (18.8%). A majority (56.5%) felt GPIs could be used as an alternative for cangrelor when bridging. The decision to use one agent over another were efficacy data, cost, and pharmacokinetic profile.

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm

2019 ◽  
Vol 9 (1) ◽  
pp. 30-38 ◽  
Author(s):  
Marcia Cortés ◽  
Sohaib Haseeb ◽  
Florencia Lambardi ◽  
Rosina Arbucci ◽  
Paula Ariznavarreta ◽  
...  
Keyword(s):  
European Society ◽  
Low Risk ◽  
Major Adverse Cardiac Events ◽  
Cardiac Events ◽  
St Segment Elevation ◽  
Heart Score ◽  
St Segment ◽  
Risk Patients ◽  
European Society Of Cardiology ◽  
Rule Out

Background: The European Society of Cardiology’s 0/1-hour algorithm improves the early triage of patients towards “rule-out” or “rule-in” of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department. Methods: In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization. Results: The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as “rule-out” and the HEART score classified 686 (50.6%) patients as “low-risk”. The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 0.29% in the HEART score “low-risk” patients ( p=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 1.1% in the HEART score “low-risk” patients ( p<0.001). Conclusion: The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.

scholarly journals Acute Coronary Syndrome and Ischemic Heart Disease in Pregnancy: Data From the EURObservational Research Programme‐European Society of Cardiology Registry of Pregnancy and Cardiac Disease

2020 ◽  
Vol 9 (15) ◽  
Author(s):  
Lucia Baris ◽  
Abdul Hakeem ◽  
Tabitha Moe ◽  
Jérôme Cornette ◽  
Nasser Taha ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Heart Disease ◽  
Cardiac Disease ◽  
Research Programme ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
European Society Of Cardiology

Background The prevalence of ischemic heart disease (IHD) in women of child‐bearing age is rising. Data on pregnancies however are scarce. The objective is to describe the pregnancy outcomes in these women. Methods and Results The European Society of Cardiology‐EURObservational Research Programme ROPAC (Registry of Pregnancy and Cardiac Disease) is a prospective registry in which data on pregnancies in women with heart disease were collected from 138 centers in 53 countries. Pregnant women with preexistent and pregnancy‐onset IHD were included. Primary end point were maternal cardiac events. Secondary end points were obstetric and fetal complications. There were 117 women with IHD, of which 104 had preexisting IHD. Median age was 35.5 years and 17.1% of women were smoking. There was no maternal mortality, heart failure occurred in 5 pregnancies (4.8%). Of the 104 women with preexisting IHD, 11 women suffered from acute coronary syndrome during pregnancy. ST‐segment‒elevation myocardial infarction were more common than non‒ST‐segment‒elevation myocardial infarction, and atherosclerosis was the most common etiology. Women who had undergone revascularization before pregnancy did not have less events than women who had not. There were 13 women with pregnancy‐onset IHD, in whom non‒ST‐segment‒elevation myocardial infarction was the most common. Smoking during pregnancy was associated with acute coronary syndrome. Caesarean section was the primary mode of delivery (55.8% in preexisting IHD, 84.6% in pregnancy‐onset IHD) and there were high rates of preterm births (20.2% and 38.5%, respectively). Conclusions Women with IHD tolerate pregnancy relatively well, however there is a high rate of ischemic events and these women should therefore be considered moderate‐ to high‐risk. Ongoing cigarette smoking is associated with acute coronary syndrome during pregnancy.

scholarly journals Assessment of quality indicators for acute myocardial infarction management in 28 countries and use of composite quality indicators for benchmarking

2020 ◽  
Vol 9 (8) ◽  
pp. 911-922 ◽  
Author(s):  
Xavier Rossello ◽  
Jesús Medina ◽  
Stuart Pocock ◽  
Frans Van de Werf ◽  
Chee Tang Chin ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Quality Indicators ◽  
European Society ◽  
Prognostic Value ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
European Society Of Cardiology ◽  
Elevation Acute Myocardial Infarction

Background: The European Society of Cardiology established a set of quality indicators for the management of acute myocardial infarction. Our aim was to evaluate their degree of attainment, prognostic value and potential use for centre benchmarking in a large international cohort. Methods: Quality indicators were extracted from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) (555 hospitals, 20 countries in Europe and Latin America, 2010–2011) and EPICOR Asia (218 hospitals, eight countries, 2011–2012) registries, including non-ST-segment elevation acute myocardial infarction ( n=6558) and ST-segment elevation acute myocardial infarction ( n=11,559) hospital survivors. The association between implementation rates for each quality indicator and two-year adjusted mortality was evaluated using adjusted Cox models. Composite quality indicators were categorized for benchmarking assessment at different levels. Results: The degree of attainment of the 17 evaluated quality indicators ranged from 13% to 100%. Attainment of most individual quality indicators was associated with two-year survival. A higher compliance with composite quality indicators was associated with lower mortality at centre-, country- and region-level. Moreover, the higher the risk for two-year mortality, the lower the compliance with composite quality indicators. Conclusions: When EPICOR and EPICOR Asia were conducted, the European Society of Cardiology quality indicators would have been attained to a limited extent, suggesting wide room for improvement in the management of acute myocardial infarction patients. After adjustment for confounding, most quality indicators were associated with reduced two-year mortality and their prognostic value should receive further attention. The two composite quality indicators can be used as a tool for benchmarking either at centre-, country- or world region-level.

scholarly journals High-sensitivity cardiac troponin concentrations at presentation in patients with ST-segment elevation myocardial infarction

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
R Wereski ◽  
K.K Lee ◽  
S Smith ◽  
A.R Chapman ◽  
D Lowe ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Funding Source ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Rule Out

Abstract Background The widespread adoption of high-sensitivity cardiac troponin testing has encouraged the use of pathways to accelerate the rule-out and rule-in myocardial infarction in the Emergency Department. These pathways are not recommended for patients with ST-segment elevation, but there is a risk they may be applied incorrectly given that interpretation of the electrocardiogram is subjective, dependent on experience, and signs may be masked in those with posterior myocardial infarction. Methods Consecutive patients with suspected acute coronary syndrome were enrolled in a stepped-wedge cluster randomized controlled trial across ten hospitals in Scotland. The index diagnosis was adjudicated two clinicians independently in all patients with high-sensitivity cardiac troponin I concentrations above the sex-specific 99th centile on serial testing and abnormalities on the electrocardiogram recorded. The proportion of patients with ST-segment elevation myocardial infarction and concentrations below the rule-out threshold (&lt;5 ng/L), 99th centile (&lt;16 ng/L and &lt;34 ng/L for women and men) and rule-in threshold (&lt;52 ng/L) at presentation were determined. Results In total 48,282 patients were recruited between June 2013, and March 2016 of which 22% (10,360/48,282) had peak cardiac troponin concentrations above the 99th centile. The adjudicated diagnosis was type 1 myocardial infarction in 55% (4,981/9,115) of patients and 10% (925/9,115) had ST-segment elevation myocardial infarction (age 65 [14] years, 68% men). The majority presented within 6 hours of symptom onset (67%, 619/925), and 84% (772/925) had cardiac troponin concentrations above the 99th centile at presentation. However, troponin concentrations were below the rule-out threshold in 2% (20/925) and the rule-in threshold in 26% (240/925) of patients with ST-segment elevation myocardial infarction. Discussion In patients with suspected acute coronary syndrome who have a final diagnosis of ST-segment elevation myocardial infarction, high-sensitivity cardiac troponin concentrations are below the rule-out and rule-in threshold at presentation in 1 in 50 and 1 in 4 patients, respectively. Clinicians should not rely on cardiac troponin concentrations to guide initial treatment decisions in patients with possible ST-segment elevation myocardial infarction. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): British Heart Foundation

scholarly journals Bleeding risk factors in patients with acute coronary syndrome: data from observational studies ORACUL II

2019 ◽  
Vol 24 (3) ◽  
pp. 7-16 ◽  
Author(s):  
V. A. Brazhnik ◽  
L. O. Minushkina ◽  
R. R. Guliev ◽  
A. O. Averkova ◽  
A. A. Rogozhina ◽  
...  
Keyword(s):  
Risk Factors ◽  
Acute Coronary Syndrome ◽  
Roc Analysis ◽  
Bleeding Risk ◽  
Killip Class ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
St Segment ◽  
Risk Scale

Aim.To identify the risk factors for bleeding of BARC scale 2-5 types in patients after acute coronary syndrome (ACS).Material and methods.The data of 1502 patients from the open multicenter study, ORACUL II, were used — 894 men (59,5%) and 608 women (40,5%), mean age — 65,7±12,9 years. Five hundred sixty (37,3%) patients had ACS with ST-segment elevation and 942 (62,7%) — ACS without ST-segment elevation. Bleeding was recorded in 164 patients (10,9%), including index admission — in 39 (2,6%) patients, of which severe (types 3-5) — 0,5%, significant — 1,7% (types 2-5).Results.Within a year after discharge, bleeding was observed in 126 (8,4%) patients, large — 0,8%, significant — 2,4%. The development of bleeding type 2-5 was associated with the presence of gastric ulcer and duodenal ulcer, gastrointestinal bleeding in history, decreased creatinine, hemoglobin clearance, age of patients, the use of anticoagulants in the composition of triple or double antithrombotic therapy, conducting of percutaneous interventional procedures, the presence of heart failure 2-4 Killip class at admission. ROC analysis showed that the predictive value of the ORACLE bleeding risk scale is 0,762, sensitivity — 62%, specificity — 78%.Conclusion.Thus, we based on routine clinical practice have created a simple scale for assessing the risk of bleeding in patients with ACS.

Performance of the European Society of Cardiology 0/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin: Systematic review and meta-analysis

2020 ◽  
pp. 204887262093539 ◽  
Author(s):  
Lucrecia M Burgos ◽  
Marcelo Trivi ◽  
Juan P Costabel
Keyword(s):  
Myocardial Infarction ◽  
Acute Coronary Syndrome ◽  
Diagnostic Accuracy ◽  
Likelihood Ratio ◽  
European Society ◽  
Cardiac Troponin ◽  
High Sensitivity ◽  
Coronary Syndrome ◽  
European Society Of Cardiology ◽  
Rule Out

Introduction: A rapid rule-out or rule-in protocol based on the 0-hour/1-hour algorithm using high-sensitivity cardiac troponin (hs-cTn) is recommended by the European Society of Cardiology (ESC); recently multiple studies have validated it in their settings. We aimed to assess the diagnostic accuracy of the 2015 ESC guidelines for management of acute coronary syndrome in patients without ST-segment elevation 0-hour/1-hour algorithm using hs-cTn for the early rule-out and rule-in of acute myocardial infarction (AMI) on presentation. Methods: Systematic searches were conducted using PubMed, the Cochrane Library and the International Clinical Trials Registry Platform to identify prospective studies from 2015 to October 2019 involving adults presenting to the emergency department with possible acute coronary syndrome in which hs-cTn measurements were obtained according to the ESC algorithm and AMI outcomes were adjudicated during the initial hospitalization. Results: Eleven studies, involving 19,213 patients, were identified. Pooled prevalence of AMI during the index hospitalization was 11.3% (95% confidence interval (CI) 3.9–18.8%). Summary sensitivity and specificity in diagnosing AMI were 99% (95% CI 98–99%; I2 63%) and 91% (95% CI 91–92%; I2 96%) respectively. The summary positive likelihood ratio was 11.6 (95% CI 8.5–15.8; I2 97%) and the pooled likelihood ratio negative 0.02 (0.01–0.03; I2 52%). Cumulative all-cause mortality at 30 days in the rule-out group was 0.11%, and 2.8% in the rule-in group, and 30 days AMI in the rule-out group was 0.08%. Conclusion: The ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin has high diagnostic accuracy; it allows safe rule-out as well as accurate rule-in of AMI, with low cumulative 30-day mortality and AMI in patients assigned the rule-out zone.

scholarly journals Antithrombotic PreTreatment and Invasive Strategies in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome

2020 ◽  
Vol 9 (8) ◽  
pp. 2578 ◽  
Author(s):  
Cyril Camaro ◽  
Peter Damman
Keyword(s):  
Acute Coronary Syndrome ◽  
Optimal Timing ◽  
Mortality Benefit ◽  
Antithrombotic Treatment ◽  
Invasive Strategy ◽  
St Segment Elevation ◽  
P2y12 Inhibitors ◽  
Coronary Syndrome ◽  
St Segment ◽  
Elevation Acute Coronary Syndrome

In the current era, the antithrombotic treatment of patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) includes standard aspirin, and one of the potent P2Y12 inhibitors ticagrelor or prasugrel. The optimal timing of ticagrelor has not been adequately studied, while prasugrel is only recommended after coronary angiography prior to PCI. The invasive strategy, including indication and timing of angiography, depends on risk stratification and a mortality benefit has been shown in selected high-risk NSTE-ACS undergoing early (<24 h) intervention.

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