Transcript ESC Guidelines for the management of NSTEMI

从最新欧洲指南看ACS诊疗进展
陈纪言
广东省人民医院
ESC Guidelines for the management of NSTEMI
• Management strategy
• Step one: initial evaluation
• Step two: diagnosis validation and risk
assessment
• Step three: invasive strategy
ESC Guidelines for the management of NSTEMI
• Treatment
– Anti-ischaemic agents
– Antiplatelet agents
– Anticoagulants
– Coronary revascularization
– Special populations and conditions
– Long-term management
ESC Guidelines for the management of NSTEMI
• Anti-ischaemic agents
– decrease myocardial oxygen demand
– increase myocardial oxygen supply
b-Blockers
Nitrates
Calcium
channel blockers
ESC Guidelines for the management of NSTEMI
• Antiplatelet agents
– Aspirin
– Clopidogrel\Prasugrel
– glycoprotein IIb/IIIa receptor inhibitors
P2y12拮抗剂的建议
ESC Guidelines for the management of NSTEMI
 clopidogrel treatment was recommended to be
withheld for 5 days and ticagrelor for 1–3 days
before CABG（PLATO trial)
 Withdrawal of clopidogrel in high risk cohorts such
as those with ongoing ischaemia in the presence of
high risk anatomy (e.g. left main or severe proximal
multivessel disease) is not recommended
 The optimal timing of restarting medication
following CABG surgery remains uncertain.
ESC Guidelines for the management of NSTEMI
• Upstream vs procedural initiation of
glycoprotein IIb/IIIa receptor inhibitors
– ACUITY Timing trial\EARLY-ACS trial
– no advantage with a routine upstream use
• may be considered if there is active
ongoing ischaemia among high risk
patients or DAPT is not feasible
ESC Guidelines for the management of NSTEMI
• Coronary revascularization
– Invasive versus conservative approach
– Timing of angiography and intervention
– Percutaneous coronary intervention
versus coronary artery bypass surgery
– Risk stratification should be performed
as early as possible
ESC Guidelines for the management of NSTEMI
• Urgent invasive strategy (<120 min after
first medical contact)
– Refractory angina (indicating evolving MI
without ST abnormalities)
– Recurrent angina despite intense
antianginal treatment, associated with ST
depression (2 mm) or deep negative T
waves.
– Clinical symptoms of heart failure or
haemodynamic instability (‘shock’).
– Life-threatening arrhythmias (ventricular
fibrillation or ventricular tachycardia).
ESC Guidelines for the management of NSTEMI
• Early invasive strategy (<24 h after first
medical contact)
– High risk patients as identified by a GRACE
risk score >140 and/or the presence of at
least one primary high risk criterion (Table 9)
should undergo invasive evaluation within 24
h.
ESC Guidelines for the management of NSTEMI
• Invasive strategy (<72 h after first
medical contact)
– less acute risk, GRACE risk score <140
• Conservative strategy (no or elective
angiography)
– No recurrence of chest pain.
– No signs of heart failure.
– No abnormalities in the initial ECG or a
second ECG (at 6–9 h).
– No rise in troponin level (at arrival and at
6–9 h).
– No inducible ischaemia.
特殊人群的治疗
ESC Guidelines for the management of NSTEMI
Special populations and conditions
- The elderly: >75 years
one of the most important predictors of risk
at higher risk of side effects from medical
treatment: bleeding
• SYNERGY trial: enoxaparin>UFH
• OASIS-5 trial: enoxaparin>fondaparinux
(TACTICS)\TIMI 18 trial: patients>75 years
with NSTE-ACS derived the largest benefit
from PCI
ESC Guidelines for the management of NSTEMI
• Gender issues
– older than men
– higher bleeding risk than men
– Contradictory results have been published
ESC Guidelines for the management of NSTEMI
• Diabetes mellitus
• independent predictor of mortality:two-fold
ESC Guidelines for the management of NSTEMI
• Chronic kidney disease
– independent predictor of mortality and of
major bleeding
– dose adjustment
– hydration and low- or iso-osmolar contrast
– medium at low volume (<4 mL/kg) are
recommended
ESC Guidelines for the management of NSTEMI
• heart failure
• independent predictors of mortality
ESC Guidelines for the management of NSTEMI
• Step five: hospital discharge and postdischarge management
ESC Guidelines for the management of NSTEMI
谢谢