New ESC Guideline on Acute ST-Segment Elevation MI

Marlene Busko

September 11, 2017

BARCELONA, SPAIN — New guidelines for managing and treating patients with acute ST-segment elevation MI (STEMI) just issued by European Society of Cardiology (ESC) update the previous 2012 guidelines with new topics and changes based on new evidence and aim to summarize information clearly in multiple tables and figures[1].

Clinicians and medical personnel can also download a free ESC pocket guidelines app.

Writing committee cochairs Dr Borja Ibáñez (Spanish National Centre for Cardiovascular Research, Madrid, Spain) and Prof Stefan James (Uppsala University, Sweden) presented the guidelines at the European Society of Cardiology (ESC) 2017 Congress, and the document was simultaneously published in European Heart Journal and on the ESC website.

"The present guidelines provide very simple messages trying to clarify any possible uncertainty," Ibáñez told theheart.org | Medscape Cardiology in an email.

"Terms like 'first medical contact' (FMC) or 'STEMI diagnosis' are clearly defined, while outdated terms like 'door-to-balloon' have been eliminated," he noted. "Treatment used to be initiated in the hospital but now it can start in the ambulance, so the 'door' varies according to the situation," he explained in a statement.

"We don't know if the patient is suffering from STEMI until the ECG, so this is a sensible starting point and the vessel should be opened within 90 minutes from then," James added.

FMC is defined as "the time point when the patient is either initially assessed by a physician, paramedic, nurse, or other trained EMS personnel who can obtain and interpret the ECG and deliver initial interventions (eg, defibrillation). FMC can be either in the prehospital setting or upon patient arrival at the hospital (eg, emergency department)."

STEMI diagnosis in the new document is defined as "the time at which the ECG of a patient with ischemic symptoms is interpreted as presenting ST-segment elevation or equivalent."

The many figures in the guideline provide the reader with a clear overview of important concepts, Ibáñez noted.

The document is very "focused on providing attractive figures, flowcharts, and tables that are easy to follow, understand, and use in clinical practice," James told theheart.org | Medscape Cardiology, all designed to make it easier to implement the recommendations into clinical practice.

The concept for identifying patients for a primary PCI strategy "is more inclusive" in this version of the guidelines, he also noted.

The document includes a chapter on MI with nonobstructive coronary arteries (MINOCA), that constitutes up to 14% of STEMI patients and demands additional diagnostic tests and tailored therapy that may differ from typical STEMI.

Other changes in the 2017 guidelines include:

  • Where fibrinolysis is the reperfusion strategy, the maximum time delay from the diagnosis of STEMI to treatment has been shortened from 30 minutes in 2012 to 10 minutes in 2017.

  • Complete revascularization in patients with multivessel disease receives a stronger recommendation, moving from class III (should not be performed) to class IIa (should be considered), with non–infarct-related arteries treated during the index procedure or another time point before discharge from the hospital.

  • Thrombus aspiration is no longer recommended, based on two large trials in more than 15,000 patients.

  • Deferred stenting, which involved opening the artery and waiting 48 hours to implant a stent, is no longer recommended.

  • For PCI, the use of drug-eluting stents instead of bare-metal stents has been upgraded from class IIa (should be considered) to class I (is recommended/indicated), as has the use of radial, instead of femoral, arterial access.

  • Dual antiplatelet therapy beyond 12 months may be considered in selected patients. Bivalirudin has been downgraded from class I to IIa (should be considered), and enoxaparin upgraded from class IIb (may be considered) to IIa (should be considered). Cangrelor (Kengreal, the Medicines Company), which was not mentioned in the 2012 document, has been recommended as an option in certain patients.

  • Additional lipid-lowering therapy is recommended in patients with high cholesterol despite taking the maximum dose of statins.

  • The cutoff for administering oxygen therapy has been lowered from less than 95% to less than 90% arterial oxygen saturation.

  • Left and right bundle branch block are now considered equal for recommending urgent angiography when patients have ischemic symptoms.

 Ibáñez reports receiving research funding (departmental or institutional) from AstraZeneca. James reports direct personal  payment (for speaker fees, honoraria, consulting, advisory board, investigator, committee member) from Bayer and Boston Scientific; payment to his institution (for speaker fees, honoraria, consulting, advisory board, investigator, committee member) from Bayer, AstraZeneca, the Medicines Company, Abbott, and Boston Scientific; and research funding (departmental or institutional) from the Medicines Company, AstraZeneca, and Abbott Vascular. Disclosures for the coauthors are available here.

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