Acute Coronary Syndrome Update - Livemedia.grstatic.livemedia.gr/...us41_20141104101428_24_hamm.pdf · Clopidogrel Prasugrel Ticagrelor Class Thienopyridine Thienopyridine Triazolopyrimidine

KERCKHOFF

KLINIK

Acute Coronary Syndrome

Update

Christian W. Hamm

Medical Clinic I

University Hospital Giessen

& Kerckhoff Heart and Thorax Center

Germany

KERCKHOFF KLINIKUNIVERSITÄTSKLINIKUM GIESSEN

Conflict of Interest – Disclosure

Christian W. Hamm

Affiliation/Financial Relationship Company

1. Honoraria for lectures Abbott, AstraZeneca ,Bayer, Berlin Chemie,

Boehringer Ingelheim, MSD, BMS,

BRAHMS, Daiichi Sankyo, Essex, GSK,

Medtronic, Lilly, SanofiAventis,

Correvio, Pfizer, Roche, The

Med. Comp., Boston Scientific, Gilead

2. Honoraria for advisory AstraZeneca, Bayer, BRAHMS, Median,

board activities Boehringer Ingelheim, Medtronic, SHS

3. Participation in AstraZeneca, MSD, Boston Scientific, GSK

clinical trials Takeda, Terumo, The Med. Comp., Gilead

4. Financial shares and options: no

Chest Pain

Acute Coronary Syndrome

persistent

ST-elevation

ST/T -

abnormalities

normal or

undetermined

ECG

STEMI NSTEMIUnstable

Angina

troponin

rise/fall

troponin

normal

Admission

Working

diagnosis

ECG

Bio-chemistry

Diagnosis

Hamm et al: European Heart Journal (2011) 32:2999–3054

www.escardio.org/guidelines European Heart Journal 2012 - doi:10.1093/eurheartj/ehs215

European Heart Journal

doi:10.1093/eurheartj/ehs215

ESC Guidelines for the management of acute myocardial

infarction in patients presenting with ST-segment

elevationThe Task Force on the management of ST-segment elevation acute myocardial

infarction of the European Society of Cardiology

Authors/Task Force Members: Ph. Gabriel Steg (Chairperson) (France)*, Stefan K. James (Chairperson) (Sweden)*, Dan Atar

(Norway), Luigi P. Badano (Italy), Carina Blomstrom Lundqvist (Sweden), Michael A. Borger (Germany), Carlo Di Mario (United

Kingdom), Kenneth Dickstein (Norway), Gregory Ducrocq (France), Francisco Fernandez-Aviles (Spain), Anthony H. Gershlick (United

Kingdom), Pantaleo Giannuzzi (Italy), Sigrun Halvorsen (Norway), Kurt Huber (Austria), Peter Juni (Switzerland), Adnan Kastrati

(Germany), Juhani Knuuti (Finland), Mattie J. Lenzen (Netherlands), Kenneth W. Mahaffey (USA), Marco Valgimigli (Italy), Arnoud van't

Hof (Netherlands), Petr Widimsky (Czech Republic), Doron Zahger (Israel)

ESC Committee for Practice Guidelines (CPG): Jeroen J. Bax (Chairman) (Netherlands), Helmut Baumgartner (Germany), Claudio

Ceconi (Italy), Veronica Dean (France), Christi Deaton (UK), Robert Fagard (Belgium), Christian Funck-Brentano (France), David Hasdai

(Israel), Arno Hoes (Netherlands), Paulus Kirchhof (Germany/UK), Juhani Knuuti (Finland), Philippe Kolh (Belgium), Theresa McDonagh

(UK), Cyril Moulin (France), Bogdan A. Popescu (Romania), Željko Reiner (Croatia), Udo Sechtem (Germany), Per Anton Sirnes

(Norway), Michal Tendera (Poland), Adam Torbicki (Poland), Alec Vahanian (France), Stephan Windecker (Switzerland)

Document Reviewers: David Hasdai (CPG Review Coordinator) (Israel), Felicity Astin (UK), Karin Åström-Olsson (Sweden), Andrzej

Budaj (Poland), Peter Clemmensen (Denmark), Jean-Philippe Collet (France), Keith A. Fox (UK), Ahmet Fuat (UK), Olivija Gustiene

(Lithuania), Christian W. Hamm (Germany), Petr Kala (Czech Replublic), Patrizio Lancellotti (Belgium), Aldo Pietro Maggioni (Italy), Béla

Merkely (Hungary), Franz-Josef Neumann (Germany), Massimo F. Piepoli (Italy), Frans Van de Werf (Belgium), Freek Verheugt

(Netherlands), Lars Wallentin (Sweden)

http://www.escardio.org/guidelines

European Heart Journal

Advance Access published August 26, 2011

www.escardio.org/guidelinesEuropean Heart Journal

doi:10.1093/eurheartj/ehu278


KERCKHOFF

KLINIKWhat is new 2014 ?

• STEMI-Upstream bivalirudin: EUROMAX

• STEMI-Upstream ticagrelor: ATLANTIC

• NSTEMI-Upfront prasugrel: ACCOAST

• Rule out: CT new scanner

Troponin & CK elevated Troponins elevated or not

Adapted from Michael Davies

ACS without ST- Elevation

NSTEMI / Unstable A.p.

ACS with ST-

Elevation STEMI

ESC Revascularisation Guideline 2014

www.escardio.org/guidelines

Anticoagulation in primary PCI

Bivalirudin (with use of GP IIb/IIIa blocker

restricted to bailout) is recommended over

unfractionated heparin and a GP IIb/IIIa blocker.


1-Year All-Cause Mortality

Stone et al, New Engl J Med 2008

Mo

rta

lity

(%

)

0

1

2

3

4

5

Time in Months

0 1 2 3 4 5 6 7 8 9 10 11 12

Bivalirudin alone (n=1800)

Heparin + GPIIb/IIIa (n=1802) 4.8%

3.4%

Diff [95%CI] =

-1.5% [-2.8,-0.1]

HR [95%CI] =

0.69 [0.50, 0.97]

P=0.029

3.1%

2.1%

Δ = 1.0%

P=0.049

Δ = 1.4%

2218 patients with STEMI with symptom onset >20 min and ≤12h

Randomized in ambulance or non-PCI hospital

Intent for primary PCI

UFH/LMWH ± GPIPer standard practice

Bivalirudin(0.75 mg/kg bolus, 1.75 mg/kg/h infusion)

+ prolonged optional infusion (PCI dose or 0.25 mg/kg/h)

(provisional GPI only)

Aspirin + P2Y12 inhibitor

(any) as soon as possibleR

1:1

Primary endpoint: 30-day death or non-CABG related major bleeding

Key Secondary endpoint: Death, Re-infarction or non-CABG major bleeding at 30 days

Clinical FU at 30 days and 1 year

EUROMAX Trial Design

Steg et al. New Engl. J. Med. 2013

0,0

2,0

4,0

6,0

8,0

10,0

0 5 10 15 20 25 30

Days from Randomization Date

Eve

nt

Rate

Bivalirudin 1089 1038 1024 1020 1007 988 791

Heparins with optional GPI

1109 1024 1003 998 984 958 765

Bivalirudin

Heparins with optional GPI 8.4%

Log-rank p = 0.002

Patients at risk:

Primary Endpoint:Death or Major Bleed, 30 day

5.1%

0,0

2,0

4,0

6,0

8,0

0 5 10 15 20 25 30

2.7%

Log-rank p < 0.001

Non–CABG-related major bleed, 30 day


Bivalirudin 1089 1040 1025 1022 1010 991 794


1109 1030 1009 1005 990 964 773

Patients at risk:

Eve

nt

Ra

te

6.1%

Bivalirudin


0,0

1,0

2,0

3,0

4,0

0 5 10 15 20 25 30

Cardiac

Non-cardiac

Log-rank p = 0.46

Log-rank p = 0.10

3.0%

Cardiac and Non-Cardiac Death, 30-day


Bivalirudin 1089 1057 1048 1044 1039 1036 1034


1109 1062 1061 1056 1050 1043 1037

Patients at risk:

Bivalirudin


2.4%

0.1%

0.5%

Eve

nt

Ra

te

Outcomes, 30 daysBivalirudin(N=1089)


(N=1109)

Relative risk [95% CI]

P Value

Reinfarction 19 (1.7) 10 (0.9) 1.93 (0.90–4.14) 0.08

Q-wave 3 (0.3) 2 (0.2) 1.53 (0.26–9.12) 0.68

Non-Q-wave 16 (1.5) 8 (0.7) 2.04 (0.88–4.74) 0.09

Stent thrombosis (ARC definition) 17 (1.6) 6 (0.5) 2.89 (1.14–7.29) 0.02

Definite 17 (1.6) 6 (0.5) 2.89 (1.14–7.29) 0.02

Probable 0 (0) 0 (0) – n/a

Acute (≤24 hours) 12 (1.1) 2 (0.2) 6.11 (1.37–27.24) 0.007

Subacute (>24 hours to 30 days) 5 (0.5) 4 (0.4) 1.27 (0.34–4.73) 0.75

Ischemia-driven revascularization 24 (2.2) 17 (1.5) 1.44 (0.78–2.66) 0.25

Reinfarction, ischemia-driven revascularization or stent thrombosis

29 (2.7) 21 (1.9) 1.41 (0.81–2.45) 0.23

Any stroke 6 (0.6) 11 (1.0) 0.56 (0.21–1.50) 0.24

Ischemic 6 (0.6) 9 (0.8) 0.68 (0.24–1.9) 0.46

Hemorrhagic 0 2 (0.2) Not applicable 0.50

Acquired thrombocytopenia 7 (0.7) 14 (1.4) 0.50 (0.20–1.24) 0.13

n/a: not applicable.

MACE and Individual CV Outcomes

Unfractionated Heparin versus Bivalirudinin Patients Undergoing PCI

Cavender, Sabatine. Lancet 2014

16 RCTs with 33,958 patients



Antithrombotic therapy in

STEMI patients undergoing primary PCI



Oral Antiplatelet Therapy


In-hospital new oral P2Y12 antagonistsPrimary PCI of STEMI

Montalescot G, et al. Lancet 2009;373:723–31 Steg PG, et al. Circulation. 2010;122:2131-41

0%

5%

10%

15%

0 2 4 6 8 10 12

Primary efficacy EP

N=7544p=0.07

Time (Months)

Cu

mu

lati

ve in

cid

ence

(%

)

ClopidogrelTicagrelor

0%

5%

10%

15%

0 50 100 150 200 250 300 350 400 450

Time (Days)

Pro

po

rtio

n o

f p

atie

nts

(%

)

9,5

12,4

10,0

HR=0.79 (0.65–0.97) NNT=41

p=0.02

RRR=21%

p=0.002

RRR=32%

6,5

ClopidogrelPrasugrel

Primary efficacy EP

TRITON PLATO

Clopidogrel Prasugrel Ticagrelor

Class Thienopyridine Thienopyridine Triazolopyrimidine

Binding Irreversible Irreversible Reversible

ActivationProdrug, limited

by metabolisationProdrug, not limited

by metabolisationActive drug

Nonresponders Yes No No

Onset of Effect 2–4 h 30 min 30 min

Duration of Effect 3–10 days 5–10 days 3–4 days

Withdrawal BeforeMajor Surgery

5 days 7 days 5 days

Adapted from Hamm CW, et al. Eur Heart J. 2011;32:2999–3054. www.escardio.org/guidelines. 21

ESC Revascularisation Guideline 2014

?


Oral Antiplatelet Therapy


Administration of Ticagrelor in the cath Lab or in the Ambulance for New ST elevation myocardial Infarction to

open the Coronary artery

G. Montalescot, COI are available at www.action-coeur.org

G. Montalescot, A.W. van’t Hof, F. Lapostolle, J Silvain, J.F. Lassen, L. Bolognese, W.J. Cantor, A. Cequier, M. Chettibi, S.G. Goodman, C.J. Hammett, K. Huber, M. Janzon,

B. Merkely, R.F. Storey, U. Zeymer, O. Stibbe, P. Ecollan, W.M.J.M. Heutz, E. Swahn,J.P. Collet, F.F. Willems, C. Baradat, M. Licour, A. Tsatsaris, E. Vicaut, C.W. Hamm,

for the ATLANTIC investigators

Pre-Hospital

In-Hospital

Design

STE –ACS planned for PCISymptoms of acute MI >30 min but <6 hours

Ticagrelor

180mg loading

dose

RANDOMIZE 1:1

DOUBLE BLIND

•Written informed consent in mobile care unit•New persistent ST-segment elevation ≥ 1 mm in two or more contiguous ECG leads

Loading dose

placebo

Loading dose

placebo

Ticagrelor

180mg loading

dose

Primary Objectives:

TIMI flow grade 3 of MI culprit vessel at initial angiography or

≥70% ST-segment elevation resolution pre-PCI

Tic

ag

relo

r9

0m

g/b

id

30d

N ~ 1870

99.201,011

73 min 31 min 14 min

90 min 63 min

28 min

159 min

Median timesto pre- and in-hospital steps

Onset of Symptoms

EKGPre-hospital LD1 LD2

EKGPre-PCI Angiography PCI

Randomization

1st Co-primary endpointNo ST-segment resolution (≥70%)

86,8%

42,5%

87,6%

47,5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-PCI Post-PCI

Pre-hospitalIn-hospital

pat

ien

ts (

%)

p = NS

p = 0.055 (NS)

2nd Co-primary endpointNo TIMI 3 flow in infarct-related artery

82,6%

17,8%

83,1%

19,6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pre-PCI Post-PCI


pat

ien

ts (

%)

p = NS

p = NS

0%

1%

2%

3%

4%

5%

6%

7%

0 4 8 12 16 20 24 28 32

Ticagrelor in-hospital

Ticagrelor pre-hospital

30

Eve

nt

rate

(K

M %

)

Major adverse CV events up to 30 days

Ticagrelor pre-hospital : 41/906 (4.5%) Ticagrelor in-hospital 42/952 (4.4%)OR : 1.03 (95% CI 0,66, 1.0) ; p = 0.9056

MACE: death, MI, stent thrombosis, stroke or urgent revascularization

Days

Clinical endpoints at 30 days

Values are %Odds ratio

(95% CI)p-value

Death (all-cause)1.68

(0.94, 3.01) 0.08

MI0.73

(0.28, 1.94) 0.53

Stroke2.11

(0.39, 11.53) 0.39

TIANot

estimableUrgent coronary revascularization

0.66 (0.21, 2.01) 0.46

Bail-out GP IIb/IIIa inhibitors0.80

(0.59, 1.10) 0.17

Definite stent thrombosis up to 30 days

0%

1%

2%

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30

Ticagrelor pre-hospital

Ticagrelor in-hospital

Eve

nt

rate

(K

M %

)

Time (days)

Ticagrelor pre-hospital 2/906 (0.2%) versusTicagrelor in-hospital 11/952 (1.2%)OR 0.19 (95% CI 0.04, 0.86), P=0.0225

P=0.0225

30days

Non-CABG-related bleeding events (PLATO definitions) - Safety population

1,8%

0,9%

2,6%

1,2%0,8%

2,0%1,6%

0,9%

2,5%

1,2%

0,5%

1,7%

0%

5%

10%

Major Minor Composite ofmajor and minor

Major Minor Composite ofmajor and minor


Within 48h of first dose After 48h up to 30 days

p = NS p = NS p = NS p = NS p = NS p = NS

pat

ien

ts (

%)

Global time effect of ticagrelor Evolution of VASP-PRI (%) in all patients (median value)

p=0.19 (T1 vs T2)

p<0.0001* (T1 vs T3)

p<0.0001* (T1 vs T4)

p<0.0001* (T1 vs T5)

T1(Pre-PCI)

T2(End of PCI)

+37’

T3(H1 Post-PCI)

+1h 52’

T4(H6 Post-PCI)

+6h 52’

T5(Before MD)

+13h 18’

LD1 LD2Wilcoxon test with Bonferroni correction p value significant if <0.01

Platelet Function Substudy

0 120 240 360 480 600 720 840 9600

10

20

30

40

50

60

70

80

90

100

VA

SP-P

RI %

Time (min from T1)

• T1 - when catheterization starts (pre PCI)

• T2 - after PCI (end of procedure)

• T3 - 1 h post-PCI

• T4 - 6 h post-PCI

• T5 - 12 h post-PCI before the first maintenance dose

Ticagrelor pre-hospital vs. in-hospital for VASP-PRI

Pre Hospital (Pre-treatment)In Hospital (CathLab) p=NS p=NS p=NS

p=NS

p=NS

T1(PrePCI)

+67’

T2(End of PCI)

+1h44’

T3(H1 Post PCI)

+2h59’

T4(H6 PostPCI)

+8h59’

T5(Before MD)

+14h25’

LD1 LD2

0

20

40

60

80

100

Pre-PCI TIMI Flow and ST resolution

Post-PCI ST resolution

Primary objective

% V

ASP

-P

RI

Absence of ST-segment resolution by patient characteristics

Characteristic Total patients Endpoint rate P ValueAge Pre-hospital In-hospital OR (95% CI) (Int.)

<65 years 1014 85.9% 87.3% 0.887 (0.618, 1.272) 0.6207≥65 years 584 88.6% 88.2% 1.037 (0.625, 1.724)<75 years 1348 86.7% 86.8% 0.994 (0.726, 1.362) 0.2940≥75 years 250 87.6% 92.0% 0.617 (0.269, 1.418)

SexMale 1288 87.0% 87.7% 0.945 (0.680, 1.312) 0.8292

Female 310 85.9% 87.5% 0.871 (0.451, 1.684)

DiabetesYes 212 88.3% 88.1% 1.015 (0.438, 2.353) 0.8319No 1386 86.6% 87.5% 0.922 (0.673, 1.261)

Location of MIAnterior 831 89.0% 87.3% 1.183 (0.775, 1.808) 0.1320

Non-anterior 767 84.7% 88.0% 0.750 (0.495, 1.136)TIMI risk score

0–2 971 86.0% 87.6% 0.867 (0.597, 1.256) 0.71293–6 599 88.3% 87.4% 1.081 (0.661, 1.767)>6 28 86.7% 92.3% 0.542 (0.043, 6.757)

Highest Killip Classifiation pre-PCII 1458 86.1% 88.2% 0.833 (0.612, 1.133) 0.1049

>I 82 93.5% 83.3% 2.865 (0.664, 12.236)

Prior ASA useYes 476 88.8% 87.1% 1.178 (0.670, 2.075) 0.3455No 1122 86.1% 87.9% 0.856 (0.604, 1.214)

GPIIb/IIIa inhibitor use before angiographyYes 117 85.2% 83.9% 1.106 (0.405, 3.021) 0.7281No 1481 87.0% 87.9% 0.918 (0.675, 1.248)

Morphine use for index event/PCI

Yes 800 90.8% 86.8% 1.493 (0.954, 2.331) 0.0050No 798 82.8% 88.4% 0.632 (0.423, 0.943)

Pre-hospital better In-hospital better10.5 2

Odds ratio(95% CI)

KERCKHOFF

KLINIK

KERCKHOFF

KLINIK

KERCKHOFF KLINIKUNIVERSITÄTSKLINIKUM GIESSEN

Conclusions

• Pre-hospital ticagrelor administration before pPCI in patients with

ongoing STEMI is safe.

• Ticagrelor does not improve pre-PCI coronary reperfusion.

• It may, however, reduce the risk of post-PCI stent thrombosis.

• Role of morphine?

Ticagrelor prehospital may be given, particularly

when long delay to pPCI is expected

Troponin & CK elevated Troponins elevated or not

Adapted from Michael Davies

ACS without ST- Elevation

NSTEMI / Unstable A.p.

ACS with ST-

Elevation STEMI

Fibrinogen

Thrombocyte

GP IIb/IIIa

--

ClopidogrelPrasugrelTicagrelorCangrelor

Aspirin

-GP IIb/IIIa Inhibitors

COXADP

Thrombocyte

Activation

AggregationIV

Oral

Anti-Platelet Therapy

-

PAR-1

Vorapaxar


Recommendations for oralantiplatelet agents (1)

Recommendations Class Level

Aspirin should be given to all patients without contraindications at an initial loading dose of 150-300 mg, and at a maintenance dose of 75-100 mg dailylong-term regardless of treatment strategy.

I A

A P2Y12 inhibitor should be added to aspirin as soon as possible and maintained

over 12 months, unless there are contraindications such as excessive risk of

bleeding.

I A

A proton pump inhibitor (preferably not omeprazole) in combination with DAPT is recommended in patients with a history of gastrointestinal haemorrhage or peptic ulcer, and appropriate for patients with multiple other risk factors (H. elicobacter pylori infection, age ≥ 65 years, concurrent use of anticoagulants or steroids).

I A

Prolonged or permanent withdrawal of P2Y12 inhibitors within 12 months after

the index event is discouraged unless clinically indicated.I C

Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all patients at moderate-to-high risk of ischaemic events (e.g. elevated troponins), regardless of initial treatment strategy and including those pre-treated withclopidogrel (which should be discontinued when ticagrelor is commenced).

I B

Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended for

P2Y12-inhibitor-naïve patients (especially diabetics) in whom coronary anatomy

is known and who are proceeding to PCI unless there is a high risk of life-

threatening bleeding or other contraindications.

I B

European Heart Journal (2011) 32:2999–3054doi:10.1093/eurheartj/ehr236

TRITON-TIMI

38

Prasugrel (60 mg loading dose, 10 mg daily dose)

is recommended for P2Y12-inhibitor-naïve patients

(especially diabetics) in whom coronary anatomy

is known and who are proceeding to PCI unless there is

a high risk of life-threatening bleeding or other

contraindications.

82723011/13


82723011/13

Days From First Dose

0 5 10 15 20 25 30

En

dp

oin

t (%

)

0

5

10

15

1996

2037

1788

1821

1775

1809

1769

1802

1762

1797

1752

1791

CV Death, MI, Stroke, UR, GPIIb/IIIa Bailout

1621

1616

No. at Risk, Primary

Efficacy End Point:

No pre-treatment

Pre-treatment

Pre-treatment10.810.0

Pre-treatment

Hazard Ratio, 0.997 (95% 0.83, 1.20)P=0.98P=0.81

(95% 0.84, 1.25) Hazard Ratio, 1.02

No Pre-treatment10.8

9.8No Pre-treatment

1° Efficacy End Point @ 7 + 30 days

(All Patients)

82723011/13

All TIMI (CABG or non-CABG) Major Bleeding

(All Treated patients)

Days From First Dose

0 5 10 15 20 25 30

En

dp

oin

t (%

)

0

1

2

3

4

5

All TIMI Major Bleeding

Pre-treatment2.9

Pre-treatment2.6

No Pre-treatment1.5

No Pre-treatment1.4

19962037

19471972

13281339

12971310

12881299

12841297

12631280

No. at Risk, All TIMI Major Bleeding:No pre-treatmentPre-treatment

Hazard Ratio, 1.97 (95% 1.26, 3.08)P=0.002

Hazard Ratio, 1.90(95% 1.19, 3.02) P=0.006

82723011/13



Antithrombotic therapy in

NSTE-ACS patients undergoing PCI


Rapid rule-out of ACS with high-sensitivity troponin.


Recommendations for diagnosisand risk stratification


Blood has to be drawn promptly for troponin (cardiac troponin T or I)

measurement.The result should be available within 60 min.The test should be

repeated 6-9 h after initial assessment if the first measurement is not conclusive.

Repeat testing after 12-24 h is advised if the clinical condition is still suggestive

of ACS.

I A

A rapid rule-out protocol (0 and 3 h) is recommended when highly sensitive

troponin tests are available.I B

An echocardiogram is recommended for all patients to evaluate regional and

global LV function and to rule in or rule out differential diagnoses.I C

Coronary angiography is indicated in patients in whom the extent of CAD or

the culprit lesion has to be determined.I C

Coronary CT angiography should be considered as an alternative to invasive

angiography to exclude ACS when there is a low to intermediate likelihood of

CAD and when troponin and ECG are inconclusive.IIa B

In patients without recurrence of pain, normal ECG findings, negative troponins

tests, and a low risk score, a non-invasive stress test for inducible ischaemia is

recommended before deciding on an invasive strategy.I A


A rapid rule-out protocol (0 and 3 h) is recommended

when highly sensitive troponin tests are available.


KERCKHOFF

KLINIK

T. Reichlin, Arch Intern Med. 2012

Hs-Troponin Elevation on Admission


Recommendations for diagnosisand risk stratification (2)


Blood has to be drawn promptly for troponin (cardiac troponin T or I)

measurement.The result should be available within 60 min.The test should be

repeated 6-9 h after initial assessment if the first measurement is not conclusive.

Repeat testing after 12-24 h is advised if the clinical condition is still suggestive

of ACS.

I A

A rapid rule-out protocol (0 and 3 h) is recommended when highly sensitive

troponin tests are available.I B

An echocardiogram is recommended for all patients to evaluate regional and

global LV function and to rule in or rule out differential diagnoses.I C

Coronary angiography is indicated in patients in whom the extent of CAD or

the culprit lesion has to be determined.I C

Coronary CT angiography should be considered as an alternative to invasive

angiography to exclude ACS when there is a low to intermediate likelihood of

CAD and when troponin and ECG are inconclusive.IIa B

In patients without recurrence of pain, normal ECG findings, negative troponins

tests, and a low risk score, a non-invasive stress test for inducible ischaemia is

recommended before deciding on an invasive strategy.I A


Coronary CT angiography should be considered as an

alternative to invasive angiography to exclude ACS

when there is a low to intermediate likelihood of CAD

and when troponin and ECG are inconclusive.


KERCKHOFF

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KERCKHOFF

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Length of Stay in the Hospital and Proportion of Patients Discharged.

Hoffmann U et al. N Engl J Med 2012;367:299-308.

KERCKHOFF

KLINIK

New: Somatom Force

Somatom Force

CHANGE AS COMPARED MAIN ADVANTAGETO „FLASH“

Faster Rotation (=> 65 ms temporal resolution)

New Detector (=> 2 x 192 slices, faster coverage, lower noise)

New Tube (=> 70 kV at high mAs)

Collimators (=> dose for sequential scan)

New Iterative Reconstruction (=> more natural look)

Courtesy of Stephan Achenbach

Clinical Results


SOMATOM FORCE: SEVERE DISEASE


SOMATOM FORCE: Clinical Results

DLP 19

=> Effective Dose 0.3 mSvCourtesy of Stephan Achenbach

SOMATOM FORCE: IMAGE QUALITY - STENTS


Rapid rule-out of ACS with high-sensitivity troponin.

CT

KERCKHOFF

KLINIK

Thank you !

KERCKHOFF

KLINIK




Aspirin should be given to all patients without contraindications at an initial loading dose of 150-300 mg, and at a maintenance dose of 75-100 mg dailylong-term regardless of treatment strategy.

I A

A P2Y12 inhibitor should be added to aspirin as soon as possible and maintained

over 12 months, unless there are contraindications such as excessive risk of

bleeding.

I A

A proton pump inhibitor (preferably not omeprazole) in combination with DAPT is recommended in patients with a history of gastrointestinal haemorrhage or peptic ulcer, and appropriate for patients with multiple other risk factors (H. elicobacter pylori infection, age ≥ 65 years, concurrent use of anticoagulants or steroids).

I A

Prolonged or permanent withdrawal of P2Y12 inhibitors within 12 months after

the index event is discouraged unless clinically indicated.I C

Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all patients at moderate-to-high risk of ischaemic events (e.g. elevated troponins), regardless of initial treatment strategy and including those pre-treated withclopidogrel (which should be discontinued when ticagrelor is commenced).

I B

Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended for

P2Y12-inhibitor-naïve patients (especially diabetics) in whom coronary anatomy

is known and who are proceeding to PCI unless there is a high risk of life-

threatening bleeding or other contraindications.

I B

Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended for all patients at moderate-to-high risk of ischaemic events (e.g. elevated troponins), regardless

of initial treatment strategy and including those pre-treated with clopidogrel (which should be discontinued

when ticagrelor is commenced).


PLATO





Clopidogrel (300 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel.

I A

A 600 mg loading dose of clopidogrel (or a supplementary 300 mg dose at PCI following an initial 300 mg loading dose) is recommended for patients scheduled for an invasive strategy when ticagrelor or prasugrel is not an option.

I B

A higher maintenance dose of clopidogrel 150 mg daily should be considered for the first 7 days in patients managed with PCI and without increased risk of bleeding.

IIa B

Increasing the maintenance dose of clopidogrel based on platelet function testing is not advised as routine, but may be considered in selected cases.

IIb B

Genotyping and/or platelet function testing may be considered in selected cases when clopidogrel is used.

IIb B

In patients pre-treated with P2Y12 inhibitors who need to undergo non-emergent major surgery (including CABG), postponing surgery at least for 5 days after cessation of ticagrelor or clopidogrel, and 7 days for prasugrel, if clinicallyfeasible and unless the patient is at high risk of ischaemic events should be considered.

IIa C

Ticagrelor or clopidogrel should be considered to be (re-)started after CABG surgery as soon as considered safe.

IIa B

The combination of aspirin with an NSAID (selective COX-2 inhibitors and non-selective NSAID) is not recommended.

III C



Recommendations for oral Antiplatelet Agents 2


Decision-making algorithm in ACS

Evaluation

• Quality of chest pain.

• Symptom-orientated

physical examination.

• Short history for the

likelihood of CAD.

• Electrocardiogram

(ST elevation?).

STEMI reperfusion

ACS

possible

1. Clinical Evaluation 2. Diagnosis/Risk Assessment 3. Coronary angiography

No CAD

early

< 24 h

< 72 h

urgent

< 120 min

no/elective

Validation

• Response to antianginal treatment.

• Biochemistry/troponin.

• ECG.

• Echocardiogram.

• Calculated risk score (GRACE).

• Risk criteria.

• Optional: CT, MRI, scintigraphy.



Recommendation for initial diagnosis

Echocardiography may assist in making the

diagnosis in uncertain cases but should not

delay transfer for angiography.


Documents

Acute Coronary Syndrome Update - Livemedia.grstatic.livemedia.gr/...us41_20141104101428_24_hamm.pdf · Clopidogrel Prasugrel Ticagrelor Class Thienopyridine Thienopyridine Triazolopyrimidine