Acute Coronary Syndromes: A Handbook for Clinical Practice (European Society of Cardiology)

Myocardial Infarction
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Another new feature is a table outlining proposed strategies to reduce the bleeding risk in patients who undergo PCI, such as adjusting anticoagulant doses to body weight and renal function, or performing PCI without interrupting oral anticoagulation, and avoiding dual anticoagulation prior to coronary angiography in chronically anticoagulated patients. The guidelines also include an excellent online Appendix with practical recommendations for treating bleeding associated with antiplatelet agents, vitamin K antagonists or the new oral anticoagulants, although many of them are not based on controlled trials..

For bleeding in patients treated with vitamin K antagonists, the administration of vitamin K reverses the effect, but it takes several hours and has not been shown to offer any benefit in emergency situations. Prothrombin complex concentrate is recommended, as it is more efficient than fresh frozen plasma and recombinant activated factor VII. In bleeding associated with the new oral anticoagulants, vitamin K or fresh frozen plasma have no demonstrated effect, and for patients with hemodynamic deterioration or life-threatening bleeding, prothrombin complex concentrate is the best option..

The characteristics, predictors, and treatment of bleeding not related to the access site, and of that related to PCI or coronary revascularization, are described. There is a section on transfusion, which mentions the higher mortality rate among transfused acute coronary syndrome patients. The guidelines emphasize the superiority of the invasive approach in the management of NSTEACS and point out that the benefit of this strategy, shown in trials carried out in the past, is being underestimated, since the generalized use of radial access and the new-generation drug-eluting stents and antiplatelet agents enable even better outcomes.

The accepted criteria for very high, high, intermediate, and low risk are clearly specified in a Table.

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In contrast to the latest European guidelines for myocardial revascularization, 7 diabetes mellitus, renal failure, postinfarction angina, and previous revascularization are considered criteria for intermediate risk, rather than secondary criteria for high risk. In accordance with existing studies, the guidelines recommend radial access, depending on the operator's experience, although they indicate that proficiency in femoral access should be maintained. A section is devoted to the identification of the culprit lesion on the basis of 4 angiographic criteria thrombus, plaque ulceration, plaque irregularity, and dissection , at least 2 of which should be present.

This definition might be useful, but has not been validated, and it may be too restricted.. The new-generation drug-eluting stents can be considered an alternative to bare-metal stents in those patients with high bleeding risk scheduled to receive dual antiplatelet therapy for no longer than 1 month.. There are detailed indications for antiplatelet therapy before and after coronary artery surgery, and the guidelines state that the recommendation of dual antiplatelet therapy for 12 months in the absence of contraindications depends on the revascularization strategy.

The level of priority and technical aspects of surgical revascularization are presented as online supplementary material.. When the criteria for very high risk are met, angiography should probably be immediate. However, the established hour limit for patients considered high-risk should be a subject of debate, as the studies cited in support of this recommendation found no clear benefit from a generalized early strategy. Moreover, any elevation in the troponin level is indicative of high risk, but minimum increases do not have the same prognostic implications as greater increases, and may not even be due to acute coronary syndrome.

Changes in T waves, also considered to indicate high risk, do not have the same value as changes in the ST segment for the prediction of the existence of serious coronary lesions or the incidence of complications. Little is said about the utility of intracoronary imaging studies in the detection of the mechanisms leading to plaque instability and the prognostic implications.

In multivessel disease, the decision on the revascularization mode should be individualized and reached by consensus among the heart team, taking into account patient preferences. Another responsibility of the heart team is to estimate the risk of bleeding and ischemia and guide the assigning of priority to revascularization surgery, while managing antiplatelet therapy.

Acute Coronary Syndromes: A Handbook for Clinical Practice

The lack of a definition of the concept of heart team and its composition in the guidelines is quite noticeable.. It is established class I-B recommendation that CABG be performed without delay in patients with hemodynamic instability, ongoing myocardial ischemia, or very high-risk coronary anatomy, regardless of the antiplatelet therapy received. However, the extension of this emergent recommendation to patients with a very high-risk anatomy even if they are stable, and regardless of the antiplatelet therapy received, is debatable.

Very high-risk coronary anatomy is not defined. The supplementary material mentions the concept of critical anatomy, which is not defined either. The recommended surgery in patients with critical anatomy is urgent during the hospital stay but not emergency surgery, all of which creates confusion. The lack of randomized studies to define the optimal priority criteria for surgery in patients who have been stabilized after NSTEACS renders it impossible to make evidence-based recommendations.

The usual approach is to delay surgery for a few days, even if the patient has left main coronary artery disease; in fact, that is what is indicated in the supplementary material of these guidelines. There is a need for uniform definitions of the terms immediate, emergent , and urgent relative to the planning of surgery, to be used consistently in documents issued by the scientific societies..

The new guidelines have eliminated specific recommendations for management according to sex and acknowledge that there is no scientific evidence to justify different strategies for the treatment of men and woman. This is one of the major changes and most positive outcomes of these guidelines.

The risk of in-hospital death in women is twice that of men, which has been attributed to the underuse of evidence-based treatments in women. It will be essential to implement strategies aimed at promoting the application of the guidelines and increasing the awareness of gender equality in terms of cardiovascular risk.. There is a section devoted to elderly and frail patients, although the approach to the particular features of this subgroup focuses almost exclusively on the chronological point of view. The only issue addressed is the need to consider cognitive or functional impairment, dependence on others and frailty, which is recognized as a powerful independent predictor of mortality.

However, there is a need to adopt an approach to the systematic evaluation of frailty, the tools that should be used, and how to incorporate them into the decision-making process. Thus, this should be an area of research in this field. With respect to patients with diabetes mellitus, the threshold for initiating glucose-lowering therapy is more precisely defined, although specific treatment regimens are not described in detail. Less strict glycemic control is recommended for patients of advanced age, and the recommendation concerning the control of renal function in diabetic patients following coronary angiography has been modified..

Patients with chronic kidney disease constitute another group at higher risk for complications. There are no changes in the recommendations regarding antiplatelet therapy, which should be the same as for patients without renal failure, although with dose adjustment when necessary, or with respect to anticoagulant therapy, in which it will be necessary to indicate unfractionated heparin or adjust the doses of other anticoagulants.

The fear of renal function deterioration secondary to coronary angiography is one of the reasons why the percentage of patients who undergo this invasive strategy is inversely proportional to the severity of the renal failure. These data indicate that the treatment strategy for these patients should be individualized, as recommended by the guidelines.. The new guidelines have included a section on the treatment of acute heart failure. With respect to ventricular assist devices, the guidelines maintain the option of using intra-aortic balloon counterpulsation in selected patients, as well as other short-term devices, and advise against the systematic use of counterpulsation in cardiogenic shock.

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Importantly, there is a change in the recommendation for implantable cardioverter defibrillators and cardiac resynchronization therapy, as the document stresses the importance of waiting at least 40 days before implantation in patients who are symptomatic despite optimal therapy and have no additional options for revascularization. This recommendation is based on the available evidence, although the ESC guidelines for the prevention of sudden death allow earlier implantation under certain circumstances.

In patients with residual ischemia, revascularization should be performed first, followed by a wait of up to 6 months before assessment of the indication for device implantation. Atrial fibrillation during hospital stay is associated with a higher risk of recurrent ischemia, heart failure, and thromboembolic complications, as well as a longer hospital stay and a higher rate of long-term mortality.

The guidelines stress the difficulty of establishing a differential diagnosis between atrial fibrillation with elevated troponin and type 1 AMI. Thus, if there is significant troponin elevation, the performance of tests for ischemia may be justified. The recommendations are based on the latest guidelines for atrial fibrillation and heart failure.. It is uncertain whether anemia is a marker associated with an elevated comorbidity burden or is an independent determinant of prognosis. Given that the optimal threshold for the justification of packed red blood cell transfusion is unknown, the recommendation in this respect has gone from I-B to IIb-C. There is a section on the management of thrombocytopenia with no significant changes..

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Antithrombotic therapy has been mentioned above. With respect to lipid-lowering therapy, the guidelines maintain the recommendation to initiate high-intensity statin therapy as early as possible or to increase the intensity of statin therapy in those receiving low- or moderate-intensity regimens. In patients with intolerance to ACE inhibitors, angiotensin II receptor blockers are an alternative, although they are only superior to the ACE inhibitors in the presence of cough.

The indication suggesting ACE inhibitors for all other patients, which in previous guidelines was a class I-B recommendation, has disappeared.. Observational studies indicate that their long-term indiscriminate administration may not be useful, 15 although, according to other studies, they could be beneficial after discharge, in the absence of ventricular dysfunction. The recommendation on glycemic control is generic, but clear: the older the patients, the greater their comorbidities, or the longer their history of diabetes mellitus, the less strict their glycemic control..

Acute Coronary Syndromes: A Handbook for Clinical Practice (European Society of Cardiology)

The recommendations on lifestyle and rehabilitation do not differ from those of earlier guidelines, although the inclusion of these patients in structured cardiac rehabilitation programs is considered a class IIa-A recommendation, without specifying the duration. The importance of the advice on aerobic exercise and smoking cessation is discussed, and diet and weight control are mentioned.

However, the document misses the opportunity to indicate clearly the type of diet that is adequate, specifically, that which is rich in virgin olive oil, nuts and other dried fruits, whose effectiveness in primary cardiovascular prevention has been demonstrated. Notable aspects are the refinement of the diagnostic algorithms in emergency cases, the adjustment of the recommendations for antithrombotic therapies and for secondary prevention to the latest available evidence, and the firm commitment to an early invasive strategy for most patients.

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Find articles by Eun Young Han. Published by Wileyand ;Blackwell A systematic review of studies of the 6-minute walk test included 6 studies on validity, one study on reliability, and 11 studies on responsiveness. Whelton, in Comprehensive Hypertension , Scotland's guidelines state that CR services should offer individualized exercise assessments, tailor the exercise components to individuals' choices, and deliver them in a range of settings SIGN SOR: strong. Throughout the series, leading international opinion leaders have been chosen to edit and contribute to the books. At a median follow-up of three years, the first co-primary outcome — a composite of cardiovascular death or MI — occurred in 7.

The effort made by the authors to provide useful recommendations on aspects not previously dealt with, such as the practical management of bleeding or the treatment of patients requiring chronic anticoagulation, is very much appreciated.. The names of all the authors of the article are listed in the Appendix..

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Home Articles in press Current Issue Archive. ISSN: Previous article Next article. Issue Pages December Download PDF. Related content. Rev Esp Cardiol. Bax, Michael A.

Borger, Carlos Brotons, Derek P. Storey, Stephan Windecker. This item has received. Article information. Table 1.

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Table 2.