2017ESC急性心梗指南

2017ESCGuidelinesforthemanagementofacutemyocardialinfarctioninpatientspresentingwithST-segmentelevationTheTaskForceforthemanagementofacutemyocardialinfarctioninpatientspresentingwithST-segmentelevationoftheEuropeanSocietyofCardiology(ESC)Authors/TaskForceMembers:BorjaIbanez*(Chairperson)(Spain),StefanJames*(Chairperson)(Sweden),StefanAgewall(Norway),ManuelJ.Antunes(Portugal),ChiaraBucciarelli-Ducci(UK),HéctorBueno(Spain),AlidaL.P.Caforio(Italy),FilippoCrea(Italy),JohnA.Goudevenos(Greece),SigrunHalvorsen(Norway),GerhardHindricks(Germany),AdnanKastrati(Germany),MattieJ.Lenzen(TheNetherlands),EvaPrescott(Denmark),MarcoRoffi(Switzerland),MarcoValgimigli(Switzerland),ChristophVarenhorst(Sweden),PascalVranckx(Belgium),PetrWidimsky(CzechRepublic)DocumentReviewers:Jean-PhilippeCollet(CPGReviewCoordinator)(France),SteenDalbyKristensen(CPGReviewCoordinator)(Denmark),VictorAboyans(France),*Correspondingauthors.Thetwochairmencontributedequallytothedocument:BorjaIbanez,DirectorClinicalResearch,CentroNacionaldeInvestigacionesCardiovascularesCarlosIII(CNIC),MelchorFernandezAlmagro3,28029Madrid,Spain;DepartmentofCardiology,IIS-FundacionJiménezDıazUniversityHospital,Madrid,Spain;andCIBERCV,Spain.Tel:þ3491453.12.00(ext:4302),Fax:þ3491453.12.45,E-mail:bibanez@cnic.esorbibanez@fjd.es.StefanJames,ProfessorofCardiology,DepartmentofMedicalSciences,ScientificDirectorUCR,UppsalaUniversityandSr.InterventionalCardiologist,DepartmentofCardiologyUppsalaUniversityHospitalUCRUppsalaClinicalResearchCenterDagHammarskjöldsv€ag14BSE-75237Uppsala,Sweden.Tel:þ46705944404,Email:stefan.james@ucr.uu.seESCCommitteeforPracticeGuidelines(CPG)andNationalCardiacSocietiesdocumentreviewers:listedintheAppendix.ESCentitieshavingparticipatedinthedevelopmentofthisdocument:Associations:AcuteCardiovascularCareAssociation(ACCA),EuropeanAssociationofPreventiveCardiology(EAPC),EuropeanAssociationofCardiovascularImaging(EACVI),EuropeanAssociationofPercutaneousCardiovascularInterventions(EAPCI),EuropeanHeartRhythmAssociation(EHRA),HeartFailureAssociation(HFA).Councils:CouncilonCardiovascularNursingandAlliedProfessions(CCNAP),CouncilforCardiologyPractice(CCP).WorkingGroups:CardiovascularPharmacotherapy,CardiovascularSurgery,CoronaryPathophysiologyandMicrocirculation,MyocardialandPericardialDiseases,Thrombosis.ThecontentoftheseEuropeanSocietyofCardiology(ESC)Guidelineshasbeenpublishedforpersonalandeducationaluseonly.Nocommercialuseisauthorized.NopartoftheESCGuidelinesmaybetranslatedorreproducedinanyformwithoutwrittenpermissionfromtheESC.PermissioncanbeobtaineduponsubmissionofawrittenrequesttoOxfordUniversityPress,thepublisheroftheEuropeanHeartJournalandthepartyauthorizedtohandlesuchpermissionsonbehalfoftheESC(journals.permissions@oxfordjournals.org).Disclaimer.TheESCGuidelinesrepresenttheviewsoftheESCandwereproducedaftercarefulconsiderationofthescientificandmedicalknowledgeandtheevidenceavail-ableatthetimeoftheirpublication.TheESCisnotresponsibleintheeventofanycontradiction,discrepancyand/orambiguitybetweentheESCGuidelinesandanyotheroffi-cialrecommendationsorguidelinesissuedbytherelevantpublichealthauthorities,inparticularinrelationtogooduseofhealthcareortherapeuticstrategies.HealthprofessionalsareencouragedtotaketheESCGuidelinesfullyintoaccountwhenexercisingtheirclinicaljudgment,aswellasinthedeterminationandtheimplementationofpre-ventive,diagnosticortherapeuticmedicalstrategies;however,theESCGuidelinesdonotoverride,inanywaywhatsoever,theindividualresponsibilityofhealthprofessionalstomakeappropriateandaccuratedecisionsinconsiderationofeachpatient’shealthconditionandinconsultationwiththatpatientand,whereappropriateand/ornecessary,thepatient’scaregiver.NordotheESCGuidelinesexempthealthprofessionalsfromtakingintofullandcarefulconsiderationtherelevantofficialupdatedrecommendationsorguidelinesissuedbythecompetentpublichealthauthorities,inordertomanageeachpatient’scaseinlightofthescientificallyaccepteddatapursuanttotheirrespectiveethicalandprofessionalobligations.Itisalsothehealthprofessional’sresponsibilitytoverifytheapplicablerulesandregulationsrelatingtodrugsandmedicaldevicesatthetimeofprescription.VCTheEuropeanSocietyofCardiology2017.Allrightsreserved.Forpermissionspleaseemail:journals.permissions@oxfordjournals.org.EuropeanHeartJournal(2017)00,1–66ESCGUIDELINESdoi:10.1093/eurheartj/ehx393Downloadedfromhttps://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehx393/4095042bygueston25November2017....................................................................................................AndreasBaumbach(UK),RaffaeleBugiardini(Italy),IoanMirceaComan(Romania),VictoriaDelgado(TheNetherlands),DonnaFitzsimons(UK),OliverGaemperli(Switzerland),AnthonyH.Gershlick(UK),StephanGielen(Germany),Veli-PekkaHarjola(Finland),HugoA.Katus(Germany),JuhaniKnuuti(Finland),PhilippeKolh(Belgium),ChristopheLeclercq(France),GregoryY.H.Lip(UK),JoaoMorais(Portugal),AleksandarN.Neskovic(Serbia),Franz-JosefNeumann(Germany),AlexanderNiessner(Austria),MassimoFrancescoPiepoli(Italy),DimitriosJ.Richter(France),EvgenyShlyakhto(RussianFederation),IainA.Simpson(UK),Ph.GabrielSteg(France),ChristianJuhlTerkelsen(Denmark),KristianThygesen(Denmark),StephanWindecker(Switzerland),JoseLuisZamorano(Spain),UweZeymer(Germany).ThedisclosureformsofallexpertsinvolvedinthedevelopmentoftheseguidelinesareavailableontheESCwebsitewww.escardio.org/guidelines...................................................................................................................................................................................................KeywordsGuidelines•Acutecoronarysyndromes•Acutemyocardialinfarction•Antithrombotictherapy•Antithrombotics•Emergencymedicalsystem•Evidence•Fibrinolysis•Ischaemicheartdisease•Primarypercutaneouscoronaryintervention•Qualityindicators•MINOCA•Reperfusiontherapy•Riskassessment•Secondaryprevention•ST-segmentelevation.TableofContentsAbbreviationsandacronyms..........................................31.Preamble..........................................................52.Introduction.......................................................62.1Definitionofacutemyocardialinfarction........................62.2EpidemiologyofST-segmentelevationmyocardialinfarction.....63.Whatisnewinthe2017version?..................................74.Emergencycare....................................................84.1Initialdiagnosis.................................................84.2Reliefofpain,breathlessness,andanxiety........................94.3Cardiacarrest.................................................104.4Pre-hospitallogisticsofcare...................................104.4.1Delays....................................................104.4.2Emergencymedicalsystem................................124.4.3OrganizationofST-segmentelevationmyocardialinfarctiontreatmentinnetworks................................125.Reperfusiontherapy..............................................135.1Selectionofreperfusionstrategies.............................135.2Primarypercutaneouscoronaryinterventionandadjunctivetherapy................................................165.2.1Proceduralaspectsofprimarypercutaneouscoronaryintervention..........................................165.2.2Periproceduralpharmacotherapy..........................185.3Fibrinolysisandpharmacoinvasivestrategy.....................205.3.1Benefitandindicationoffibrinolysis........................205.3.2Pre-hospitalfibrinolysis....................................215.3.3Angiographyandpercutaneouscoronaryinterventionafterfibrinolysis(pharmacoinvasivestrategy)....................215.3.4Comparisonoffibrinolyticagents..........................225.3.5Adjunctiveantiplateletandanticoagulanttherapies.........225.3.6Hazardsoffibrinolysis.....................................235.3.7Contraindicationstofibrinolytictherapy...................235.4Coronaryarterybypassgraftsurgery...........................236.Managementduringhospitalizationandatdischarge................246.1Coronarycareunit/intensivecardiaccareunit..................246.2Monitoring....................................................246.3Ambulation...................................................246.4Lengthofstay.................................................246.5Specialpatientsubsets.........................................256.5.1Patientstakingoralanticoagulation.........................256.5.2Elderlypatients...........................................256.5.3Renaldysfunction.........................................256.5.4Non-reperfusedpatients..................................256.5.5Patientswithdiabetes.....................................266.6.Riskassessment...............................................286.6.1Clinicalriskassessment....................................286.6.2Non-invasiveimaginginmanagementandriskstratification...................................................287.Long-termtherapiesforST-segmentelevationmyocardialinfarction...........................................................297.1Lifestyleinterventionsandriskfactorcontrol...................297.1.1Smokingcessation........................................297.1.2Diet,alcohol,andweightcontrol...........................297.1.3Exercise-basedcardiacrehabilitation.......................307.1.4Resumptionofactivities...................................307.1.5Bloodpressurecontrol....................................307.1.6Adherencetotreatment..................................307.2Antithrombotictherapy.......................................307.2.1Aspirin...................................................307.2.2Durationofdualantiplatelettherapyandantithromboticcombinationtherapies..........................................317.3Beta-blockers.................................................327.3.1Earlyintravenousbeta-blockeradministration..............327.3.2Mid-andlong-termbeta-blockertreatment................327.4Lipid-loweringtherapy........................................322ESCGuidelinesDownloadedfromhttps://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehx393/4095042bygueston25November2017..........................................................................................................................................................................7.5Nitrates......................................................337.6Calciumantagonists...........................................337.7Angiotensin-convertingenzymeinhibitorsandangiotensinIIreceptorblockers................................................337.8Mineralocorticoid/aldosteronereceptorantagonists............338.ComplicationsfollowingST-segmentelevationmyocardialinfarction...........................................................378.1Myocardialdysfunction........................................378.1.1Leftventriculardysfunction................................378.1.2Rightventricularinvolvement..............................378.2Heartfailure..................................................378.2.1Clinicalpresentations.....................................378.2.2Management..............................................378.3Managementofarrhythmiasandconductiondisturbancesintheacutephase.................................................398.3.1Supraventriculararrhythmias..............................398.3.2Ventriculararrhythmias...................................408.3.3Sinusbradycardiaandatrioventricularblock................418.4Mechanicalcomplications......................................428.4.1Freewallrupture.........................................428.4.2Ventricularseptalrupture.................................428.4.3Papillarymusclerupture...................................428.5Pericarditis....................................................428.5.1Earlyandlate(Dresslersyndrome)infarct-associatedpericarditis.....................................................428.5.2Pericardialeffusion........................................429.Myocardialinfarctionwithnon-obstructivecoronaryarteries.......4210.Assessmentofqualityofcare.....................................4211.Gapsintheevidenceandareasforfutureresearch................4412.Keymessages....................................................4613.Evidenced-based‘todoandnottodo’messagesfromtheGuidelines.................................................4714.Webaddenda...................................................5015.Appendix.......................................................5016.References......................................................51AbbreviationsandacronymsACEangiotensin-convertingenzymeACCAAcuteCardiovascularCareAssociationACSacutecoronarysyndromeAFatrialfibrillationALBATROSSAldosteroneLethaleffectsBlockadeinAcutemyocardialinfarctionTreatedwithorwithoutReperfusiontoimproveOutcomeandSurvivalatSixmonthsfollow-upAMIacutemyocardialinfarctionARBangiotensinIIreceptorblockerASSENT3ASsessmentoftheSafetyandEfficacyofaNewThrombolytic3ATLANTICAdministrationofTicagrelorintheCathLaborintheAmbulanceforNewSTElevationMyocardialInfarctiontoOpentheCoronaryArteryATLASACS2–TIMI51Anti-XaTherapytoLowercardiovasculareventsinAdditiontoStandardtherapyinsubjectswithAcuteCoronarySyndrome–ThrombolysisInMyocardialInfarction51ATOLLAcutemyocardialinfarctionTreatedwithprimaryangioplastyandinTravenousenOxaparinorunfractionatedheparintoLowerischaemicandbleedingeventsatshort-andLong-termfollow-upAVatrioventricularb.i.d.bisindie(twiceaday)BMIbodymassindexBMSbare-metalstentBNPB-typenatriureticpeptideCABGcoronaryarterybypassgraftsurgeryCADcoronaryarterydiseaseCAPITALAMICombinedAngioplastyandPharmacologicalInterventionversusThrombolyticsALoneinAcuteMyocardialInfarctionCCNAPCouncilonCardiovascularNursingandAlliedProfessionsCCPCouncilforCardiologyPractice;CCUcoronarycareunitCHA2DS2-VAScCardiacfailure,Hypertension,Age75(Doubled),Diabetes,Stroke(Doubled)–VASculardisease,Age65–74andSexcategory(Female)CIconfidenceintervalCKDchronickidneydiseaseCMRcardiacmagneticresonanceCPGCommitteeforPracticeGuidelinesCRISPAMICounterpulsationtoReduceInfarctSizePre-PCI-AcuteMyocardialInfarctionCTcomputedtomographyCOMFORTABLE-AMIEffectofbiolimus-elutingstentswithbiodegradablepolymervs.bare-metalstentsoncardiovasculareventsamongpatientswithacutemyocardialinfarctiontrial;Compare-AcuteComparisonBetweenFFRGuidedRevascularizationVersusConventionalStrategyinAcuteSTEMIPatientsWithMultivesseldiseasetrialCURRENT-OASIS7TheClopidogrelandaspirinOptimalDoseusagetoreducerecurrentevents–SeventhorganizationtoassessstrategiesinischaemicsyndromesCvLPRITCompleteVersusLesion-OnlyPrimaryPCITrialDANAMIDANishStudyofOptimalAcuteTreatmentofPatientswithST-segmentElevationMyocardialInfarctionDANAMI3-DEFERDANAMI3–DeferredversusconventionalstentimplantationinpatientswithST-segmentelevationmyocardialinfarctionESCGuidelines3Downloadedfromhttps://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehx393/4095042bygueston25November2017............................................................................................................................................................................DANAMI-3–PRIMULTIDANAMI3–CompleterevascularisationversustreatmentoftheculpritlesiononlyinpatientswithST-segmentelevationmyocardialinfarctionandmultivesseldiseaseDAPTdualantiplatelettherapyDESdrug-elutingstentEACVIEuropeanAssociationofCardiovascularImagingEAPCEuropeanAssociationofPreventiveCardiologyEAPCIEuropeanAssociationofPercutaneousCardiovascularInterventionsEARLY-BAMIEarlyIntravenousBeta-BlockersinPatientsWithST-SegmentElevationMyocardialInfarctionBeforePrimaryPercutaneousCoronaryInterventionECGelectrocardiogramECLSextracorporeallifesupportECMOextracorporealmembraneoxygenationeGFRestimatedglomerularfiltrationrateEHRAEuropeanHeartRhythmAssociationEMSemergencymedicalsystemEPHESUSEplerenonePost-AMIHeartfailureEfficacyandSUrvivalStudyESCEuropeanSocietyofCardiologyEXAMINATIONEverolimus-ElutingStentsVersusBare-MetalStentsinST-SegmentElevationMyocardialInfarctionExTRACT–TIMI25EnoxaparinandThrombolysisReperfusionforAcutemyocardialinfarctionTreatment–ThrombolysisInMyocardialInfarctionFFRfractionalflowreserveFMCfirstmedicalcontactFOCUSFixed-DoseCombinationDrugforSecondaryCardiovascularPreventionFOURIERFurtherCardiovascularOutcomesResearchwithPCSK9InhibitioninSubjectswithElevatedRisktrial.GPglycoproteinGRACEGlobalRegistryofAcuteCoronaryEventsGRACIAGrupodeAnalisisdelaCardiopatıaIsquémicaAgudaHDL-Chigh-densitylipoproteincholesterolHFAHeartFailureAssociationHRhazardratioIABPintra-aorticballoonpumpICCUintensivecardiaccareunitICDimplantablecardioverterdefibrillatorIMPROVE-ITImprovedReductionofOutcomes:VytorinEfficacyInternationalTrialIRAinfarct-relatedarteryIUinternationalunitsi.v.intravenousLBBBleftbundlebranchblockLDL-Clow-densitylipoproteincholesterolLGElategadoliniumenhancementLVleftventricle/ventricularLVADLeftventricularassistdeviceLVEFleftventricularejectionfractionMACEmajoradversecardiaceventMATRIXMinimizingAdverseHaemorrhagicEventsbyTRansradialAccessSiteandSystemicImplementationofangioXMETOCARD-CNICEffectofMetoprololinCardioprotectionDuringanAcuteMyocardialInfarctionMImyocardialinfarctionMINOCAmyocardialinfarctionwithnon-obstructivecoronaryarteriesMRAmineralocorticoidreceptorantagonistMVOmicrovascularobstructionNORSTENTNorwegianCoronaryStentNSTEMInon-ST-segmentelevationmyocardialinfarctionNT-proBNPN-terminalproB-typenatriureticpeptideOASIS-6OrganizationfortheAssessmentofStrategiesforIschemicSyndromeso.d.omnidie(onceaday)PAMI-IISecondPrimaryAngioplastyinMyocardialInfarctionPaO2partialpressureofoxygenPCIpercutaneouscoronaryinterventionPCSK9proproteinconvertasesubtilisin/kexintype9PEGASUS-TIMI54PreventionofCardiovascularEventsinPatientswithPriorHeartAttackUsingTicagrelorComparedtoPlaceboonaBackgroundofAspirin–ThrombolysisinMyocardialInfarction54PETpositronemissiontomographyPIONEERAF-PCIOpen-Label,Randomized,Controlled,MulticenterStudyExploringTwoTreatmentStrategiesofRivaroxabanandaDose-AdjustedOralVitaminKAntagonistTreatmentStrategyinSubjectswithAtrialFibrillationwhoUndergoPercutaneousCoronaryInterventionp.o.peros(orally)PPIprotonpumpinhibitorPRAMIPreventiveAngioplastyinAcuteMyocardialInfarctionPRODIGYPROlongingDualAntiplateletTreatmentAfterGradingstent-inducedIntimalhyperplasiastudYRBBBrightbundlebranchblockREMINDERADouble-Blind,Randomized,Placebo-ControlledTrialEvaluatingTheSafetyAndEfficacyOfEarlyTreatmentWithEplerenoneInPatientsWithAcuteMyocardialInfarctionRIFLE-STEACSRadialVersusFemoralRandomizedInvestigationinST-ElevationAcuteCoronarySyndromeRIVALRadialVersusFemoralAccessforCoronaryinterventionRVrightventricle/ventricularSaO2arterialoxygensaturation4ESCGuidelinesDownloadedfromhttps://academic.oup.com/eurheartj/advance-article-abstract/doi/10.1093/eurheartj/ehx393/4095042bygueston25November2017.......................................................................................................SBPsystolicbloodpressures.c.subcutaneousSGLT2sodium-glucoseco-transporter-2SPECTsingle-photonemissioncomputedtomographySTEMIST-segmentelevationmyocardialinfarctionSTREAMSTrategicReperfusionEarlyAfterMyocardialinfarctionTIMIThrombolysisInMyocardialInfarctionTNK-tPATenecteplasetissueplasminogenactivatorTOTALTrialofRoutineAspirationThrombectomywithPCIversusPCIAloneinPatientswithSTEMItPAtissueplasminogenactivatorUFHunfractionatedheparinVALIANTVALsartanInAcutemyocardialiNfarcTionVFventricularfibrillationVTventriculartachycardia24/724haday,sevendaysaweek1.PreambleGuidelinessummarizeandevaluateavailableevidencewiththeaimofassistinghealthprofessionalsinselectingthebestmanagementstrat-egiesforanindividualpatientwithagivencondition.Guidelinesandtheirrecommendationsshouldfacilitatedecisionmakingofhealthprofessionalsintheirdailypractice.However,thefinaldecisionscon-cerninganindividualpatientmustbemadebytheresponsiblehealthprofessional(s)inconsultationwiththepatientandcaregiver