Acute Coronary

Syndrome: ¿Deberíamos optar por una

coronariografía precoz en el síndrome
coronario agudo sin elevación del segmento
ST? Registro CARDIOCHUS-HUSJ
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 Dra. Charigan Abou Jokh Casas

 
 SCA - IAM sin elevación del ST
 
 24 Marzo 2020

Comentario de la Autora: Dra. Charigan Abou Jokh Casas

En los pacientes con síndrome coronario agudo sin elevación del segmento ST de alto
riesgo, de un registro contemporáneo de la práctica clínica, la coronariografía precoz puede
estar asociada con una reducción de la mortalidad por cualquier causa y la mortalidad
cardiovascular en el seguimiento a largo plazo.

La coronariografía desempeña un papel fundamental en el tratamiento del infarto agudo de

miocardio sin elevación del segmento ST a la hora de confirmar el diagnóstico, estratificar
el riesgo, elegir la estrategia de revascularización y el tratamiento antitrombótico adecuado.
A pesar de esto, persiste incertidumbre y heterogeneidad en la literatura y en la práctica
clínica diaria con respecto al momento del tratamiento invasivo en el manejo del síndrome
coronario agudo sin elevación del segmento ST. Por esta razón, decidimos analizar el
efecto pronóstico de una estrategia invasiva precoz en pacientes con infarto sin elevación
del segmento ST de alto riesgo (score de GRACE>140) a partir de una cohorte
contemporánea de pacientes provenientes de 2 hospitales terciarios españoles.

Métodos:
 Inclusión consecutiva de pacientes ingresados desde el año 2005 hasta 2016
inclusive, en 2 centros (Complejo hospitalario universitario de Santiago de Compostela y
Hospital Universitario de San Juan) con diagnóstico de síndrome coronario agudo sin
elevación del segmento ST, según las guías de práctica clínica vigentes, obteniendo así un
total de 5.104 pacientes.
 Se evaluó el riesgo de mortalidad según el score GRACE: alto riesgo>140.
 Tratamiento invasivo temprano o precoz: aquel realizado<24 horas tras el ingreso.
Tratamiento invasivo tardío: aquel realizado<24 horas tras el ingreso.
 Se realizó un propensity score matching con el objetivo de obtener un subgrupo
supuestamente bien equilibrado de pacientes, con la misma probabilidad de recibir un
tratamiento invasivo precoz, asignando así a 1.890 sujetos a coronariografia temprana o
tardía, con una pérdida del seguimiento de 2.6% de pacientes. Con respecto a los pacientes
con enfermedad multivaso, tras la revascularización del vaso culpable, se trato el resto de
lesiones ante signos de isquemia objetivos o disfunción del ventrículo izquierdo.
 Los eventos adversos cardiovasculares mayores en el seguimiento comprendían la
mortalidad por cualquier causa, el infarto agudo de miocardio, la hospitalización por
insuficiencia cardiaca y una nueva revascularización no programada.

Resultados:
Se realizó coronariografia en un 90% de los 5.673 pacientes con infarto de miocardio sin
elevación del ST; se optó por coronariografía precoz a 2.087 pacientes (40,9%) con una
mediana de seguimiento de 59 meses. Los pacientes tenían una media de 67,1 años, la
mayoría varones (72,3%) con una puntuación GRACE media de 132,5. A casi 5 años de
seguimiento, la mortalidad por cualquier causa fue del 19%, la mortalidad cardiovascular
del 12,5%, y el 51,1% de los pacientes sufrieron al menos 1 evento cardiovascular mayor.
Tanto la mortalidad por cualquier causa como la mortalidad cardiovascular de los pacientes
sometidos a coronariografía precoz resultaron más bajas que las de los sometidos a
coronariografía tardía (el 16,1 frente al 21,5%; p<0,001; y el 10,9 frente al 14,1%;
p=0,002).

Como se muestra en las curvas de Kaplan-Meier (figura adjunta), los pacientes con
puntuación GRACE>140 a quienes se practicó una coronariografía precoz presentaban
tasas inferiores de mortalidad por cualquier causa y mortalidad cardiovascular, aunque no
se observaron dichas diferencias entre los pacientes de moderado o bajo riesgo, GRACE
<140. Después de ajustar por las variables de confusión, la revascularización temprana
realizada a los pacientes con SCASEST de alto riesgo frente a la tardía se asoció con una
reducción significativa de la mortalidad cardiovascular (HR=0,79; IC95%, 0,63-0,97), pero
no se halló una diferencia significativa entre ambas estrategias invasivas en relación con la
mortalidad por cualquier causa de los pacientes de alto riesgo (HR=0,86; IC95%, 0,71-
1,05).

La duración de la estancia hospitalaria fue menor en el grupo de intervención precoz (6,8

frente a 10,2 días), diferencia que mantuvo su significación estadística tras emparejar por
puntuación de propensión (6,8 frente a 9,2 días). La coronariografía precoz mostró una
tendencia inversa no significativa en los pacientes con puntuación GRACE<140.
Resaltar de nuestro trabajo:
Este es el primer estudio incluyendo dos hospitales españoles y pacientes de la vida real
con síndrome coronario agudo sin elevación del ST con un seguimiento largo, de hasta casi
5 años, demostrando que la coronariografía precoz realizada a pacientes de alto riesgo, se
asoció con un descenso de la mortalidad por cualquier causa y la mortalidad cardiovascular
tempranas y a largo plazo, comparada con la estrategia tardía, hallazgos que se explicarían
por la contribución de un porcentaje mayor de pacientes revascularizados al grupo de
tratamiento invasivo precoz.

Nuestros resultados podrían tener ciertas repercusiones para el abordaje clínico del infarto
sin elevación del ST y la organización de los sistemas de salud, sugiriendo así desarrollar
un “sistema de atención en red” para los pacientes con infarto sin elevación del ST de alto
riesgo que permita el acceso a la coronariografía precoz, sobre todo en los hospitales que no
disponen de un laboratorio de cateterismo cardiaco en funcionamiento las 24 horas del día,
los fines de semana y/o durante el periodo vacacional.
 Referencias:

1. Rev Esp Cardiol. - Coronariografía precoz y mortalidad a largo plazo en infarto

agudo de miocardio de alto riesgo. Registro CARDIOCHUS-HUSJ.

Comentario de la Dra. Charigan Abou Jokh Casas

https://www.cardioteca.com/videos/video-sindrome-coronario-agudo/3890-controversias-en-
tratamiento-antitrombotico-parte-i.html

Utilización e interpretación de la troponina

cardiaca para el diagnóstico del infarto agudo
miocardio en los servicios de urgencias
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 Dr. Alfredo Bardají

 
 Biomarcadores - SCA
 
 25 Febrero 2021

Comentario del Autor: Dr. Alfredo Bardají

Artículo de consenso para la utilización e interpretación de troponina cardiaca en pacientes
atendidos en Servicios de Urgencias por sospecha de síndrome coronario agudo.

El diagnóstico del infarto agudo de miocardio (IAM) el Servicio de Urgencias (SU) es

 siempre un reto. El uso generalizado de troponina cardiaca (Tnc) de alta sensibilidad, así
como la evidencia científica actual de su utilidad que se ha ido plasmando diferentes guías
de práctica clínica para pacientes con sospecha de síndrome coronario agudo, obliga tener
algoritmos previamente definidos en todos los SU.

El presente artículo es un Documento de Consenso realizado por miembros de la Sociedad

Española de Cardiología, Sociedad Española de Medicina de Urgencias y Sociedad
Española de Medicina de Laboratorio.

En el documento se comentan las propiedades generales de la Tnc, los métodos de

inmunoanálisis para su determinación, las diferencias entre Tnc T y Tnc I, así como las
diferencias en la Tnc contemporánea con respecto a la Tnc de alta sensibilidad.

El documento también especifica el concepto de IAM tipo 1, de IAM tipo 2 y de daño

miocárdico. Se proponen dos algoritmos: uno basado en la Tnc contemporánea y otro en la
Tnc de alta sensibilidad. En este último caso, los autores de este consenso recomiendan
algoritmo 0-3 horas para ser utilizado en aquellos casos en los que existe una sospecha de
síndrome coronario agudo con ECG que no muestra elevación persistente del segmento ST.
En función de la Tnc inicial y de la Tnc realizada a las 3 horas se puede descartar un IAM
(y considerar en este caso otros diagnósticos), o confirmar un IAM. El documento también
especifica el criterio daño miocárdico agudo o crónico en los pacientes que no tienen un
contexto clínico de síndrome coronario agudo, en función del valor delta (es decir, el
porcentaje de diferencia entre dos Tnc obtenida con un intervalo de 3 horas).

Este documento pretende servir de base para la elaboración de protocolos asistenciales en

todos los SU de hospitales españoles.

Referencias:

1. Emergencias. - Utilización e interpretación de la troponina cardiaca para el

diagnóstico del infarto agudo miocardio en los servicios de urgencias.

Comentario del Dr. Alfredo Bardají

Dr. Alfredo Bardají

Jefe de Servicio de Cardiología. Hospital Universitario de Tarragona Joan XXIII. Profesor
Titular de Medicina. Universidad Rovira Virgili. Orcid id: https://orcid.org/0000-0003-
1900-6974

Commentary on the new ESC

Guidelines on Chronic Coronary
Syndromes
Vol. 18, N° 6 - 08 Jan 2020

Dr. Per Anton Sirnes , FESC

Presented during the European Society of Cardiology annual meeting in 2019, the new ESC
Guidelines on Chronic Coronary Syndromes (CCS) embody an evolution in our clinical
understanding of coronary artery disease (CAD), which is a dynamic process of plaque
accumulation and functional changes of coronary circulation that can be modified by lifestyle
changes, pharmacological therapies and revascularisation. This article looks at these new
guidelines and why the change of name to Chronic Coronary Syndromes (CCS) from Stable
Coronary Artery Disease (SCAD) better reflects the innate nature of the syndrome. The
improved accuracy of imaging techniques, especially coronary artery CT, has had major
implications on the diagnostic algorithm, thus reducing the role of traditional exercise ECG in
the diagnostic work-up. 
Topic(s):

Coronary Artery Disease (Chronic)

One of the main events at the last ESC congress in Paris was the launch of the new ESC
Guidelines on Chronic Coronary Syndromes (CCS) [1]. This is a change of title from the last
guidelines in 2013 [2] which were called the “Guidelines on stable coronary artery disease”.
The new guidelines recognise that coronary artery disease (CAD) may have many different
facets and is a dynamic process of plaque accumulation and functional changes of coronary
circulation that can be modified by lifestyle changes, pharmacological therapies and
revascularisation (Figure 1). To reflect the dynamic nature of the syndrome, the new guidelines
have been named Chronic Coronary Syndromes (CCS) as opposed to the Acute Coronary
Syndromes (ACS) guidelines.
All Figures are from the current guidelines, courtesy of the ESC and publisher.
Read the full version of the new CCS Guidelines
here: https://academic.oup.com/eurheartj/advance-
article/doi/10.1093/eurheartj/ehz425/5556137
Figure 1. Natural history of chronic coronary syndromes.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].

The new Guidelines, well written and clinically oriented, are built around the six major clinical
scenarios of CCS:

1. Patients with angina and/or dyspnoea, and suspected coronary artery disease.
2. Patients with new onset of heart failure or reduced left ventricular function.
3. Patients with a long-standing diagnosis of chronic coronary syndrome. 
4. Patients with angina without obstructive disease in the epicardial coronary arteries.
 5. Asymptomatic subjects who undergo screening for possible subclinical CAD. 
6. Chronic coronary disease in special subgroups such as hypertension, valve disease, refractory
angina, very old persons and renal failure.

The guidelines underscore, like the previous ones, the importance of a thorough clinical history
before further evaluation. They have also kept in the recommendation for an initial
echocardiographic examination in all patients (Ia); as well as preferably also carotid ultrasound
to detect subclinical atherosclerosis (IIa).

Pre-test probability and clinical likelihood

The previous guidelines [2] introduced the concept of pretest probability (PTP) based on
variables such as sex, age and angina characteristics. However, recent publications [3] have
shown that the probability figures in the previous GUIDELINES were grossly overestimated.
The new GUIDELINES have an updated Table (Figure 2) showing numbers indicating
probability of significant CAD which are around 1/3 of the previous Table.
Figure 2. Updated Pre-test probability (PTP) of obstructive coronary artery disease based
on sex, age and angina characteristics.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1], Table 5. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the
diagnosis and management of chronic coronary syndromes: The Task Force for the diagnosis
and management of chronic coronary syndromes of the European Society of Cardiology
(ESC). Eur Heart J. 2019 Aug 31. [Epub ahead of print].
Thus, a 38-year-old man with atypical angina has only a 4% PTP of having obstructive CAD
and further diagnostic testing - besides a good history, basal blood tests, an ECG and possibly
an echo exam - is not necessary. Some CAD patients have dyspnoea as the only symptom and
in this new version of the Table, there is a new column for this group.
This pre-test probability can be further modified by applying other known clinical risk markers
such as smoking and lipid status, ECG changes, coronary CT, carotid ultrasound, etc., and can
be correspondingly diminished or augmented to give a clinical likelihood ratio (Figure 3) for
obstructive CAD.
This likelihood ratio is then further applied to the various diagnostic tests to rule in or rule out
obstructive CAD.
Figure 3.  Introducing the clinical likelihood ratio in the diagnostic sequence.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].
 
Which tests offer the best and worst performance?
The traditional exercise electrocardiogram (ECG) test was kept in the diagnostic algorithm in
the previous GUIDELINES; however, it is now no longer among the tests recommended for the
diagnosis of obstructive CAD. The diagnostic performance of the traditional exercise ECG is so
poor that it can only reliably rule out CAD in patients with very low PTP and rule in CAD in
patients with very high PTP. Thus, an exercise ECG is not generally recommended in the
clinical diagnostic workout (IIb) provided that other and more precise diagnostic methods are
available, keeping in mind the very high risk of false-negative and false-positive test results. 
Accordingly, exercise ECG has been downgraded to a class IIb recommendation with respect to
CAD diagnosis.
Figure 4. Demonstrating the poor performance of exercise ECG for the exclusion or
confirmation of significant CAD based on the clinical likelihood ratio.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].

Still, the guidelines recognise that an exercise ECG provides a lot of other valuable information
such as exercise tolerance and capacity, which has a strong impact on long-term prognosis,
heart rate and blood pressure response and information regarding exercise-induced arrhythmias
in selected patients. Thus, the time has not come to throw the ergometer or the treadmill away.
However, assessing a patient with suspected angina purely by exercise testing is not
recommended.
Computed tomography (CT) angiography (CTA) is now the recommended initial test for
patients with a low to moderate clinical likelihood of CAD. Patients with a moderate to high
likelihood should be triaged to a non-invasive test for ischaemia such as stress echo, single
photon emission computed tomography (SPECT), stress magnetic resonance imaging (MRI)
perfusion or positron emission tomography (PET), or directly to invasive angiography in
patients with a very high likelihood.
Figure 5. Illustration of the recommended diagnostic algorithm with coronary CTA in a
central position.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].
Assessment of risk in secondary prevention

The guidelines recommend that every patient with suspected or documented chronic stable
coronary artery disease should undergo an assessment of the future risk of death or a cardiac
event. They define low risk as a yearly mortality rate of below 1% and high risk as a yearly
mortality rate of above 3%.
Figure 6.  Risk classes in stable CAD.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].
The left ventricular (LV) function is recognised as the strongest predictor of long-term survival
and a patient with an LVEF <50% is already at high risk of cardiovascular death (annual
mortality rate >3%), even without accounting for additional event risk factors such as those
outlined in Figure 7.
Figure 7 & 8. Recommendations for risk assessment.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].
 
The various components are discussed in more detail in the online supplementary data [1]. 
Ejection fraction (EF) is important and should be assessed in every patient with suspected or
established CAD suspected; however, 50% of deaths in stable CAD patients are sudden and
most of these have an EF of >50% [1]. One of the new recommendations is the global
longitudinal strain (GLS) and this has been included in the guidelines with a class IIb
recommendation. A GLS which is reduced by >2 standard deviation (SD) from the lower
normal reference value gives an incremental value in the risk assessment of patients with CCS,
particularly in those with an EF >35% [4].

Pharmacological treatment

There have been no landmark trials necessitating a major change regarding the drugs
recommended for angina treatment since the 2013 guidelines. The class Ia recommendation is
still to use beta-blockers and/or calcium channel blockers to control heart rate and symptoms
with long-acting nitrates as the first second line addition. Newer second-line drugs such as
nicorandil, ranolazine, ivabradine and trimetazidine, have class IIa recommendations when
symptoms are not adequately controlled by first-line drugs and nitrates; these are discussed in
detail in the supplement paper [1].
Regarding medication for event prevention, 75-100 mg aspirin is recommended (class Ia) life-
long in patients with a previous myocardial infarction (MI) or revascularisation with 75 mg
clopidogrel as an alternative. For patients without an MI or previous revascularisation, aspirin
only has a class IIb recommendation.  
Adding a long-term second antithrombotic drug to aspirin should be considered in those with a
high risk of ischaemic events and a low bleeding risk and may be considered in those with a
moderately increased risk of ischaemic events. The options are clopidogrel, prasugrel,
ticagrelor or low-dose rivaroxaban. In highly selected patients with AF and a history of MI and
a high risk of recurrent ischaemic events, antiplatelet therapy in addition to oral anticoagulation
may be considered. Regarding dual antiplatelet therapy, the recommendations are in line with
the recent ESC focused update [5].

Lifestyle modifications and event preventing therapy

Emphasis is placed on the various lifestyle modifications as outlined in the recent lipids [6] and
preventive [7] guidelines. Regarding low-density lipoprotein (LDL) targets, it is surprising that
these new  stable CAD guidelines continue with an LDL target of <1.8 mmol/l (<70 mg/dL) or
at least 50% reduction, while the lipid guidelines [6] now recommend secondary prevention in
very high-risk patients, an low-density lipoprotein cholesterol (LDL-C) goal of <1.4 mmol/L
(<55 mg/dL); for those with a second coronary event within two years while on maximally
tolerated statin-based therapy, a target of <1 mmol/l may be considered.
Angiotensin-converting enzyme (ACE) inhibitors are recommended for those with other
indications and should otherwise be considered in CCS patients at very high risk of
cardiovascular events. Likewise, beta-blockers are recommended in heart failure (besides as an
anti-anginal therapy) and should be considered in those with previous ST-elevation myocardial
infarction (STEMI).

Revascularisation

Revascularisation by percutaneous coronary intervention (PCI) or coronary artery bypass

grafting (CABG) has previously mainly been regarded as a symptomatic treatment unless there
is reduced LV function and/or severe proximal CAD. This is discussed in detail in the recent
guidelines on myocardial revascularisation [8]. The new CCS guidelines place emphasis on
several recent studies indicating a prognostic benefit of revascularisation and they promote a
less restrictive indication for revascularisation in CCS, looking at the specific anatomy [e.g.,
left main (LM)] or extended ischaemia (>10%) and using physiologic measures of stenosis
significance such as fractional flow reserve (FFR). However, the results of the recent
ISCHEMIA trial [9] suggest that an optimal medical management in CAD is still a successful
road to pursue, and that revascularisation should be clinically and symptomatically guided
(https://www.ischemiatrial.org). A practical approach is given in Figure 9 which also
underscores the importance of angina.
Figure 9.  A practical approach to revascularisation in CCS.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].

Angina without coronary stenosis, vasospastic angina,

microvascular angina and chronic refractory angina

The diagnostic and therapeutic challenges of these entities are discussed. Coronary flow
resistance can be evaluated by transthoracic echo looking at left anterior descending (LAD)
artery flow, by MRI perfusion or by PET scan, while arteriolar dysregulation requires
assessment of endothelial function with intracoronary acetylcholine infusion; treatment
approaches are outlined. For refractory angina, several of the non-pharmacological treatments
have now been included in the new guidelines with class IIb recommendations: enhanced
external counter pulsation, coronary sinus constriction and spinal cord stimulation. However,
based on the available data, autologous cell therapy is not recommended.
Long-term follow-up of patients with CCS

This is a new chapter of special interest to the office-based practicing cardiologist. An annual
evaluation by a cardiovascular practitioner is warranted, even if the patient is asymptomatic. It
may be beneficial to evaluate LV function and test for ischaemia every 3-5 years, even in
asymptomatic patients. The recommendations are nicely illustrated in nice figures (Figure 10
and 11)
Figures 10 & 11. Recommendations for long-term follow-up in CCS.
With permission of Oxford University Press on behalf of the European Society of Cardiology
From reference [1]. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis
and management of chronic coronary syndromes: The Task Force for the diagnosis and
management of chronic coronary syndromes of the European Society of Cardiology (ESC). Eur
Heart J. 2019 Aug 31. [Epub ahead of print].
References

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management of dyslipidaemias of the European Society of Cardiology (ESC) and European
Atherosclerosis Society (EAS). Eur Heart J. 2019; ehz455. 
7. Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, Cooney MT, Corrà U,
Cosyns B, Deaton C, Graham I, Hall MS, Hobbs FDR, Løchen ML, Löllgen H, Marques-Vidal
P, Perk J, Prescott E, Redon J, Richter DJ, Sattar N, Smulders Y, Tiberi M, van der Worp HB,
van Dis I, Verschuren WMM, Binno S; ESC Scientific Document Group. 2016 European
Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force
of the European Society of Cardiology and Other Societies on Cardiovascular Disease
Prevention in Clinical Practice. Eur Heart J. 2016;37:2315-81. 
8. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA,
Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ,
Seferovic PM, Sibbing D, Stefanini GG, Windecker S, Yadav R, Zembala MO; ESC Scientific
Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J.
2019;40:87-165. 
9. AHA scientific sessions 2019  ISCHEMIA - International Study of Comparative Health
Effectiveness With Medical and Invasive Approaches: Primary Report of Clinical Outcomes 

Notes to editor

Author:
Per Anton Sirnes, MD, PhD, FESC
Cardiology Practice
Ostlandske Hjertesenter, Moss, Norway
 
Address for correspondence:
Dr. Per Anton Sirnes,
Østlandske Hjertesenter,
Lilleeng Helsepark, Lilleengvn 8, 1523 Moss, Norway
E-mail: pas@cardio.no
 
Author disclosures:
The author has in the last 5 years received travel grants, lecture and advisory board fees from
Amgen, Sanofi, Bayer, Novo-Nordisk,  Novartis, Boehringer, MSD.
The content of this article reflects the personal opinion of the author/s and is not necessarily the official
position of the European Society of Cardiology.

Our mission: To reduce the burden of cardiovascular disease.

 

   

29 AUG 2020

NSTEMI

What’s new in the 2020 ESC Clinical Practice

Guideline on the management of acute
coronary syndromes in patients presenting
without persistent ST-segment elevation
(NSTE-ACS)?
Reported from the European Society of Cardiology ESC
Congress 2020 Digital Experience
Majority of ischemic heart disease patients present with NSTEACS . Management
of NSTEACS starts with correct diagnosis, appropriate timely initiation of the right
pharmacotherapy, provision of coronary angiography/intervention procedures and
secondary preventative care. 5 years on from the last ESC NSTEACS guidelines,
what does the new 2020 guidelines offer that will impact or change our practice
today?

For the first time ever, the ESC Annual Scientific Congress #ESCCongress is
being held virtually (“The Digital Experience”) as a consequence of the COVID-
19 pandemic! However this does not seem to have dampened the enthusiasm of
attendance at the congress with this year’s ESC Congress showing record number
of registrations of >100K on day 1 and perhaps turning it into “The Digital
Revolution” of cardiovascular learning and sharing!

In 2020, outwith the pandemic, cardiovascular disease in particular ischaemic

(coronary) heart disease still remains world’s number 1 killer! The ESC’s mission is
to reduce the global burden of cardiovascular disease. One of the major highlights
of the yearly ESC congress is the publication of ESC Clinical Practice Guidelines
(CPG) on various topics that provide recommendations on the best care for our
patients based on best evidence. This year among the 4 CPGs that are published
we have the new 2020 ESC CPG on the management of acute coronary
syndromes in patients presenting without persistent ST-segment elevation co-
chaired by Professors Collet and Thiele (1). The other 2020 ESC CPGs are on
Sports Cardiology/Physical Activity, Atrial Fibrillation and Adult Congenital Heart
Disease

How will these new guidelines impact practice today?

Majority of ischemic heart disease patients present with non ST segment
elevation acute coronary syndrome (NSTEACS). Management of NSTEACS
starts with correct diagnosis, appropriate timely initiation of the right
pharmacotherapy, provision of coronary angiography/intervention procedures and
secondary preventative care. 5 years on from the last ESC NSTEACS guidelines
(2), what does the new 2020 guidelines offer that will impact or change our practice
today?

First of all the 2020 ESC NSTEACS guidelines has introduced new sections on the
following important topics:

 Myocardial infarction with non-obstructed coronary arteries (MINOCA)

 Spontaneous coronary artery dissection (SCAD)
 Quality indicators in NSTE-ACS treatment
The new ESC NSTEACS guidelines also offers recommendations on new or
revised concepts on the following:

 Rapid rule-in and rule-out algorithms

 Risk stratification for an early invasive approach
  Definition of high bleeding risk
 Definition of very high and high-ischaemic risk
 The gap in evidence and corresponding randomized trials to be performed

Clinical evaluation: Always back to basics!

The COVID-19 pandemic resulted in halving heart attack admissions worldwide
due to fear of hospital visits among many potential reasons behind this.
However, NSTEACS can be a life threatening condition and therefore seeking
help when the symptoms occur is vital to save lives and to avoid future
complications including heart failure.

The new ESC guidelines have indeed emphasized the importance of evaluation of
clinical presentation and provide the following description of clinical presentation in
the context of NSTEACS : “Typical chest discomfort is characterized by a
retrosternal sensation of pain, pressure or heaviness (‘angina’) radiating to the left
arm, to both arms or to the right arm, neck or jaw, which may be intermittent
(usually lasting several minutes) or persistent. Additional symptoms such as
sweating, nausea, epigastric pain, dyspnoea and syncope may be present.
Atypical presentations include isolated epigastric pain, indigestion-like symptoms
and isolated dyspnoea or fatigue. Atypical complaints are more often observed in
the elderly, in women and in patients with diabetes, chronic renal disease or
dementia. The exacerbation of symptoms by physical exertion and their relief at
rest increase the probability of myocardial ischaemia”.

Diagnosis and strategy

Starting with the diagnosis, the new 2020 ESC guidelines, recommends ESC
0h/2h-algorithm with blood sampling at 0 h and 2 h from 0h, if a high-sensitivity
cardiac troponin test with a validated 0 h/2 h algorithm is available.

Invasive strategy: In terms of the invasive strategy, an immediate invasive

strategy (<2 h) is recommended in patients with at least one of the very-high-risk
criteria.

 Haemodynamic instability or cardiogenic shock

 Recurrent or refractory chest pain despite medical treatment
 Life-threatening arrhythmias or cardiac arrest
 Mechanical complications of MI
 Heart failure clearly related to NSTE-ACS
 Presence of ST-segment depression >1 mm in ≥6 leads additional to ST-segment
elevation in aVR and/or V1
It should however be noted that such patients are often excluded from
randomised clinical trials reflecting a gap in robust evidence for the above
very high risk patients and the need for further research.
An early invasive strategy within 24 h is recommended in patients with any of the
high-risk criteria:

 Dynamic or presumably new contiguous ST/S-segment changes suggesting

ongoing ischemia
 Transient ST-segment elevation
 GRACE risk score >140
The above recommendations regarding the timing of early invasive strategy
within 24 hours are based on findings from meta-analysis once again
emphasising the need for robust RCTs to provide definitive answers. Thus
reiterating the need for careful evaluation of patient selection with regards to
the timing of invasive strategy in NSTEACS . Of note, none of the meta-analysis
observed a benefit with an early invasive strategy with respect to the endpoints
death, non-fatal MI, or stroke among unselected NSTE-ACS patients but showed a
lower risk of recurrent/refractory ischaemia and a shorter length of hospital stay
with invasive strategy. The new guidelines also recommends complete
revascularisation should be considered in NSTE-ACS patients without cardiogenic
shock and with multi-vessel CAD.

Among low risk patients, a selective invasive strategy or non-invasive imaging to

guide invasive coronary angiography is recommended. CCTA is recommended as
an alternative to invasive coronary angiography to exclude acute coronary
syndrome when there is a low-to-intermediate likelihood of coronary artery disease
and when cardiac troponin and/or ECG are normal or inconclusive (IA
recommendation). For MINOCA patients, it is recommended to perform CMR in all
patients without an obvious underlying cause.

Pharmacotherapy
In terms of pharmacotherapy, it is no longer recommended to administer routine
pre-treatment with a P2Y12 receptor inhibitor to patients in whom the coronary
anatomy is not known and early invasive management is planned. ASA continues
to be recommended for all patients without contraindications for long-term
treatment. A P2Y12 inhibitor is recommended in addition to aspirin, and maintained
over 12 months unless there are contraindications or an excessive risk of bleeding.
Based on the ISAR REACT 5 trial, the new guidelines has recommended
Prasugrel should be preferred over ticagrelor for NSTE-ACS patients who proceed
to PCI. In patients with non-valvular atrial fibrillation (CHA2DS2-VASC score ≥ 1 in
men and ≥2 in women), a very short period of triple therapy (up to 1 week from the
acute event) is recommended followed by dual antithrombotic therapy using a
NOAC at the recommended dose for stroke prevention and single oral antiplatelet
agent (by preference clopidogrel).
Risk assessments
In terms risk assessments, the new guideline continues to support (IIB evidence)
regarding the use of GRACE risk score models for estimating prognosis. In terms
of bleeding risk, CRUSADE bleeding risk score may be considered in patients
undergoing coronary angiography. An alternative score may be the bleeding risk
assessment according to the Academic Research Collaboration-High
Bleeding Risk (ARC-HBR). The DAPT and the PRECISE-DAPT (PREdicting
bleeding Complications In patients undergoing Stent implantation and subsEquent
Dual Anti Platelet Therapy), were designed to guide and inform decision making on
DAPT duration. However given none of these risk prediction models have been
prospectively tested in the setting of RCTs, their value in improving patient
outcomes remains unclear.

Treating an ageing population: special groups

Special groups: Our population is ageing. Up to 50% of patients who suffer
NSTEACS are aged 70 years of age and over. Though there are many
observational studies, adequately powered large RCTs in older patients with
NSTEACS is currently lacking. There has been 1 small RCT (the After Eighty
Study, n=457) that has been published since the 2015 NSTEACS guidelines which
showed reduction in MI and urgent revascularisation using the invasive strategy
with no difference in death, stroke or bleeding. Based on this small study, the 2020
NSTEACS guideline committee recommend (Evidence 1B) to offer the same
diagnostic and interventional strategies to older patients as younger
patients. Importantly, given a lot of the evidence is based on studies among
younger patients, the guideline acknowledges the need for more robust
studies to definitively answer many unanswered questions in older people
with NSTEACS .

Quality Indicators
Finally, Quality indicators (QIs) are sets of measures that enable the quantification
of adherence to guideline recommendations. It consists of seven domains: (1)
centre organization, (2) the reperfusion/invasive strategy, (3) in-hospital risk
assessment, (4) antithrombotic treatment during hospitalization, (5) secondary
prevention discharge treatments, (6) patient satisfaction, and (7) composite QI risk-
adjusted 30-day mortality. The ESC 2020 NSTEACS guidelines have now
incorporated this to measure opportunities to improve care and outcomes for our
patients.

Conclusion: despite progress, gaps in knowledge require further

evaluation to improve patient outcomes!
Despite significant progress and advances in the care of NSTEACS patients,
the ESC 2020 NSTEACS guidelines also highlight a number of gaps in
knowledge in NSTEACS care which require further evaluation emphasizing the
need for completion of ongoing studies and further ongoing research to continue to
improve the care we provide to our patients, to improve their outcomes!

References

1. 2020 ESC Guidelines for the management of acute coronary syndromes in patients

presenting without persistent ST-segment elevation: The Task Force for the
management of acute coronary syndromes in patients presenting without persistent
ST-segment elevation of the European Society of Cardiology (ESC)

2. 2015 ESC Guidelines for the management of acute coronary syndromes in patients

presenting without persistent ST-segment elevation: Task Force for the Management
of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment
Elevation of the European Society of Cardiology (ESC)

Pronóstico de los pacientes con disfunción

ventricular izquierda y cardiopatía isquémica
estable conocida o sospechada. Importancia
del miocardio en riesgo más allá del
miocardio viable
  
  
  
  
  
  


 Dr. Vicente Bodí Peris

 

 Isquemia/Angina - Cardiopatía Isquémica

 20 Octubre 2014

Comentario del Autor: Dr. Vicente Bodí Peris

La insuficiencia cardiaca constituye una de las principales causas de mortalidad y

morbilidad en nuestro entorno. Aproximadamente la mitad de los pacientes con
insuficiencia cardiaca presentan disfunción sistólica del ventrículo izquierdo. La cardiopatía
isquémica es una de las causas más prevalentes de insuficiencia cardiaca con disfunción
sistólica y se asocia a un peor pronóstico. Desde hace varias décadas convivimos con el
concepto de viabilidad miocárdica: la presencia de miocardio potencialmente recuperable
abre una esperanza a este tipo de pacientes de tal manera que mediante la revascularización
podría lograrse una mejora de la contractilidad y potencialmente del pronóstico.

Pronóstico de los pacientes con disfunción ventricular izquierda y cardiopatía isquémica estable
conocida o sospechada. Importancia del miocardio en riesgo más allá del miocardio viable

Este paradigma ha entrado sin embargo en cierta controversia cuando se ha testado en

ensayos aleatorizados recientes como el STICH y sus subestudios. Si bien una mayor
cantidad de miocardio se asocia a mejor pronóstico, la revascularización quirúrgica de los
pacientes con disfunción sistólica y miocardio viable no siempre conlleva una reducción del
riesgo. En los pacientes con cardiopatía isquémica estable y disfunción sistólica existe un
factor similar al de viabilidad, pero no idéntico, que quizás ha quedado algo relegado: la
isquemia miocárdica.

En la actualidad las técnicas de imagen y en especial la resonancia magnética cardiaca de

estrés permiten una valoración integral del paciente con cardiopatía isquémica. En una sola
sesión es posible valorar, entre otros índices, la función sistólica, la necrosis (a partir de la
captación tardía de gadolinio) y la isquemia miocárdica (mediante el análisis de los
defectos de perfusión inducidos con el estrés). En el presente estudio planteamos analizar el
papel pronóstico de la necrosis miocárdica (miocardio no viable) y la isquemia (miocardio
en riesgo) en pacientes estudiados con resonancia magnética cardiaca de estrés por
disfunción sistólica y cardiopatía isquémica estable conocida o sospechada.

Se trata de un registro prospectivo multicéntrico que incluyó a todos los pacientes remitidos
desde 2003 a 2010 por disfunción sistólica y cardiopatía isquémica estable conocida o
sospechada para estudio con resonancia magnética cardiaca de estrés con dipiridamol. De
532 pacientes valorados, finalmente se incluyeron 391 con una fracción de eyección media
del 39% en los que aproximadamente la mitad ya se conocía la presencia de cardiopatía
isquémica (se remitían para toma de decisiones) y la otra mitad se remitían para filiar la
etiología de la disfunción ventricular. Nos centramos en la predicción de eventos mayores
(n=47, 12%), muerte (n=25) o infarto (n=22), durante un seguimiento medio aproximado de
2 años.

De manera interesante, la variable más potente asociada con el pronóstico fue la presencia y
la magnitud de la isquemia miocárdica. Los pacientes con isquemia miocárdica (en más de
2 segmentos) presentaron una mayor probabilidad de eventos mayores (17% frente a 5%,
p<0,001). La extensión de la isquemia fue mayor en los pacientes con eventos mayores (6
segmentos frente a 3 segmentos, p <0,001). Más aún, en el estudio multivariado sólo la
edad y la isquemia miocárdica (que multiplicó por 2,86 el riesgo de evento mayor) fueron
predictores independientes de eventos mayores durante el seguimiento. Respecto a la
necrosis miocárdica se detectó una tendencia a más extensión en los pacientes con eventos.
Sin embargo no fue un predictor independiente tras el ajuste por la isquemia miocárdica.
Más aún, en ausencia de isquemia, la presencia de necrosis se asoció a un riesgo de eventos
mayores igual a los pacientes sin isquemia ni necrosis (7% frente a 5%). La presencia de
necrosis (en más de 2 segmentos) sólo incrementó de manera significativa el riesgo de
eventos mayores (16%) si ocurría simultáneamente con la isquemia miocárdica.

Nuestro estudio sugiere que en los pacientes con disfunción ventricular, la presencia y la
extensión de la isquemia miocárdica juegan un papel crucial en el pronóstico de tal manera
que son aquellos casos con isquemia los que presentan una tasa más elevada de eventos
mayores, muerte o infarto, a largo plazo. En paralelo a los datos derivados de ensayos
recientes, la extensión de la necrosis se asoció a más eventos pero esta asociación fue
mucho más débil que en el caso de la isquemia.

El diagnóstico etiológico y la estratificación de riesgo de los pacientes con disfunción

ventricular son procesos complejos. La resonancia magnética cardiaca es una técnica ideal
para la valoración integral de los pacientes con estas características pues permite en una
misma sesión y con alta fiabilidad cuantificar la función sistólica, la extensión del
miocardio viable/necrótico y la isquemia. La validación pronóstica de esta técnica se había
realizado en poblaciones no seleccionadas de pacientes con cardiopatía isquémica conocida
o sospechada.

El presente estudio demuestra, por una parte, el potencial de la resonancia magnética

cardiaca de estrés para predecir el riesgo de eventos mayores en pacientes con disfunción
ventricular; los resultados sugieren la necesidad de analizar no sólo la extensión de la
necrosis o del miocardio viable residual sino también de la isquemia miocárdica. Podría
ahora especularse que la resonancia magnética cardiaca de estrés puede ser útil para
detectar a los pacientes con disfunción ventricular izquierda, cardiopatía isquémica estable
e isquemia severa que pueden beneficiarse de la revascularización coronaria en términos de
reducción de eventos mayores. En cualquier caso, el estudio comentado debe entenderse en
el campo de la estratificación pronóstica, las implicaciones en cuanto a toma de decisiones
requieren de estudios aleatorizados diseñados a tal efecto.

Enlaces:
1. PubMed - Prognostic value of myocardial ischemia and necrosis in depressed left
ventricular function: a multicenter stress cardiac magnetic resonance registry »