ESC Updates Guidelines for Treating STEMI Patients

BARCELONA, Spain—The European Society of Cardiology (ESC) has issued new guidelines for the management of acute MI patients presenting with ST-segment elevation, placing a new emphasis on the use of radial access, drug-eluting stents, and complete revascularization as part of their upgraded recommendations.  

“While being evidence-based, we feel the guidelines are very user-friendly,” Stefan James, MD (Uppsala University, Sweden), the chair of the task force charged with drafting the 2017 guidelines, told TCTMD. “We want clinicians to be able to use it and find answers to most of their clinical questions. We hope that this will be a didactic, educational product as well as a scientifically-based protocol.”

The end product, he said, is designed to be not only practical, but readable. “If nobody’s reading them, they’re not going to be used and they’re not going to have an effect on patient care,” said James.

The new guidelines, which were released here at the ESC Congress and published in the European Heart Journal, include a number of changes from the 2012 recommendations. One of the major changes is that physicians may now consider complete revascularization for STEMI patients (class IIa) based on clinical trials such as PRAMI, CVLPRIT, and DANAMI-3-PRIMULTI, among others. Complete revascularization during the index PCI also applies to the STEMI patient in shock.

Five years ago, the ESC recommended against complete revascularization.

Clarifying Patients Eligible for Primary PCI

Transradial access gets a significant boost in the new guidelines, as does the preferential use of drug-eluting stents over bare-metal stents. Transradial access and use of DES are both class I recommendations, an upgrade from the class IIa recommendation in 2012. Thrombus aspiration is no longer recommended in STEMI cases (class III).

Additionally, James told TCTMD that the report helps clarify which patients are eligible for primary PCI. While patients with ST-segment elevation should undergo primary PCI, some individuals can present with atypical electrocardiographic presentations. These include patients with left bundle branch block, ventricular paced rhythms, and ST depressions resulting from an isolated posterior MI or ischemia due to left main coronary artery occlusion/multivessel disease.

“As long as the patient has symptoms and the clinical evaluation points to the occlusion of a coronary artery, the patient should be sent for an angiography for diagnostic purposes,” said James. “Also, patients without any ECG changes, but who are at high risk for coronary occlusion and have symptoms aligned with that, they should also undergo early angiography as a diagnostic procedure.”

The guidelines also include a new section on how to manage MI patients with nonobstructive coronary arteries. James notes that a sizeable proportion of MIs, in the range of 1% to 14%, occur in patients without significant obstructions. The 2017 guidelines provide recommendations for how to diagnose and treat these patients, including directions on the use of invasive and noninvasive testing.

Advising on Medication Use

Regarding antithrombotic medications, use of bivalirudin has been downgraded and enoxaparin (as an alternative to heparin) upgraded, with both agents now given a class IIa indication for use. Citing the CHAMPION-PHOENIX study, the ESC recommends use of cangrelor (Kengreal, The Medicines Company) in the catheterization laboratory (class IIa) if P2Y12 inhibitors have not been administered, with glycoprotein IIb/IIIa inhibitors reserved for bailout situations.

“We don’t recommend against the use of IIb/IIIa inhibitors, but the evidence is now old and not really up to date,” said James. “It has a stronger recommendation for bailout, but for routine use we don’t give a specific recommendation anymore.”

There are several new recommendations in 2017, including an emphasis on LDL-cholesterol lowering. For patients treated with maximally tolerated statin therapy, if LDL cholesterol is greater than 70 mg/dL, the ESC recommends additional LDL lowering (class IIa). Although they do not mention specific drugs, they cite the IMPROVE-IT study with ezetimibe (Zetia, Merck/Schering-Plough) and FOURIER with evolocumab (Repatha, Amgen) as support for the recommendation.

The ESC advises physicians to switch to a more potent P2Y12 inhibitor 48 hours after fibrinolysis and to extend ticagrelor for 36 months in high-risk patients (both class IIb). The latter recommendation is based on data from the PEGASUS-TIMI 54 study.

Finally, the ESC task force provides recommendations on the use of quality indicators for the assessment of care. These include various quality indicators that can be used at the institution level, as well as measures for assessing reperfusion therapy and antithrombotic treatment, among other metrics.