2015 edition clinical decision-making toolkit · the acca clinical decision-making toolkit is...
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A Registered Branch of the ESC
AcuteCardiovascularCare Association
ACUTE CARDIOVASCULAR CARE ASSOCIATION
TOOLKITCLINICAL DECISION-MAKING
2015 EDITION
www.escardio.org/ACCA
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The ACCA Clinical Decision-Making Toolkit is produced by the Acute Cardiovascular Care Association. Developed and distributed through an educational grant from AstraZeneca and Novartis Pharma AG.AstraZeneca and Novartis Pharma AG were not involved in the development of this publication and in no way infl uenced its contents.
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ISBN: 978-2-9537898-4-3
Héctor Bueno, M.D., PhD., FESC, FAHA Editor in Chief
Pascal Vranckx, MD, PhDAssociate Editor
Eric Bonnefoy, MD, PhDAssociate Editor
A Registered Branch of the ESC
AcuteCardiovascularCare Association
The Acute Cardiovascular Care Association Clinical Decision-Making
TOOLKITp.I
I
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Preface
The best care of patients with acute cardiovascular syndromes relies not only on specialists but also on systems of care that involve many non-cardiologists. Several of these syndromes require immediate diagnosis and decisions on treatment, some of them life-saving. Critical decisions must often be made quickly by professionals with different backgrounds and levels of expertise with limited resources. This poses a signifi cant clinical challenge. Against this background, the ACCA Clinical Decision-Making Toolkit was created as a comprehensive resource encompassing all aspects of acute cardiovascular care but structured as an easy-to-use instrument in environments where initial acute cardiovascular care is typically initiated. Comprehensive tables, clear diagrams and algorithms, based on the ESC clinical practice guidelines as well as in clinical experience should provide diagnostic and therapeutic guidance at a glance.The Second Edition of the ACCA Toolkit has been updated with the 2014 and 2015 ESC Guidelines, and enriched with a new chapter with up-to-date coverage of drugs most frequently used in acute cardiovascular care. However, it does not replace textbooks and other sources of information that need to be consulted to reach an optimal management of these patients.
The ACCA Toolkit is available through different platforms:Printed booklet, available at congresses where ESC-ACCA is representedWeb-based pdf fi le downloadable at www.escardio.org/ACCAMobile application for smartphones/tablets available in both Apple & Googleplay stores
Héctor Bueno, M.D., PhD., FESC, FAHAEditor in Chief
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ContentsList of Authors ............................................................................................................................................................................................................................................................................................................................... Page IVChapter 1: KEY SYMPTOMS
Chest Pain - M. Lettino, F. Schiele ........................................................................................................................................................................................................................................................ Page 2Dyspnea - C. Müller ......................................................................................................................................................................................................................................................................................................... Page 9Syncope - R. Sutton .......................................................................................................................................................................................................................................................................................................... Page 16
Chapter 2: ACUTE CORONARY SYNDROMES General concepts - H. Bueno ...................................................................................................................................................................................................................................................................... Page 24Non ST-segment elevation ACS - H. Bueno .................................................................................................................................................................................................................. Page 29STEMI - D. Zahger, P. Clemmensen .................................................................................................................................................................................................................................................. Page 35
Chapter 3: ACUTE HEART FAILURE Heart failure and pulmonary oedema - I.C.C. van der Horst, G. Filippatos ................................................................................................... Page 40Cardiogenic shock - P. Vranckx, U. Zeymer .................................................................................................................................................................................................................... Page 49
Chapter 4: CARDIAC ARREST AND CPR - N. Nikolaou, L. Bossaert ..................................................................................................... Page 57Chapter 5: RHYTHM DISTURBANCES
Supraventricular tachycardias and atrial fi brillation - J. Brugada .......................................................................................................................................... Page 66Ventricular tachycardias - M. Santini, C. Lavalle, S. Lanzara ............................................................................................................................................................ Page 70 Bradyarrhythmias - B. Gorenek .............................................................................................................................................................................................................................................................. Page 73
Chapter 6: ACUTE VASCULAR SYNDROMES Acute aortic syndromes - A. Evangelista .............................................................................................................................................................................................................................. Page 78Acute pulmonary embolism - A. Torbicki ........................................................................................................................................................................................................................... Page 88
Chapter 7: ACUTE MYOCARDIAL/PERICARDIAL SYNDROMES Acute myocarditis - A. Keren, A. Caforio ............................................................................................................................................................................................................................ Page 98Acute pericarditis and cardiac tamponade - C. Vrints, S. Price ............................................................................................................................................... Page 103
Chapter 8: DRUGS IN ACUTE CARDIOVASCULAR CARE - A. de Lorenzo ............................................................. Page 107Abbreviations ................................................................................................................................................................................................................................................................................................................................... Page 145
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List of Authors• Leo Bossaert Department of Medicine, University and University Hospital Antwerp, Antwerp, Belgium• Josep Brugada Department of Cardiology, Hospital Clinic Universitat de Barcelona, Barcelona, Spain• Héctor Bueno Department of Cardiology, Hospital Universitario 12 de Octubre and Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain• Alida Caforio Department of Cardiology, Padua University Medical School, Padua, Italy• Peter Clemmensen Department of Cardiology, Rigshospitalet Copenhagen University, Copenhagen, Denmark• Artur Evangelista Department of Cardiology, Hospital Universitario Vall d’Hebrón, Barcelona, Spain• Gerasimos Filippatos Department of Cardiology, Attikon University Hospital, Athens, Greece• Bulent Gorenek Department of Cardiology, Eskisehir Osmangazy University, Eskisehir, Turkey• Andre Keren Heart Failure and Heart Muscle Disease Center, Hadassah University Hospital, Jerusalem, Israel• Stefania Lanzara Department of Emergency, Ospedale Madre Giuseppina Vannini, Rome, Italy• Carlo Lavalle Department of Cardiology, Ospedale San Filippo Neri, Rome Italy• Maddalena Lettino Clinical Cardiology Unit, IRCCS Istituto Clinico Humanitas, Milano, Italy• Ana de Lorenzo Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain• Christian Müller Department of Cardiology, University Hospital Basel, Basel,Switzerland• Nikolaos Nikolaou Departement of Cardiology, Konstantopouleio General Hospital, Athens, Greece• Susanna Price Consultant Cardiologist & Intensivist, Royal Brompton Hospital, London, United Kingdom• Massimo Santini Department of Cardiology, Ospedale San Filippo Neri, Rome, Italy• François Schiele Department of Cardiology, University Hospital Jean-Minjoz, Besancon, France• Richard Sutton Department of Cardiology, National Heart and Lung Institute Imperial College, London, United Kingdom • Adam Torbicki Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of Postgraduate Medical Education, ECZ Otwock, Poland• Iwan C.C. van der Horst Department of Critical Care. University Medical Center Groningen, Groningen, The Netherlands• Pascal Vranckx Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium• Christiaan Vrints Department of Cardiology, Antwerp University Hospital, Edegem, Belgium• Doron Zahger Department of Cardiology, Soroka Univ, Medical Center, Beer Sheva, Israel• Uwe Zeymer Department of Cardiology, Herzzentrum Klinikum Ludwigshafen, Ludwigshafen, Germany
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CHAPTER 1: KEY SYMPTOMS
1.1 CHEST PAIN �������������������������������������������������������������������������������������������������������������������������������������� p�2M� Lettino, F� Schiele
1.2 DYSPNEA ���������������������������������������������������������������������������������������������������������������������������������������������� p�9C� Müller
1.3 SYNCOPE ������������������������������������������������������������������������������������������������������������������������������������������� p�16R� Sutton
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1. Presentation
2. ECG
3. Troponin
4. Diagnosis
STEMI = ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction; UA = unstable angina.Reference:RoffietAl.EurHeartJ2015;eurheartj.ehv320
LowLikelihood HighLikelihood
Noncardiac OtherCardiacUA STEMINSTEMI
p.2Initial assessment of patients with CHEST PAIN 1.1
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First call for chest pain Higher risk / probability Lower risk / probability
Arguments for vital risk
• Cardiorespiratory arrest, syncope / loss of consciousness, neurological defect
• Dyspnea• Nausea – vomiting• Arrhythmias–tachycardia
• Normal consciousness• Normalbreathing
(see chapter 1.2 page 9)• Normalheartrhythm
Context, CV risk Age>40years,previousCVdisease(MI,stroke,PE),modifiableCVriskfactors(smoker,HTN,hypercholesterolemia,diabetes),chronicCVtreatment
• Age<40years,• NopreviousCVdisease• NoCVriskfactors• Nochronictreatment
Chest Pain Medial/lateralthoracicpain,intense, withdyspnea
• Depends on position/ palpation/ movements
• Variableintensity,shortduration(<1min)• Hyperthermia
Cardiac Ischemic Pain
Retro-sternal,constriction,jaw/cervical/arm/backirradiation,spontaneous,prolonged>20min+dyspnea,sweating,lightheadedness,nausea
• Lateral, abdominal irradiation • No neuro-vegetative symptoms
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Factors to be considered in the evaluationafter the first call for CHEST PAIN 1.1
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NoYes
Origin of Chest Pain?
High probability for ACS Low probability for ACS
Emergency transportwith trained medical team
ECG, decision for reperfusion,antithrombotics, immediate
transport to ED/cathlab(see chapter 2)
Acute Cardiac Disease
Emergency transport
No Acute Cardiac Disease
Emergency transportwith trained medical team
Hospital admission to theEmergency Department
Emergency care: Resuscitation, hemodynamic or
rhythm restoration (see chapter 4)
Cardiology ward
Non-cardiology ward
Discharge afterprolonged observation
APPROACH AFTER FIRST CALL FOR OUT-OF-HOSPITAL CHEST PAIN
Arguments for vital risk? (see chapter 1.1 page 3(see chapter 1.1 page 3( )
p.41.1Approach after fi rst call for out-of-hospital CHEST PAIN
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NoYes
Origin of Chest Pain?
High probability for ACS Low probability for ACS
Emergency transportwith trained medical team
ECG, decision for reperfusion,antithrombotics, immediate
transport to ED/cathlab(see chapter 2)
Acute Cardiac Disease
Emergency transport
No Acute Cardiac Disease
Emergency transportwith trained medical team
Hospital admission to theEmergency Department
Emergency care: Resuscitation, hemodynamic or
rhythm restoration (see chapter 4)
Cardiology ward
Non-cardiology ward
Discharge afterprolonged observation
APPROACH AFTER FIRST CALL FOR OUT-OF-HOSPITAL CHEST PAIN
Arguments for vital risk?
p.51.1
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First medical contact Higher risk / probability Lower risk / probability
Hemodynamic, respiratory, neurological distress
• Cardiopulmonaryarrest,hypotension, tachycardia,shock
• Dyspnea,hypoxemia,lungrales(Killipclass>2)• ECG: ST segment deviation
• Normal consciousness, no motion defects• NormalHRandBP• NormalbreathingandSpO2, no loss
of pulse
Probability for ACS
• Context,typicalsymptomsconsistentwith myocardialischemia
• ECGchanges• BedsideTn
• NoCVrisk,atypicalsymptoms,normalECG
• Negative bedside Tn only if onset of pain >6hours(see chapter 2.1 page 24)
STEMI NSTEACS Uncertain diagnosis (see chapter 2.1 page 24)
• ECG criteria for STEMI (see chapter 2.3 page 35)
• ST depression or normal ECG• Normal ECG →Repeat12-leadECGrecording
• OtherST-segmentabnormalitiesnotrelated to STEMI (see chapter 2.3)
Type of reperfusion
Time assessment
• Primary PCI or thrombolysis? Primary PCIifdelay<120(preferably<90)minor <60minifonsetofpain<120min Consider age, anterior wall location
• Times:Onsetofpain,call,firstmedicalcontact,ECG,door,ballooninflationorneedle(lytic drug) administration
• Noreperfusionifdelay>12h, no symptoms, no ST-segment elevation
p.61.1Factors to be considered in the evalutation
during the first medical contact for CHEST PAIN
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Yes
Resuscitation, hemodynamic or respiratory support
(see chapters 3 & 4)
Type of reperfusion (primary PCI or fibrinolysis)Record times (onset, call, contact)
High probability Low probability
No
FIRST MEDICAL CONTACT IN PATIENTS WITH CHEST PAIN (HOME-AMBULANCE)
Hemodynamic, respiratory or neurological distress? (see chapter 1.1 page 8)
ST-segment elevation
ECG <10 min → ACS ?
No ST-segment elevation butother ECG changes or persistent pain
Suspect ACS Uncertain diagnosis
No antithrombotic treatmentTransfer to a proximity center
(with or without cath-lab)Start antiplatelet and anticoagulant treatment
Transfer to a center with cath-lab
Non cardiovascular disease? • Sepsis • Acute respiratory distress • GI disease, bleeding, others
Acute cardiovascular disease other than ACS? • Acute aortic syndrome (see chapter 6) • Pulmonary embolism (see chapter 6) • Acute pericarditis (see chapter 7) • Acute heart failure (see chapter 3)
p.71.1First medical contact in patients with CHEST PAIN (home-ambulance)
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• Diagnosis of NSTEACS (see chapter 2)• Acute aortic syndrome (see chapter 6)• Acute pulmonary embolism (see chapter 6)• Acute pericarditis (see chapter 7)• Acute heart failure (see chapter 3)• Aortic stenosis, hyperthrophic cardiomyopathy• Acute gastro-oesophageal disease• Acute pleuro-pulmonary disease• Acute psychogenic disorders
Repeat clinical and ECG examinationLaboratory: Tn, renal function, Hb,D-dimers Imaging: TTE, CT scanDiagnostic coronary angiography
Yes No
MANAGEMENT OF PATIENTS WITH CHEST PAIN (EMERGENCY ROOM)Hemodynamic, respiratory or neurological distress? (see chapter 1.1 page 6)
STEMI,NSTEACS with persistent pain,
Hemodynamic distress
No direct transfer to cath-lab → ED, Chest Pain Unit,
cardiology ward, other wards
Other CVD or No ACS
Resuscitation, hemodynamic or respiratory support
(see chapters 3 & 4)
Direct transfer to cath-lab
STEMI (see chapter 2)
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Management of patients with CHEST PAIN (emergency room) 1.1
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DYSPNEA: DIFERENTIAL DIAGNOSIS
50% have ≥2 diagnoses, which may result in acute respiratory failure*!
• ECG • Chest X-ray • Blood count • Tn • BNP • Venous BG • D-dimers if suspicion of PE
Basic measures
• BP, HR, respiratory rate, SpO2 & temperature • Start oxygen to target SpO2 94-98% • Start i.v. line & monitor patient
Criteria for transfer to ICU (despite treatment for 30 minutes)
• Respiratory rate >35/min • SBP <90 mmHg • SpO2 <85% • HR >120 bpm
Investigations:
Acute heartfailure
Acute coronary syndrome
Exacerbated COPDor other
chronic lung disease
Other causes, including • Asthma • Severe sepsis • Tumor • Pneumothorax • Pleural effusion/ascites • Anxiety disorder • Anemia • Bronchitis • Metabolic acidosis • Neurologic disease
Pneumonia Pulmonaryembolism
* Defined as ≥1 criterion: • Respiratory rate ≥25/min • PaO2 ≤75 mmHg • SpO2 ≤92% in ambient air • PaCO2 ≥45 mmHg with arterial pH ≤7.35
Reference:RayPetal.Acuterespiratoryfailureintheelderly:etiology,emergencydiagnosisandprognosis.CriticalCare(2006),10(3):R82.
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DYSPNEA: Diferential diagnosis 1.2
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DYSPNEA: ACUTE HEART FAILURE (see chapter 3.1)
BASIC WORK-UP• Immediate 12-lead ECG, cardiac monitor, BP, respiratory rate, pulse oximetry• Clinical findings Most commonly: lower extremity edema, jugular venous distension, rales; work up for underlying cardiac disease and triggers• Laboratory findings Complete blood count, chemistries, cardiac enzymes, BNP, TSH, ABG as needed
• Chest X-ray (lung ultrasound)• Echocardiogram During admission (earlier if decompensated aortic stenosis or endocarditis are suspected)• Coronary angiography Emergent in patients with ACS; delayed in patients with suspected coronary artery disease
• Positioning Keep head of bed elevated above level of legs• Oxygen Up to 12 L/min via non-rebreather, titrate oxygen saturation to 94%• Nitroglycerin 1-2 SL tablets or 2-3 patches 10 mg (1st choice). In pulmonary edema with severe shortness of breath: NTG drip 0.05% (100 mg in 200 ml) - Start with 25 µg/min = 3 ml/h, check BP after 5 and 10 min - Increase dose per SHO/attending recommendations by 25 µg/min at a time as long as SBP >90 mmHg - Additional BP check 5 and 10 min after each increase in dosing - Check BP every 20 min once a steady drip rate is reached• Furosemide 40-120 mg i.v. (adjust based on kidney function and clinical findings; monitor creatinine)• Morphine 2 mg i.v. (preceeded by 10 mg i.v. metoclopramide PRN)• Consider digoxin 0.5 (-1.0) mg i.v. in patients with atrial fibrillation• Anticoagulation Therapeutic dosing in ACS and atrial fibrillation: Enoxaparin 1 mg/kg body weight as 1st dose
Unstable after 30 minutes
CCU/ICU transfer Ward transfer
Stable after 30 minutes
p.10DYSPNEA: Acute heart failure (see chapter 3.1) 1.2
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Reference:WareLBandMatthayMA.AcutePulmonaryEdema.NewEnglJMed(2005);353:2788-2796.
DYSPNEA: ACUTE HEART FAILURE (see chapter 3.1)
BASIC WORK-UP• Immediate 12-lead ECG, cardiac monitor, BP, respiratory rate, pulse oximetry• Clinical findings Most commonly: lower extremity edema, jugular venous distension, rales; work up for underlying cardiac disease and triggers• Laboratory findings Complete blood count, chemistries, cardiac enzymes, BNP, TSH, ABG as needed
• Chest X-ray (lung ultrasound)• Echocardiogram During admission (earlier if decompensated aortic stenosis or endocarditis are suspected)• Coronary angiography Emergent in patients with ACS; delayed in patients with suspected coronary artery disease
• Positioning Keep head of bed elevated above level of legs• Oxygen Up to 12 L/min via non-rebreather, titrate oxygen saturation to 94%• Nitroglycerin 1-2 SL tablets or 2-3 patches 10 mg (1st choice). In pulmonary edema with severe shortness of breath: NTG drip 0.05% (100 mg in 200 ml) - Start with 25 µg/min = 3 ml/h, check BP after 5 and 10 min - Increase dose per SHO/attending recommendations by 25 µg/min at a time as long as SBP >90 mmHg - Additional BP check 5 and 10 min after each increase in dosing - Check BP every 20 min once a steady drip rate is reached• Furosemide 40-120 mg i.v. (adjust based on kidney function and clinical findings; monitor creatinine)• Morphine 2 mg i.v. (preceeded by 10 mg i.v. metoclopramide PRN)• Consider digoxin 0.5 (-1.0) mg i.v. in patients with atrial fibrillation• Anticoagulation Therapeutic dosing in ACS and atrial fibrillation: Enoxaparin 1 mg/kg body weight as 1st dose
Unstable after 30 minutes
CCU/ICU transfer Ward transfer
Stable after 30 minutes
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DYSPNEA: ACUTE PULMONARY EMBOLISM (see chapter 6.2)
Priorities: 1. Vital signs 2. Diagnostic screening dependent upon clinical stratification
Hemodynamically unstable Hemodynamically stable
Intermediateprobability
Total score 2-6
Highprobability
Total score >6
Lowprobability
Total score <2
Outpatient management possible?→ Risk stratification
Initiate transfer to ICU
Immediate TTE (if available)
PE confirmed: Treatment(see chapter 6.2)
Resultinconclusive→ CT-angio
Rightventriculardysfunction
Wells criteria for PE: Score• Clinical signs and symptoms of deep vein thrombosis (DVT) + 3.0• No alternative diagnosis (or alternative diagnosis less likely than PE) + 3.0• Heart rate >100/min + 1.5• Immobilization or operation within the last 4 weeks + 1.5• Previous DVT or PE + 1.5• Hemoptysis + 1.0• Malignant tumor with treatment within the last 6 months or palliative care + 1.0
ABG, ECG, chest X-ray plus clinical assessment of PE probability (risk factors) plus monitoring
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DYSPNEA: Acute pulmonary embolism (see chapter 6.2) 1.2
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Copyright:SteinPD,WoodardPK,WegJG,etal.Diagnosticpathwaysinacutepulmonaryembolism:recommendationsofthePIOPEDIIinvestigators.AmJMed(2006);119:1048–55.-GoldhaberSZ.Pulmonaryembolism.Lancet(2004);363(9417)1295-1305.-AgnelliGandBecattiniC.AcutePulmonaryEmbolism.NewEnglJMed(2010);363:266-274.
DYSPNEA: ACUTE PULMONARY EMBOLISM (see chapter 6.2)
Priorities: 1. Vital signs 2. Diagnostic screening dependent upon clinical stratification
Hemodynamically unstable Hemodynamically stable
Intermediateprobability
Total score 2-6
Highprobability
Total score >6
Lowprobability
Total score <2
Outpatient management possible?→ Risk stratification
Initiate transfer to ICU
Immediate TTE (if available)
PE confirmed: Treatment(see chapter 6.2)
Resultinconclusive→ CT-angio
Rightventriculardysfunction
Wells criteria for PE: Score• Clinical signs and symptoms of deep vein thrombosis (DVT) + 3.0• No alternative diagnosis (or alternative diagnosis less likely than PE) + 3.0• Heart rate >100/min + 1.5• Immobilization or operation within the last 4 weeks + 1.5• Previous DVT or PE + 1.5• Hemoptysis + 1.0• Malignant tumor with treatment within the last 6 months or palliative care + 1.0
ABG, ECG, chest X-ray plus clinical assessment of PE probability (risk factors) plus monitoring
(see chapter 6.2)
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DYSPNEA: COPD EXACERBATION
• Verify diagnosis (DD: PE, acute heart failure, pneumothorax) • Oxygen administration → SpO2 target 88-92% (Beware of carbonarcosis: ABC after 1 h)
Definition: Known COPD and/or • Progressive dyspnea and/or • Change in quantitiy and color of sputum and/or • Heavy coughing
• COPD classification (GOLD)
• Etiology
• Hospitalisation indicated?
• Follow-up
• Evaluate ICU criteria• NIV indicated?
• Laboratory findings: Blood count, coagulation, ProCT, perhaps BNP, D-Dimers• Chest X-ray; ECG (exclusion of differential diagnoses)• Sputum cultures (always in case of hospitalisation or previous outpatient antibiotic treatment)
• Oxygen therapy 2-(4) l; target saturation 90% • Salbutamol/ipratropium inhalations ≥4-6 x/d, if needed long-term inhalation• Systemic steroids prednisone 0.5 mg/kg of body weight for 5 days• Antibiotic treatment should be considered; always indicated in stage Gold IV• Physiotherapy
• History, clinical examination (blood pressure, pulse, oxygen saturation, vigilance)
Copyright:LeuppiJDetal.JAMA.2013Jun5;309(21):2223-31.
p.14p.14DYSPNEA: COPD exacerbation 1.2
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DYSPNEA: COMMUNITY-ACQUIRED PNEUMONIA
Objective: diagnostics, risk stratification & empirical immediate treatment <2(-4) hrs.
Definition
Complications
• Chest X-ray if dyspnea & cough • Laboratory workup clinical chemistry; BGA; procalcitonin• Sputum if patient admitted• Blood cultures (2x2) if patient admitted• Legionella antigen (urine) if Legionellosis suspected • Pneumococcus antigen (urine) if no other pathogen isolated
Risk stratification → manageable on an outpatient basis?- Pneumonia Severity Index- CURB-65
• Treatment; procalcitonin guided treatment• Consider outpatient treatment where PSI I-III or CURB65 0 or 1• Minimum 5-day course of treatment and afebrile for 48-72 h, 7-10 days, 14 days where intracellular organisms (e.g. Legionella) are present
Copyrights:MandellLAetal.InfectiousDiseasesSocietyofAmerica/AmericanThoracicSocietyconsensusguidelinesonthemanagementofcommunity-acquiredpneumoniainadults.ClinInfectDis.(2007);44Suppl2:S27-72.-HalmEAandTeirsteinAS.ManagementofCommunity-AcquiredPneumoniaNewEnglJMed(2002);347:2039-2045-WoodheadMetal.GuidelinesforthemanagementofadultlowerrespiratorytractinfectionsERJDecember1,(2005);26(6)1138-1180.
p.15p.15DYSPNEA: Community-acquired pneumonia 1.2
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Syncopeisatransientlossofconsciousnessduetoglobalcerebralhypoperfusion(usually,itselfduetoaperiodoflowbloodpressure)characterisedbyrapidonset,shortduration,spontaneousandcompleterecovery.
Thedifferentiationbetweensyncopeandnon-syncopalconditionswithrealorapparentLOCcanbeachievedinmostcaseswithadetailed clinical history butsometimescanbeextremelydifficult.Thefollowingquestionsshouldbeanswered: •WasLOCcomplete? •WasLOCtransientwithrapidonsetandshortduration? •Didthepatientrecoverspontaneously,completelyandwithoutsequelae? •Didthepatientloseposturaltone?
Iftheanswerstothesequestionsarepositive,theepisodehasahighlikelihoodofbeingsyncope.Iftheanswertooneormoreofthesequestionsisnegative,excludeotherformsofLOCbeforeproceedingwithsyncopeevaluation.
Loss of Consciousness?
TLOCTrauma Not Trauma
• Accidental • Fall• Other abnormal mental state
No
NoYes
Yes
• Coma• Intoxication
• Metabolic disturbance• Aborted sudden death
Transient, rapid onset,short time, self-terminating
Syncope Epilepsy PsychogenicReference:SuttonR.Clinicalclassificationofsyncope.-ProgCardiovascDis.(2013);55(4):339-44.
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SYNCOPE: Assessment of patients with transient loss of conscioussness (TLOC) 1.3
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Vasovagal syncopeisdiagnosedifsyncopeisprecipitatedbyemotionaldistressororthostaticstressandisassociatedwithtypicalprodrome.
Situational syncopeisdiagnosedifsyncopeoccursduringorimmediatelyafterspecifictriggers.
Orthostatic syncopeisdiagnosedwhenitoccursafterstandingupandthereisdocumentation oforthostatichypotension.
Arrhythmia related syncopeisdiagnosedbyECGwhenthereis: •Persistentsinusbradycardia<40bpminawakeorrepetitivesinoatrialblockorsinuspauses>3s •MobitzII2ndor3rddegreeAVblock •AlternatingleftandrightBBB •VTorrapidparoxysmalSVT •Non-sustainedepisodesofpolymorphicVTandlongorshortQTinterval •PacemakerorICDmalfunctionwithcardiacpauses
Cardiac ischemia related syncopeisdiagnosedwhensyncopepresentswithECGevidenceofacuteischemiawithorwithoutmyocardialinfarction.
Cardiovascular syncopeisdiagnosedwhensyncopepresentsinpatientswithprolapsingatrialmyxoma,severeaorticstenosis,pulmonaryhypertension,pulmonaryembolusoracuteaorticdissection.
Reference:MoyaAetal.EurHeartJ(2009)30,2631–2671(1).
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SYNCOPE: Diagnostic criteria (1)Diagnostic criteria with initial evaluation 1.3
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Patients with suspected syncope presenting to ED or clinic
“Uncertain” or unexplained syncope Certain diagnosis of syncope
Risk stratification
High risk Intermediate risk Low risk
Observation UnitHome if stable,
Admit to hospitalif evidence of high risk
HomeOutpatient SMU
referral
Outpatient SMUfor diagnosis, treatment
and follow-up as appropriateHospital admission
Inpatient SMU
Initiate therapyInpatient SMU, outpatient SMU orpersonal physician as appropriate
Copyright:SuttonR,BrignoleM,BendittDG.Keychallengesinthecurrentmanagementofsyncope.NatRevCardiol.(2012);(10):590-8.
Oncesyncopeisconsideredtobethelikelydiagnosis,riskstratificationisrequiredtodeterminefurthermanagement.p.18p.18
SYNCOPE: Evaluation and risk stratification of patients with suspected syncope 1.3
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Carotid sinus massage Orthostatic Hypotension
Indications• CSMisindicatedinpatients>40yearswithsyncopeofunknown
aetiology after initial evaluation;• CSMshouldbeavoidedinpatientswithpreviousMI, TIAorstrokewithinthepast3monthsandin patientswithcarotidbruits(exceptifcarotidDoppler studiesexcludedsignificantstenosis)
Recommendations: Active standing Indications• Manualintermittentdeterminationwithsphygmomanometer ofBPsupineand,whenOHissuspected,duringactive standingfor3minisindicatedasinitialevaluation;
• Continuous beat-to-beat non-invasive pressure measurement maybehelpfulincasesofdoubt
Diagnostic criteria• CSM is diagnostic if syncope is reproduced in presenceofasystolelongerthan3sand/orafallin systolicBP>50mmHg
Diagnostic criteria• Thetestisdiagnosticwhenthereisasymptomaticfallin systolicBPfrombaselinevalue≥20mmHgordiastolic BP≥10mmHgoradecreaseinsystolicBPto<90mmHg;
• Thetestshouldbeconsidereddiagnosticwhenthereisan asymptomaticfallinsystolicBPfrombaselinevalue≥20mmHg ordiastolicBP>10mmHgoradecreaseinsystolicBP to<90mmHg
Reference:MoyaAetal.EurHeartJ(2009)30,2631–2671(2).
p.19p.19
SYNCOPE: Diagnostic criteria (2)Diagnostic criteria with provocation maneuvers 1.01.3
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Treatment of reflex syncope Treatment of orthostatic hypotension
• Explanationofthediagnosis,provisionofreassuranceandexplanation of risk of recurrence are in all patients
• IsometricPCMareindicatedinpatientswithprodrome• CardiacpacingshouldbeconsideredinpatientswithdominantcardioinhibitoryCSS• Cardiacpacingshouldbeconsideredinpatientswithfrequentrecurrentreflexsyncope, age>40yearsanddocumentedspontaneouscardioinhibitoryresponseduringmonitoring
• MidodrinemaybeindicatedinpatientswithVVSrefractorytolifestylemeasures• Tilttrainingmaybeusefulforeducationofpatientsbutlong-termbenefitdepends
on compliance• Cardiacpacingmaybeindicatedinpatientswithtilt-induced cardioinhibitoryresponsewithrecurrentfrequentunpredictable syncopeandage>40afteralternativetherapyhasfailed
• Triggersorsituationsinducingsyncopemustbeavoidedasmuchaspossible• Hypotensivedrugsmustbemodifiedordiscontinued• Cardiacpacingisnotindicatedintheabsenceofadocumented cardioinhibitoryreflex
• Beta-adrenergicblockingdrugsarenotindicated• Fluidconsumptionandsaltinthedietshouldbeincreased
• Adequatehydrationandsaltintakemust be maintained
• Midodrineshouldbeadministeredasadjunctivetherapyifneeded
• Fludrocortisoneshouldbeadministeredasadjunctivetherapyifneeded
• PCM may be indicated • Abdominal binders and/or support
stockings to reduce venous pooling may be indicated
• Head-uptiltsleeping(>10°)toincreasefluidvolumemaybeindicated
• Triggers or situations inducing syncope mustbeavoidedasmuchaspossible
• Hypotensivedrugsadministeredforconcomitant conditions must be discontinued or reduced
Copyright:MoyaAetal.EurHeartJ(2009)30,2631–2671(3).
p.20p.20Treatment according to type of SYNCOPE (1) 1.01.3
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Treatment of arrhythmic syncopeCardiac Pacing• Pacingisindicatedinpatientswithsinusnodediseaseinwhom
syncope is demonstrated to be due to sinus arrest (symptom-ECGcorrelation)withoutacorrectablecause
• Pacingisindicatedinsinusnodediseasepatientswithsyncopeand abnormal CSNRT
• Pacingisindicatedinsinusnodediseasepatientswithsyncopeandasymptomaticpauses>3sec.(withpossibleexceptionsofyoung trained persons, during sleep and in medicated patients)
• Pacingisindicatedinpatientswithsyncopeand2nddegreeMobitzII,advancedorcompleteAVblock
• Pacingisindicatedinpatientswithsyncope,BBBandpositiveEPS• PacingshouldbeconsideredinpatientswithunexplainedsyncopeandBBB
• Pacingmaybeindicatedinpatientswithunexplainedsyncopeandsinusnodediseasewithpersistentsinusbradycardiaitselfasymptomatic
• Pacingisnotindicatedinpatientswithunexplainedsyncopewithoutevidenceofanyconductiondisturbance
Catheter ablation• Catheterablationisindicatedinpatientswithsymptom/ arrhythmiaECGcorrelationinbothSVTandVTintheabsenceofstructuralheartdisease(withexceptionofatrialfibrillation)
• Catheterablationmaybeindicatedinpatientswithsyncopeduetotheonsetofrapidatrialfibrillation
Antiarrhythmic drug therapy• Antiarrhythmicdrugtherapy,includingratecontroldrugs,isindicatedinpatientswithsyncopeduetoonsetofrapidatrialfibrillation
• Drugtherapyshouldbeconsideredinpatientswithsymptom/ arrhythmiaECGcorrelationinbothSVTandVTwhencatheterablationcannotbeundertakenorhasfailed
Implantable Cardioverter Defibrillator (ICD) • ICDisindicatedinpatientswithdocumentedVTandstructuralheartdisease
• ICDisindicatedwhensustainedmonomorphicVTisinducedatEPSinpatientswithpreviousmyocardialinfarction
• ICDshouldbeconsideredinpatientswithdocumentedVTandinheritedcardiomyopathiesorchannelopathies
Copyright:MoyaAetal.EurHeartJ(2009)30,2631–2671(4).
p.21p.21Treatment according to type of SYNCOPE (2) 1.3
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p.22
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CHAPTER 2: ACUTE CORONARY SYNDROMES
2.1 GENERAL CONCEPTS �������������������������������������������������������������������������������������������������������� p�24H� Bueno
2.2 NON ST-SEGMENT ELEVATION ACS �������������������������������������������������������������� p�29 H� Bueno
2.3 ST-SEGMENT ELEVATION MI (STEMI) ���������������������������������������������������������� p�35D� Zahger, P� Clemmensen
p.232
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hs-cTn <ULNhs-cTn > ULN
ACUTE CORONARY SYNDROMES: DIAGNOSIS
CHEST PAIN or symptoms sugestive of myocardial ischemia
ECG
ST elevation(persistent)
LBBB ST/T abnormalities Normal ECG
STEMI
Pain resolves with nitroglycerin 1st hsTn
NSTEMI Unstable Angina Work-up
differential diagnoses
Pain onset >6h Pain onset <6h
Re-test hs-cTn (3h later)See next page for 1h rule-in & rule-out algorithm
hs-cTnno change
� hs-cTn(1 value >ULN)
hs-cTn>x5 ULN
orclinical
diagnosis clear
Potential noncardiac
causes for abnormal Tn
ConsiderSTEMI
Yes
No
Reference: Roffi M. Eur Heart J 2015;eurheartj.ehv320
p.24
ACUTE CORONARY SYNDROMES: Diagnosis (1) 2.1
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Suspected NSTEMI
Other0h ≥ D ng/l
or0-1h ≥E ng/l
ObserveRule-out Rule-in
0h or
<B ng/land
0-1h <Cng/l
A B C D E
hs-cTnT (Elecsys)* 5 12 3 52 5
hs-cTnl (Architect)* 2 5 2 52 6
hs-cTnl (Dimension Vista)* 0.5 5 2 107 19
0h <A ng/l
• NSTEMI can be ruled-out at presentation, if hs-cTn concentration is very low• NSTEMI can be ruled out by the combination of low baseline levels and the lack of a relevant increase within 1 h• NSTEMI is highly likely if initial hs-cTn concentration is at least moderately elevated or hs-cTn concentrations show
a clear rise within the first hour
Reference: Roffi M. Eur Heart J 2015;eurheartj.ehv320
*Cut-off levels are assay-specific.
p.25
ACUTE CORONARY SYNDROMES: Diagnosis (2)0-1 H Rule-in & rule out test for NSTEMI 2.1
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Causes of chest pain Not related to ACS
Causes of troponin elevationNot related to ACS
Primary cardiovascular• Acute pericarditis, pericardial effusion• Acute myocarditis• Severe hypertensive crisis• Stress cardiomyopathy (Tako-Tsubo syndrome)• Hypertrophic cardiomyopathy, aortic stenosis • Severe acute heart failure • Acute aortic syndrome (dissection, hematoma)• Pulmonary embolism, pulmonary infarction• Cardiac contusion
Primary cardiovascular• Acute myo(peri)carditis• Severe hypertensive crisis• Pulmonary edema or severe congestive heart failure• Stress cardiomyopathy (Tako-Tsubo syndrome)• Post- tachy- or bradyarrhythmias• Cardiac contusion or cardiac procedures (ablation, cardioversion, or
endomyocardial biopsy)• Aortic dissection, aortic valve disease or hypertrophic cardiomyopathy• Pulmonary embolism, severe pulmonary hypertension
Primary non-cardiovascular• Oesophageal spasm, oesophagitis, Gastro
Esophageal Reflux (GER)• Peptic ulcer disease, cholecystitis, pancreatitis• Pneumonia, bronchitis, asthma attack• Pleuritis, pleural effusion, pneumothorax• Pulmonary embolism, severe pulmonary
hypertension• Thoracic trauma• Costochondritis, rib fracture • Cervical / thoracic vertebral or discal damage• Herpes Zoster
Primary non-cardiovascular• Renal dysfunction (acute or chronic)• Critical illness (sepsis, repiratory failure…)• Acute neurological damage (i.e. stroke, subarachnoid hemorrhage)• Severe burns (affecting >30% of body surface area)• Rhabdomyolysis• Drug toxicity (chemotherapy with adriamycin, 5-fluorouracil,
herceptin, snake venoms…)• Inflammatory or degenerative muscle diseases• Hypothyroidism• Infiltrative diseases (amyloidosis, hemochromatosis, sarcoidosis)• Scleroderma
p.26
ACUTE CORONARY SYNDROMES: Differential diagnosis (1) 2.1
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ST-segment elevation Negative T waves
Fixed• LV aneurysm• LBBB, WPW, hypertrophic cardiomyopathy, LVH• Pacemaker stimulation• Early repolarisation (elevated J-point)Dynamic• Acute (myo)pericarditis• Pulmonary embolism• Electrolyte disturbances (hyperkalemia)• Acute brain damage (stroke, subarachnoid haemorrhage)• Tako Tsubo syndrome
• Normal variants, i.e. women (right precordial leads), children, teenagers
• Evolutive changes post myocardial infarction
• Chronic ischemic heart disease• Acute (myo)pericarditis, cardiomyopathies• BBB, LVH, WPW• Post-tachycardia or pacemaker stimulation• Metabolic or ionic disturbances
ST-segment depression Prominent T waves
Fixed• Abnormal QRS (LBBB, WPW, pacemaker stimulation…)• LVH, hypertrophic cardiomyopathy• Chronic ischemic heart diseaseDynamic• Acute (myo)pericarditis • Severe hypertensive crisis• Acute pulmonary hypertension • Drug effects (digoxin)• Electrolyte disturbances (hyperkalemia) • Shock, pancreatitis• Intermitent LBBB, WPW, pacing • Hyperventilation• Post-tachycardia / cardioversion • Tako Tsubo syndrome
• Normal variants, i.e. early repolarisation• Metabolic or ionic disturbances
(i.e. hyperkalemia)• Acute neurological damage (stroke, subarachnoid haemorrhage)
p.27
ACUTE CORONARY SYNDROMES: Differential diagnosis (2)Causes of repolarisation abnormalities in the ECG not related to ACS 2.1
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2ECG
(<10 min)
3Diagnosis /
Risk assessment
4Medical
Treatment
5InvasiveStrategy
STEMI (see chapter 2.3)
ThrombolysisFor STEMI if primary
PCI not timelyavailable
PrimaryPCI
1Clinical
Evaluation
NSTE ACS(see chapter 2.2)
ACS unclear(Rule out ACS) (see chapter 1.1)
No ACS
Chest Pain Unit
• Clinical presentation (BP, HR)
• ECG presentation
• Past history
• Ischemic risk (i.e. GRACE, TIMI scores)
• Bleeding risk (i.e. CRUSADE score)
• Additional information (labs, imaging...) optional
Anti-ischemictherapy
Antiplatelettherapy
Anticoagulation
Emergent<2 hours
Urgent*
2-24 hours
Early24-72hours
No /Elective
Quality ofchest pain
Clinicalcontext
Probabilityof CAD
Physicalexamination
GENERAL APPROACH TO THE PATIENT WITH CHEST PAIN / SUSPECTED ACS
ECG
Rule out noncardiac causes
* 3-12 hours after thrombolysis.
p.28
General approach to the patient with chest pain/suspected ACS 2.1
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Ischemic risk
Grace risk score Timi risk scorePredictive Factors• Age• HR*
• SBP*
• Creatinine (mg/dl)*• Killip class*
• Cardiac arrest*
• ST-segment deviation• Elevated cardiac markers
OutcomesIn-hospital, 6-month, 1-year and 3-year mortality1-year death/MI
Predictive Factors• Age 65 years • At least 3 risk factors for CAD • Signifi cant (>50%) coronary stenosis• ST deviation • Severe anginal symptoms (>2 events in last 24 h)• Use of aspirin in last 7 days • Elevated serum cardiac markers
OutcomeAll-cause mortality / new or recurrent MI / severe recurrent ischemia requiring urgent revascularisation at 14 days
* At admission.
Risk calculation www.gracescore.org/WebSite/default.aspx?ReturnUrl=%2f
Risk calculationwww.timi.org/index.php?page=calculators
p.29NON ST-SEGMENT ELEVATION ACS: Risk stratifi cation (1) 2.2
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Bleeding risk
Crusade risk scorePredictive Factors• Sex• HR*
• SBP*
• Creatinine (mg/dl)*• Baseline hematocrit*
• GFR: Cockcroft-Gault*
• Diabetes• Prior vascular disease• Signs of congestive heart failure*
OutcomeIn-hospital major bleeding
Copyrights: Eagle KA et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death in an international registry. JAMA. (2004) ;291(22):2727-33.
Antman EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. (2000);284(7):835-42.
Subherwal S, et al Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation (2009) ;119(14):1873-82.
* At admission.
Risk calculationwww.crusadebleedingscore.org
p.30NON ST-SEGMENT ELEVATION ACS: Risk stratification (2) 2.2
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Initial treatment*• Nitrates• Morphine• Oxygen (if SatO2 < 95%)
One of the following: • Fondaparinux • Enoxaparin • UFH • Bivalirudin
Aspirin + one of: • Ticagrelor • Prasugrel • ClopidogrelOptionally: • GP IIb/IIIa inhibitors • Cangrelor
• Nitrates• Beta-blockers• Calcium antagonists
• Statins• ACE inh. (or ARB)• Aldosterone inhibitors
Pharmacologicaltreatment*
Anti ischemictreatment
Antithrombotictherapy
Anticoagulation Antiplatelets
PCICABG
Other preventivetherapies
Myocardialrevascularisation
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
p.31
NON ST-SEGMENT ELEVATION ACS: Treatment (1)General overview 2.2
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NSTE-ACS patients with non-valvular atrial fibrillation
PCI
Low to intermediate(e.g. HAS-BLED = 0–2)
Tripletherapy
High(e.g. HAS-BLED ≥3)
Triple or dualtherapy a
Dualtherapy b
Dualtherapy b
Dualtherapyb
0
4 weeks
6 months
12 months
Lifelong
Oral anticoagulation (VKA or NOACs) Aspirin 75–100 mg daily Clopidogrel 75 mg dailyO
MonotherapycO
A C
O A C
O C or A
O C or AO C or A
O A C
Medically managed / CABGManagement strategy
Bleeding risk
Tim
e fr
om P
CI/
AC
S
CHA2DS2-VASc = Cardiac failure, Hypertension, Age ≥ 75 [2 points], Diabetes, Stroke [2 points] – Vascular disease, Age 65–74, Sex category.
a Dual therapy with oral anticoagulation and clopidogrel may be considered in selected patients (low ischaemic risk).
b Aspirin as an alternative to clopidogrel may be considered in patients on dual therapy (i.e., oral anticoagulation plus single antiplatelet); triple therapy may be considered up to 12 months in patients at very high risk for ischaemic events.
c Dual therapy with oral anticoagulation and one antiplatelet agent (aspirin or clopidogrel) beyond one year may be considered in patients at very high risk of coronary events.
d In patients undergoing coronary stenting, dual antiplatelet therapy may be an alternative to triple or a combination of anticoagulants and single antiplatelet therapy if the CHA2DS2-VASc score is 1 (males) or 2 (females).
Reference: Eur Heart J 2015;eurheartj.ehv320- Figure 5.
p.32
NON ST-SEGMENT ELEVATION ACS: Treatment (2)Antithrombotic strategies in patients with NSTE-ACS and non-valvular atrial fibrillation 2.2
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Very-high-risk criteria
• Haemodynamic instability or cardiogenic shock• Recurrent or ongoing chest pain refractory to medical treatment• Life-threatening arrhythmias or cardiac arrest• Mechanical complications of MI• Acute heart failure• Recurrent dynamic ST-T wave changes, particularly with intermittent ST-elevation
High-risk criteria • Rise or fall in cardiac troponin compatible with MI• Dynamic ST- or T-wave changes (symptomatic or silent)• GRACE score >140
Intermediate-risk criteria
• Diabetes mellitus• Renal insufficienty (eGFR <60 mL/min/1.73 m2)• LVEF <40% or congestive heart failure• Early post-infarction angina• Prior PCI• Prior CABG• GRACE risk score >109 and <140
Low-risk criteria
• Any characteristics not mentioned above
Reference: Roffi M. Eur Heart J 2015;eurheartj.ehv320
p.33
NON ST-SEGMENT ELEVATION ACS: Treatment (3)Risk criteria mandating invasive strategy in NSTE-ACS 2.2
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Symptoms Onset
First medical contact NSTE-ACS diagnosis
PCI center
Very high
ImmediateInvasive(<2 hr)
Earlyinvasive(<24 hr)
Invasive(<72 hr)
Non-invasivetesting if
appropriate
High
Intermediate
Immediate transfer to PCI center
Same-day transfer
Transfer
Transfer optional
Ris
k st
rati
ficat
ion
The
rape
utic
stra
tegy
Low
EMS or Non–PCI center
Very high
High
Intermediate
Low
Reference: Eur Heart J 2015;eurheartj.ehv320 - Figure 6.
p.34
NON ST-SEGMENT ELEVATION ACS: Treatment (4)Timing and strategy for invasive management 2.2
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STEMI is diagnosed according to the presence of the following acute ischemic ECG changes:
In the absence of LVH and LBBB:• New ST elevation at the J point in 2 contiguous leads with ≥ 0.2 mV in men or ≥ 0.15 mV in women
in leads V2-V3 and/or ≥ 0.1 mV in other leads → Contiguous leads mean lead groups such as anterior leads (V1-V6), inferior leads (II, III, aVF)
or lateral/apical leads (I, aVL).
In the presence LBBB or ST depression:• New LBBB, and symptoms suggestive of ACS • ST depression in leads V1–V3 indicate inferobasal myocardial ischemia (especially when the terminal T-wave is positive)
In suspected posterior (circumflex artery- related) or right ventricle-related infarction:• ST elevation in V7 (at the left posterior axillary line), V8 (at the left midscapular line), and V9 (at the left
paraspinal border), using a cut-point > 0.05 mV → Capture an overlooked left dominant circumflex using posterior leads in the fifth interspace
• ST elevation in right precordial leads (V3R and V4R), using a cut-off point > 0.05 mV, and > 0.1 mV in men <30 years → Capture suspected right ventricular infarction using right precordial leads
Reference: Steg G et al. Eur Heart J. (2012);33:2569-619 (6).
p.352.3STEMI: Electrocardiographic diagnosis
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Yes No
No
Preferably<60 min
Immediately
Preferably 3–24 h
Preferably�90 min(�60 min in early presenters) Preferably
�30 min
Immediate transferto PCI center
Immediate transferto PCI center
Yes
STEMI diagnosisa
Primary-PCI capable center
Primary-PCI
Coronary angiography
Rescue PCI
EMS or non primary-PCIcapable center
ImmediatefibrinolysisSuccessful fibrinolysis?
PCI possible <120 min?
a The time point the diagnosis is confirmed with patient history and ECG ideally within 10 min from First Medical Contact (FMC). All delays are related to FMC. Reference: Steg G et al. Eur Heart J. (2012);33:2569-619 (6).
p.362.3STEMI: Treatment (1)
General overview of initial management
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Pre hospital PCI CCU/ICCU MedicationTitration Day 2-7
Reference: Steg G et al. Eur Heart J. (2012);33:2569-619 (7).Pre-hospital management of patients with chest pain and/or dyspnoea of cardiac origin. A position paper of the Acute Cardiovascular Care Association (ACCA) of the ESC - European Heart Journal: Acute Cardiovascular Care August 27, 2015 2048872615604119.
Acetylicsalisylic Acid 300 mgHeparin 70 IU/kg
Bivalirudinor GPI: Eptifibatide Tirofiban AbxicimabFollow local in-lab instruction / dosing
Metoprolol 25 mg x 2or carvedilol 3,25 mg x 2or bisoprolol 2,5 mg x 2
Atorvastatin 80 mg x 1or Rosuvastatin 40 mg x 1
Acetylicsalisylic Acid 75 mg x 1Ticagrelor 90 mg x 2 or Prasugrel 10/5 mg x 1or Clopidogrel 75 mg x 1
Metoprolol 200mg x 1 or carvedilol 25 mg x 2 or bisoprolol 5 mg x 2or Ca-antagonist (see chapter 2.2)
Start ACE-i or ARB in DM, LVSD, CHF, or to control BPAldosterone RBStart or continue anti-diabetic medication
Ticagrelor 180 mg or Prasugrel 60 mg or Clopidogrel 600 mg
p.372.3STEMI: Treatment (2)
Primary PCI - First 24 hours and days 2-7
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
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p.382.3
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CHAPTER 3: ACUTE HEART FAILURE
3.1 HEART FAILURE AND PULMONARY OEDEMA ��������������������������������� p�40 I�C�C� van der Horst, G� Filippatos
3.2 CARDIOGENIC SHOCK ����������������������������������������������������������������������������������������������������� p�49P� Vranckx, U� Zeymer
3p.39
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ACUTE HEART FAILURE: DIAGNOSIS AND CAUSES (1)
Rapid onset of, or worsening of symptoms
and signs of heart failure*
Cardiovascular risk profile*
Precipitating factors*
Precipitating factors*
High likelihood ofacute heart failure*
Intermediate to highlikelihood ofacute heart failure*
Intermediate likelihoodof acute heart failure*
History ofheart failure
Yes
No
Yes
20-40%
60-80%
Yes
No
No
Rule outdifferentialdiagnosis*
* (See page 41)�
ACUTE HEART FAILURE: Diagnosis and causes (I) 3.1p.40
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1• Symptoms: Dyspnea (on effort or at rest)/breathlessness, fatigue, orthopnea, cough, weight gain/ankle swelling 2• Signs: Tachypnea, tachycardia, low or normal blood pressure, raised jugular venous pressure, 3rd/4th
heart sound, rales, oedema, intolerance of the supine position3•Cardiovascularriskprofile: Older age, HTN, diabetes, smoking, dyslipidemia, family history, history of CVD4• Precipitating factors: Myocardial ischemia, rhythm disturbances, medication (NSAID, negative inotropic agents),
infection, noncompliance5• Differential diagnosis: Exacerbated pulmonary disease, pneumonia, pulmonary embolism, pneumothorax,
acute respiratory distress syndrome, (severe) anaemia, hyperventilation (acidosis), sepsis/septic shock, redistributive/hypovolemic shock
6• Likelihood: Depending on the site off presentation the underlying cause of acute heart failure is likely to differ� Cardiologists see more often worsening heart failure and physicians at the Emergency Department more often see patients with preserved systolic left ventricular function
MAIN CAUSES OF ACUTE HEART FAILURE • Coronary artery disease • Congenital heart disease • Pleural effusion• Hypertension • Arrhythmia (tachy-, brady-) • Anxiety disorder• Cardiomyopathy (familial, acquired) • Conduction disorder (blocks) • Neurologic disease• Valvular heart disease • Volume overload (renal, iatrogenic)• Peri-/endocardial disease • Tumor
Reference: McMurray JJ et al, Eur Heart J (2012) ;33(14):1787-847 (19)�
ACUTE HEART FAILURE: Diagnosis and causes (2) 3.1p.41
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RESUSCITATION AREA/CCU/ICUTo stabilize vital signs (echo if needed) and/or
immediate non-invasive ventilation
DIAGNOSTIC TESTS• ECG• Laboratory tests • Echo (lung, heart)• Chest X-ray
SEVERITY SCORE (excluding shock)Respiratory distress
RR > 25/min,SpO2<90% on O2,
or increased work of breathing
Haemodynamic instabilityLow or high blood pressure,
Severy arrhythmia,HR <40 or >130/min
IV THERAPY
Yes
Yes
Yes
No
No
High risk ACS
SHOCK
INIT
IAL
30-6
0 M
ININ
ITIA
L 30
-60
MIN
Ventilation support – Echocardiogram – ICU/CCU
Cardiac catheterisation laboratory
(see chapter 3.1 page 43)
(see chapter 3.1 page 44)(see chapter 3.1 page 45)
Algorithm for the management of acute heart failure� Depicted from Mebazaa A et al� Eur J Heart Fail� (2015);17(6):544-58�
SUSPECTED ACUTE HEART FAILURE 3.1p.42
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Start NON-INVASIVE VENTILATION (NIV)(positive pressure, bilevel) + PEEP 5-10 mmHg
Consider ENDOTRACHEAL INTUBATION (ETT)****
Get support on time
AB
C
Sufficient oxygenation(SpO2>90%)
Sufficient ventilation(pCO2<45mmHg)***
Sufficient oxygenation (SpO2>90%)
Sufficient oxygenation (SpO2>90%)
Oxygen* + PEEP 5-10 mmHg + Ventilatory Support (pressure support)
OXYGEN* (+ oropharyngeal airway [Guedel/Mayo]/ nasopharyngeal airway and upright position)
Oxygen* + Positive End-Expiratory Pressure (PEEP) 5-7.5 mmHg
Nasal: 1 ltr = FiO2 22%, 2 ltr = 25%, 3 ltr = 27%, 4 ltr = 30%, 5 ltr = 35%Mask: 2 ltr = FiO2 25%, 4 ltr = 30%, 6 ltr = 40%, 7 ltr = 45%, >8 ltr = 50%Mask + reservoir: 6 ltr = FiO2 60%, 7 ltr = 70%, 8 ltr = 80%, 10 ltr = 90% Venturimask**: 24% = FiO2 24%, 35% = 35%, 40% = 40%, 60% = 50%
Yes
Yes
Yes
Yes
~5 minutes to reassess
~15 minutes to reassess
No
No
NoNo
Start CONTINUOUS POSITIVEAIRWAY PRESSURE (CPAP)
* Goal SpO2 94-98%� ** Use the predefined liters of oxygen. When using higher flows the FiO2 will drop� *** For a patient with COPD, a pCO2 of 45-50 mmHg may be optimal� Aim for a normal pH� **** Consider if the above fails or when patient is fatigued�
ACUTE HEART FAILURE: Initial diagnosis and treatment Airway (A) & Breathing (B) 3.1p.43
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References: Mebazaa A et al� Intensive Care Med� (2015) Sep 14� [Epub ahead of print]; Mueller C et al� Eur Heart J Acute Cardiovasc Care� (2015) Jun 29�
C - CIRCULATION* HR (bradycardia [<60/min], normal [60-100/min], tachycardia [>100/min]), rhythm (regular, irregular), SBP (very low [<90t mmHg], low, normal [110-140 mmHg], high [>140 mmHg]), and elevated jugular pressure should be checked
INSTRUMENTATION & INVESTIGATIONS: Consider intravenous (central) & arterial line (BP monitoring) Laboratory measures • Cardiac markers (troponin, (BNP/NT-proBNP, MR-proANP) • Complete blood count, electrolytes, creatinine, urea, glucose, inflammation, TSH Standard 12-lead ECG • Venous blood gases, D-dimer (suspicion of acute pulmonary embolism) • Rhythm, rate, conduction times? • Signs of ischemia/myocardial infarction? Hypertrophy? Echocardiography • Ventricular function (systolic and diastolic)? • Presence of valve dysfunction (severe stenosis/insufficiency)? • Pericardial effusion/tamponade?
ACTIONS: Rule in/out diagnosis of acute heart failure as diagnosis for symptoms and signs Establish cause of diseaseDetermine severity of diseaseStart treatment as soon as possible, i�e� both heart failure and the factors identified as triggers
D – DISABILITY DUE TO NEUROLOGICAL DETERIORATION Normal consiousness/altered mental status? Measurement of mental state with AVPU (alert, visual, pain or unresponsive) Glasgow Coma Scale: EMV score <8 Consider ETT Anxiety, restlessness? Consider morphine 2�0-5 mg i�v� bolus (diluted in normal saline), preceded by metoclopramide 10 mg i�v� PRNE – EXPOSURE & EXAMINATION Temperature/fever : central and peripheral Weight Skin/extremities: circulation (e.g. capilary refill), color Urinary output (<0.5ml/kg/hr) Insert indwelling catheter; the benefits should outweigh the risks of infection and long-term complications
ACUTE HEART FAILURE: Initial diagnosis (CDE) 3.1p.44
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1 Inotropic drugs • Dobutamine 2�5 μg/kg/min • Milrinone bolus 25 μg/kg in10-20 min,
continuous 0�375 μg/kg/min2 Vasopressor i.v.
• Norepinephrine 0�2 μg/kg/min3 Diuretics i.v.
• Furosemide 20-40 mg bolus, continuous 100 mg/6 h
4 Consider hypertonic saline + diuretic
5 Consider mechanical circulatory support
1 Diuretics i.v. • Furosemide 20-40 mg bolus,
continuous 100 mg/6 h*
2 Inotropic drugs • Dobutamine continuous 2�5 μg/kg/min • Milrinone bolus 25 μg/kg in 10-20 min, continuous 0�375 μg/kg/min • Levosimendan bolus 12 μg/kg in
10 min, continuous 0�1 μg/kg/min3 Consider to start ACE-I/ARB,
beta-blocker, MRA. *See chapter 8: Use of drugs in acute cardiovascular care.(See table page 47-48)
1 Vasodilators • Nitroglycerine spray 400 μg sublingual, repeat ~5-10 min • Nitroglycerine i�v� continuously ~10 μg/min, increase ~5 μg/min • Nitroprusside 0�3 μg/kg/min
increase to 5 microg/kg/min2 Diuretics i.v.
• Furosemide 20-40 mg bolus, continuous 100 mg/6 h3 Consider to start ACE-I/ARB,
beta-blocker, MRA. *See chapter 8: Use of drugs in acute cardiovascular care.(See table page 47-48)
Low cardiac output<10% >60%
No
No
Yes
Yes
C: Circulatory failure/shock <90 mmHg
C: Volume overload, SBP>110 mmHg?
ACUTE HEART FAILURE: INITIAL TREATMENT (C) CLINICAL SCENARIOS*
* Use higher dose in patients on chonic diuretic treatment for HF (i�e� 2�5 times normal dose)�
ACUTE HEART FAILURE: Initial treatment (C) IV therapy 3.1p.45
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No acute heart failure
MONITORINGDyspnea (VAS, RR), BP, SpO2, HR and
rhythm, urine output, peripheral perfusion
TREATMENT OBJECTIVES to prevent organ aggrevation:Improve symptoms, maintain SBP >90 mmHg and
REASSESSMENTClinical, biological and phychosocial parameters
by trained nurses
Observation unit (< 24h)
Discharge home
Ward (cardiology, internal medicine, geriatrics)
Rehabilitation program
Visit to cardiologist < 1-2 weeks
Palliative care hospitals
ICU/CCU
Confirmed acute heart failure
DIAGNOSTIC TESTS
OBS
ERVA
TIO
N U
P TO
120
MIN
ADM
ISSIO
N/D
ISCH
ARG
E
(sprove symptoms, maintain SBP >90 mmHg and
(sprove symptoms, maintain SBP >90 mmHg and
ee table page 47-48prove symptoms, maintain SBP >90 mmHg and
ee table page 47-48prove symptoms, maintain SBP >90 mmHg and
)ee table page 47-48)ee table page 47-48peripheralperfusion, maintain SpO2 >90%
Algorithm for the management of acute heart failure� Depicted from Mebazaa A et al� Eur J Heart Fail� (2015);17(6):544-58
MANAGEMENT OF ACUTE HEART FAILURE 3.1p.46
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Normotension/Hypertension
Hypotension Low Heart rate Potassium Renal impairment
<100>85 mmHg
<85 mmHg <60≥50 bpm
<50 bpm ≤3.5 mg/dL >5.5 mg/dL Cr < 2.5,eGFR > 30
Cr > 2.5,eGFR < 30
ACE-I/ARB Review/increase Reduce/ stop
Stop No change No change Review/increase
Stop Review Stop
Beta-blocker No change Reduce/ stop
Stop Reduce Stop No change No change No change No change
MRA No change No change Stop No change No change Review/increase
Stop Reduce Stop
Diuretics Increase Reduce Stop No change No change Review/ No change
Review/ increase
No change Review
CCB, calcium channel blockers (mg/dL); Cr, creatinine blood level (mg/dL); eGFR, estimated glomerular filtration rate ml/min/1.73 m2; MRA, mineralocorticoid receptor antagonist; (*) amiodarone� - Depicted from Mebazaa A et al� Eur J Heart Fail� (2015);17(6):544-58�
ACUTE HEART FAILURE: Treatment (C) and preventive measuresManagementoforaltherapyinAHFinthefirst48hours
3.1p.47
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CCB, calcium channel blockers (mg/dL); Cr, creatinine blood level (mg/dL); eGFR, estimated glomerular filtration rate ml/min/1.73 m2; MRA, mineralocorticoid receptor antagonist; (*) amiodarone� - Depicted from Mebazaa A et al� Eur J Heart Fail� (2015);17(6):544-58�
Thrombosis prophylaxis should be started in patients not anticoagulated (enoxaparin 1 mg/kg as first dose)Maintain an adequate nutritional status with a nutritional support of 20-25 kcal/kg/day within the first 48 hours
Normotension/Hypertension
Hypotension Low Heart rate Potassium Renal impairment
<100>85 mmHg
<85 mmHg <60≥50 bpm
<50 bpm ≤3.5 mg/dL >5.5 mg/dL Cr < 2.5,eGFR > 30
Cr > 2.5,eGFR < 30
Other vasodilators (Nitrates)
Increase Reduce/stop
Stop No change No change No change
No change No change No change
Other heart rate slowing drugs (amiodarone, CCB, Ivabradine)
Review Reduce/stop
Stop Reduce/stop
Stop Review/stop (*)
No change No change No change
3.1ACUTE HEART FAILURE: Treatment (C) and preventive measures (Cont.)ManagementoforaltherapyinAHFinthefirst48hours p.48
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Clinical condition defined as the inability of the heart to deliver an adequate amount of blood to the tissues to meet resting metabolic demands as a result of impairment of its pumping function�
Hemodynamiccriteriatodefinecardiogenicshock
• Systolic blood pressure <80 to 90 mmHg or mean arterial pressure 30 mmHg lower than baseline
• Severe reduction in cardiac index: <1�8 L/min/m2 without support or <2�0 to 2�2 L/min/m2 with support
• Adequate or elevated filling pressure:Left ventricular end-diastolic pressure >18 mmHg or Right ventricular end-diastolic pressure >10 to 15 mmHg
CARDIOGENIC SHOCK: Definition 3.2p.49
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LV pump failure is the primary insult in most forms of CS, but other parts of the circulatory system contribute to shock with inadequate compensation or additional defects�
CARDIOGENIC SHOCK: Causes 3.2p.50
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This protocol should be initiated as soon as cardiogenic shock/end organ hypoperfusion is recognised and should not be delayed pending intensive care admission�
In persistent drug-resistant cardiogenic shock,consider mechanical circulatory support
EARLY TRIAGE & MONITORINGStart high fl ow O2 Establish i�v� access
• Age: 65–74, ≥75• Heart rate >100 beats per minute• Systolic blood pressure <100 mmHg• Proportional pulse pressure ≤25 % (CI <2�2l/min/m2)• Orthopnea (PCWP >22 mmHg)• Tachypnea (>20/min), >30/min (!)• Killip class II-IV • Clinical symptoms of tissue hypoperfusion/hypoxia:
- cool extremities, - decreased urine output (urine output <40 ml/h)- decreased capillary refi ll or mottling - alteration in mental status
INITIAL RESUSCITATION• Arterial and a central venous catheterization with a catheter capable of measuring central venous oxygen saturation
• Standard transthoracic echocardiogram to assess left (and right) ventricular function and for the detection of potential mechanical complications following MI
• Early coronary angiography in specialized myocardial intervention center when signs and/or symptoms of ongoing myocardial ischemia (e�g� ST segment elevation myocardial infarction)�
• CORRECT: hypoglycemia & hypocalcemia,• TREAT: sustaned arrhythmias: brady- or tachy-• Isotonic saline-fl uid challenge of 20 to 30 ml per kilogram of body weight
over a 30-minute period to achieve a central venous pressure of 8 to 12 mmHg or until perfusion improves (with a maximum of 500 ml)
• CONSIDER NIVmechanical ventilation for comfort (fatigue, distress) or as needed:- To correct acidosis - To correct hypoxemia
• INOTROPIC SUPPORT (dobutamine and/or vasopressor support)
TREATMENT GOALS • a mean arterial pressure of 60 mmHg or above, • a mean pulmonary artery wedge pressure of 18 mmHg or below, • a central venous pressure of 8 to 12 mmHg, • a urinary ouput of 0,5 ml or more per hour per kilogram of body weight • an arterial pH of 7�3 to 7�5 • a central venous saturation (ScvO2) ≥70% (provided SpO2 ≥93% and Hb level ≥9 g/dl)
0 min
5 min
15 min
60 min
EMER
GEN
CY D
EPA
RTM
ENT
CARD
IAC
INTE
NSI
VE C
ARE
UN
IT
CARDIOGENIC SHOCK: Initial triage and management 3.2p.51
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Ventilator modeTidal Volume goalPlateau Pressure goalAnticipated PEEP levelsVentilator rate and pH goalInspiration: Expiration timeOxygenation goal: • PaO2
• SpO2
Pressure assist/controlReduce tidal volume to 6-8 ml/kg lean body weight≤ 30 cm H2O5-10 cm H2O12-20, adjusted to achieve a pH ≥ 7�30 if possible1:1 to 1:2
50-80 mmHg> 90%
Predicted body weight calculation: • Male: 50 + 0�91 (height in cm - 152�4) • Female: 45�5 + 0�91 (height in cm - 152�4)
Some patients with CS will require increased PEEP to attain functional residual capacity and maintain oxygenation, and peak pressures above 30 cm H2O to attain effective tidal volumes of 6-8ml/kg with adequate CO2 removal�
*See chapter 8: Use of drugs in acute cardiovascular care�
For more informations on individual drug doses and indications:
CARDIOGENIC SHOCK: Treatment and ventilator procedures 3.2p.52
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CARDIOGENIC SHOCK: MANAGEMENT FOLLOWING STEMI
Assess volume statusTreat sustained arrhythmias: brady- or tachy-Consider mechanical ventilation for comfort (during PCI) and/or as needed: • to correct acidosis • to correct hypoxemiaInotropic support (dobutamine and/or vasopressor support)
Signs (ST-segment elevation or new LBBB)and/or clinical symptoms of ongoing
myocardial ischemia
Early coronary angiography± Pulmonary artery catheter± IABP in selected patients
in a specialised Myocardial Intervention Center
PCI ± stentingof the culprit lesion
CABG+ correct mechanical complications
Pump failureRV, LV, both
Shor
t-ter
m m
echa
nica
l cir
culat
ory
supp
ort
Aortic dissectionPericardial tamponade
• Acute severe mitral valve regurgitation • Ventricular septum rupture • Severe aortic/mitral valve stenosis
Operating theater ± coronary angiography
Emergency echocardiography± Tissue doppler imaging
± Color flow imagingNo
NSTEACS,Delayed CSYes
CARDIOGENIC SHOCK: Management following STEMI 3.2p.53
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72-hrs
2-weeks
1-month ...
Left ventricular support BiVentricular support
Partial support
IABP Impella 2,5 Tandem-heart
Impella 5,0 ImplantableECMOLevitronix
Full support
Level of support
Pulmonary support
CARDIOGENIC SHOCK:Mechanical circulatory support, basic characteristics 3.2
p.54
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Different systems for mechanical circulatory support are available to the medical community� The available devices differ in terms of the insertion procedure, mechanical properties, and mode of action. A minimal flow rate of 70 ml/kg/min, representing a cardiac index of at least 2.5 L/m², is generally required to provide adequate organ perfusion. This flow is the sum of the mechanical circulatory support output and the remaining function of the heart�
The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory cardiogenic shock
Type Support Access
Intra-aortic balloon pump
Balloon counterpulsation
Pulsatile flow <0.5 L Arterial: 7�5 French
Impella RecoverLP 2�5
CPLP 5�0
Axial flow Continuous flow <2�5 L <4,0 L <5�0 L
Arterial: 12 FrenchArterial: 14 FrenchArterial: 21 French
Tandemheart
Centrifugal flow
<5�0 L
Continuous flow <5�0 L
Venous: 21 FrenchArterial: 15-17 French
Venous: 15-29 FrenchArterial: 15-29 French
Cardiohelp
(www�save-score�com)�
3.2p.55
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3.2p.56
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CHAPTER 4: CARDIAC ARREST AND CARDIOPULMONARY RESUSCITATION
THE CHAIN OF SURVIVAL
Monsieurs KG, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 1. Executive Summary. Resuscitation 2015; 95C:1-80, DOI:10.1016/j.resuscitation.2015.07.038
p.574
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OUT OF HOSPITAL CARDIAC ARREST: ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
VICTIM COLLAPSES
Victim respondsVictim unresponsive
Leave victim as foundFind out what is wrong
Reassess victim regularly Shout for helpOpen airway
Assess breathing
Not breathing normally
Call for an ambulanceStart CPR 30:2
Send or go for an AED
As soon as AED arrives
Start AED,listen to and follow voice prompts
AED Assesses rhythm
AED not available
30 chest compressions: 2 rescue breaths
Continue until victim starts to wake up: to move, open eyes, and breathe normally
No shock advised
Immediately resume CPR 30:2 for 2 min
Shock advised
1 shock
Immediately resumeCPR 30:2 for 2 min
Breathing normally
Put victim in recovery positionand call for an ambulance
Approach safelyCheck response
p.584OUT OF HOSPITAL CARDIAC ARREST:
Assessment of a collapsed victim and initial treatment
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OUT OF HOSPITAL CARDIAC ARREST: ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
VICTIM COLLAPSES
Victim respondsVictim unresponsive
Leave victim as foundFind out what is wrong
Reassess victim regularly Shout for helpOpen airway
Assess breathing
Not breathing normally
Call for an ambulanceStart CPR 30:2
Send or go for an AED
As soon as AED arrives
Start AED,listen to and follow voice prompts
AED Assesses rhythm
AED not available
30 chest compressions: 2 rescue breaths
Continue until victim starts to wake up: to move, open eyes, and breathe normally
No shock advised
Immediately resume CPR 30:2 for 2 min
Shock advised
1 shock
Immediately resumeCPR 30:2 for 2 min
Breathing normally
Put victim in recovery positionand call for an ambulance
Approach safelyCheck response
p.594
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IN-HOSPITAL CARDIAC ARREST: ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
Collapsed/sick patient
Shout for HELP & assess patient
YesNo
Assess ABCDERecognise & treat
oxygen; monitoring, i.v. access
Call resuscitationteam
CPR 30:2with oxygen and airway adjuncts
Call resuscitation teamif appropriate
Apply pads/monitorAttempt defibrillation
if appropriate
Handover to resuscitation teamAdvanced Life Supportwhen resuscitation team arrives
Signs of life?
p.604IN-HOSPITAL CARDIAC ARREST:
Assessment of a collapsed victim and initial treatment
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IN-HOSPITAL CARDIAC ARREST: ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
Collapsed/sick patient
Shout for HELP & assess patient
YesNo
Assess ABCDERecognise & treat
oxygen; monitoring, i.v. access
Call resuscitationteam
CPR 30:2with oxygen and airway adjuncts
Call resuscitation teamif appropriate
Apply pads/monitorAttempt defibrillation
if appropriate
Handover to resuscitation teamAdvanced Life Supportwhen resuscitation team arrives
Signs of life?
p.614
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IN-HOSPITAL CARDIAC ARREST: ADVANCED LIFE SUPPORT
Unresponsiveand not breathing
normally ?
Assessrhythm
CPR 30:2Attach defibrillator/monitor
Minimise interruptions
DURING CPR• Ensure high-quality chest compressions• Minimise interruptions to compressions• Give Oxygen• Use waveform capnography• Continuous chest compressions when advanced airway in place• Vascular access (intravenous, intraosseous) • Give adrenaline every 3-5 min• Give amiodarone after 3 shocks• Correct reversible causes
REVERSIBLE CAUSES • Hypoxia• Hypovolaemia• Hypo-/hyperkalaemia/metabolic• Hypothermia
• Thrombosis• Tamponade - cardiac• Toxins• Tension pneumothorax
Call resuscitationteam
Shockable(VF/Pulseless VT)
1 Shock Return ofspontaneous circulation
IMMEDIATE POST CARDIACARREST TREATMENT
Immediately resume:CPR for 2 min
Minimise interruptions
Non-shockable(PEA/Asystole)
Immediately resume:CPR for 2 min
Minimise interruptions • Use ABCDE approach• Aim for SaO2 94-98%• Aim for normal PaCO2
• 12-lead ECG• Treat precipitating cause• Temperature control / Therapeutic hypothermia
CONSIDER• Ultrasound imaging• Mechanical chest compressions to facilitate transfer/treatment• Coronary angiography and PCI• Extracorporeal CPR
p.624IN-HOSPITAL CARDIAC ARREST: Advanced life support
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IN-HOSPITAL CARDIAC ARREST: ADVANCED LIFE SUPPORT
Unresponsiveand not breathing
normally ?
Assessrhythm
CPR 30:2Attach defibrillator/monitor
Minimise interruptions
DURING CPR• Ensure high-quality chest compressions• Minimise interruptions to compressions• Give Oxygen• Use waveform capnography• Continuous chest compressions when advanced airway in place• Vascular access (intravenous, intraosseous) • Give adrenaline every 3-5 min• Give amiodarone after 3 shocks• Correct reversible causes
REVERSIBLE CAUSES • Hypoxia• Hypovolaemia• Hypo-/hyperkalaemia/metabolic• Hypothermia
• Thrombosis• Tamponade - cardiac• Toxins• Tension pneumothorax
Call resuscitationteam
Shockable(VF/Pulseless VT)
1 Shock Return ofspontaneous circulation
IMMEDIATE POST CARDIACARREST TREATMENT
Immediately resume:CPR for 2 min
Minimise interruptions
Non-shockable(PEA/Asystole)
Immediately resume:CPR for 2 min
Minimise interruptions • Use ABCDE approach• Aim for SaO2 94-98%• Aim for normal PaCO2
• 12-lead ECG• Treat precipitating cause• Temperature control / Therapeutic hypothermia
CONSIDER• Ultrasound imaging• Mechanical chest compressions to facilitate transfer/treatment• Coronary angiography and PCI• Extracorporeal CPR
p.634
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Give adrenaline and amiodaroneafter 3rd shock
Adrenaline: 1 mg i.v.(10 ml 1:10,000 or 1 ml 1:1000)
repeated every 3-5 min (alternate loops)given without interrupting
chest compressions
Amiodarone 300 mg bolus i.v.
Second bolus dose of 150 mg i.v.if VF/VT persists
followed by infusion of 900 mg over 24 h
Adrenaline: 1mg i.v. (10 ml 1:10,000 or 1 ml 1:1000)given as soon as circulatory access is obtained
Repeat every 3-5 min (alternate loops)Give without interrupting chest compressions
IN-HOSPITAL CARDIAC ARREST: DRUG THERAPY DURING ADVANCED LIFE SUPPORT
Cardiac Arrest
Non-shockable rhythm
Shockable rhythm(VF, pulseless VT)
p.644IN-HOSPITAL CARDIAC ARREST: Drug therapy during advanced life support
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p.655
CHAPTER 5: RHYTHM DISTURBANCES
5.1 SUPRAVENTRICULAR TACHYCARDIAS AND ATRIAL FIBRILLATION ���������������������������������������������������������������������������������������������� p�66J� Brugada
5.2 VENTRICULAR TACHYCARDIAS ������������������������������������������������������������������������� p�70M� Santini, C� Lavalle, S� Lanzara
5.3 BRADYARRHYTHMIAS ���������������������������������������������������������������������������������������������������� p�73B� Gorenek
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5.1
QRS morphology similar to QRS morphologyin sinus rhythm?
QRS morphology similar to QRS morphologyin sinus rhythm?
YES
QRS complex <120 msec
Supraventr.Tachycardia
QRS complex >120 msec
Supraventr.Tachycardia
+ BBB
QRS complex <120 msec
QRS complex >120 msec
Fascicular Tachycardiaor SVT with
aberrant conduction
(see chapter 5.1 page 67)
Ventricular Tachycardia or SVT with
aberrant conduction (see chapter 5.2
page 70)
QRS complex <120 msec
QRS complex >120 msec
AFconductingover AVN
AF + BBBor
AF + WPW
AF+
WPW
IrregularVentricular Tachycardia
Variable QRSmorphology
NO YES NO
TACHYARRHYTHMIAS: DIAGNOSTIC CRITERIATachycardia
> 100 beats/minute
IrregularRegular
p.66
TACHYARRHYTHMIAS: Diagnostic criteria
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• Concordant precordial pattern (all leads + or all leads –)• No RS pattern in precordial leads • RS pattern with beginning of R wave to nadir of S wave <100 msec
Consider SVT using
the AV node (AVNRT, AVNT)
Atrial flutteror atrial
tachycardia
VentricularTachycardia
VentricularTachycardia
VentricularTachycardia
Consider Sinus tachycardia
or non properadministration of
adenosine(too slow, insufficient
dose, etc)
Typicalmorphologyin V1 & V6
(see chapter 5.2page 70)
More As than Vs
More Vs than As
WideQRS complex
NarrowQRS complex
TACHYARRHYTHMIAS: DIAGNOSTIC MANEUVERSRegular tachycardia
Vagal maneuvers ori.v. adenosine
No changeTachycardia terminates
AV relation changes
p.675.1TACHYARRHYTHMIAS: Diagnostic maneuvers
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Hemodynamicallynon-stable
Immediate electricalcardioversion
No termination
Hemodynamicallystable
Vagal maneuversand/or i.v. Adenosine
Less than 48 hours since initiationAND
hemodynamically stable
CardioversionElectrical or pharmacological
using oral or i.v. flecainide(only in normal heart)or i.v. vernakalant
Anticoagulationis initiated using i.v. heparine
Hemodynamically non-stable
Immediate electricalCardioversion
If no cardioversion is considered:rate control using betablockers
or calcium antagonists,together with properanticoagulation,
if required
Narrow QRScomplex tachycardia
Reconsider diagnosis: sinus tachycardia, atrial tachycardia
If no evidence:Intravenous verapamil
Wide QRScomplex tachycardia
Reconsider the diagnosis of Ventricular Tachycardia even
if hemodynamically stable
Do not administerverapimil
More than 48 hours ORunknown time of initiation,
ANDPatient chronically anticoagulated
ORa TEE showing no thrombus
Electrical or pharmacologicalCardioversion
Termination
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (1)
Regular Supraventricular Tachycardias with or without bundle branch block
Irregular and narrow QRS complexTachycardia
p.68
TACHYARRHYTHMIAS: Therapeutic algorithms (1) 5.1
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Hemodynamically non-stable
Immediate electricalCardioversion
If no cardioversion is considered:rate control using betablockers orcalcium antagonists (only if VT andAF+WPW is excluded), together
with proper anticoagulationif required
Less than 48 hours since initiationAND
hemodynamically stable
Cardioversionelectrical or pharmacological
using oral or i.v. flecainide(only in normal heart)or i.v. amiodarone
Anticoagulationis initiated using i.v. heparin
More than 48 hoursor unknown initiation,
ANDpatient chronically anticoagulated or a TEE showing no thrombus
Electrical or pharmacologicalCardioversion
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (2)
Irregular and wide QRS complex Tachycardia
p.69TACHYARRHYTHMIAS: Therapeutic algorithms (2) 5.1
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VENTRICULAR TACHYCARDIAS: DIFERENTIAL DIAGNOSIS OF WIDE QRS TACHYCARDIA
EKG signs of atrio-ventricular dissociationRandom P waves unrelated to QRS complexesCapture beats / fusion beats / second degree V-A block
1st Step
2nd Step
3rd Step
Concordant pattern in precordial leadsNo RS morphology in any of the precordial leads
An interval >100 ms from the beginning of theQRS complex to the nadir of S in a precordial lead
Morphology in precordial leads
RBBB morphology LBBB morphology
Morphologyin aVR lead
Initial R wave
Initial R waveor q >40 msec
V1: qR, R, R’V6: rS,QS
V1: rsR’, RSR’V6: qRs
Aberrant conduction
V6: R V1: rS; R >30 ms,S nadir >60 ms,notching of the
S wave
V6: qR, QS
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Notch in thedescending
Q wave limb
Vi/Vt ≤1
VT
VT
Aberrant conduction
VT
p.70
VENTRICULAR TACHYSCARDIAS: Diferential diagnosis of wide QRS tachyscardias 5.2
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VENTRICULAR TACHYCARDIAS: DIFERENTIAL DIAGNOSIS OF WIDE QRS TACHYCARDIA
EKG signs of atrio-ventricular dissociationRandom P waves unrelated to QRS complexesCapture beats / fusion beats / second degree V-A block
1st Step
2nd Step
3rd Step
Concordant pattern in precordial leadsNo RS morphology in any of the precordial leads
An interval >100 ms from the beginning of theQRS complex to the nadir of S in a precordial lead
Morphology in precordial leads
RBBB morphology LBBB morphology
Morphologyin aVR lead
Initial R wave
Initial R waveor q >40 msec
V1: qR, R, R’V6: rS,QS
V1: rsR’, RSR’V6: qRs
Aberrant conduction
V6: R V1: rS; R >30 ms,S nadir >60 ms,notching of the
S wave
V6: qR, QS
Yes
Yes
Yes
No
No
No
Yes
No
No
No
No
Yes
Yes
Yes
Notch in thedescending
Q wave limb
Vi/Vt ≤1
VT
VT
Aberrant conduction
VT
p.715.2
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MANAGEMENT OF WIDE QRS TACHYCARDIASHemodynamic Tolerance
Stable
Regular rhythmIrregular rhythm
Vagal maneuverand/or
i.v. adenosine (push)
Differential Diagnosis• Sedation or analgesia• Synchronised cardioversion 100 to 200 J (monophasic) or 50-100 J (biphasic)
ACLS Resuscitation algorithm• Immediate high- energy defibrillation (200J biphasic or 360 monophasic)• Resume CPR and continue according to the ACLS algorithm
Drugs used in the ACLSalgorithm• Epinephrine 1 mg i.v./i.o. (repeat every 3-5min)• Vasopressin 40 i.v./i.o. • Amiodarone 300 mg i.v./i.o. once then consider an additional 150 mg i.v./i.o. dose• Lidocaine 1-1.5 mg/kg first dose then 0.5-0-75 mg/kg i.v./i.o. for max 3 doses or 3 mg/kg• Magnesium loading dose 1-2 gr i.v./i.o. for torsade des pointes
Interruption orslow down HR
Yes
YesNo
No
DifferentialDiagnosis
(see chapter 5.1page 67)
SVT
AF with aberrant ventricular conduction • β-blockers• i.v.• Verapamil or diltazem Pre excited AF • Class 1 AADs Polymorphic VT • Amiodarone
Amiodarone 150 mg i.v.(can be repeated up to a
maximum dose of 2.2 g in 24 h) Synchronised cardioversion
With pulsePulseless
Non-stable
p.72
Management of wide QRS TACHYSCARDIAS 5.2
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Sinus node dysfunction Atrioventricular (AV) blocks
• Sinus bradycardia. It is a rhythm that originates from the sinus node and has a rate of under 60 beats per minute
• Sinoatrial exit block. The depolarisations that occur in the sinus node cannot leave the node towards the atria
• Sinus arrest.Sinuspauseorarrestisdefinedasthe transient absence of sinus P waveson the ECG
• First degree AV block. Atrioventricular impulse transmission is delayed, resulting in a PR interval longer than 200 msec
• Second degree AV block. Mobitz type I (Wenckebach block): Progressive PR interval prolongation, which precedes a nonconducted P wave
• Second degree AV block. Mobitz type II: PR interval remains unchanged prior to a P wave that suddenly fails to conduct to the ventricles
• Third degree (complete) AV block.No atrial impulses reach the ventricle
p.73BRADYARRHYTHMIAS: Defi nitions and diagnosis 5.3
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• Rule out and treat any underlying causes of bradyarrhythmia• Treat symptomatic patients only
Temporary transvenous pacing
Be Careful! • Complications are common! • Shall not be used routinely •Useonlyasalastresourcewhenchronotropicdrugsareinsufficient • Every effort should be made to implant a permanent pacemaker as soon as possible,
if the indications are established.
Indications limited to: • High-degree AV block without escape rhythm • Life threatening bradyarrhythmias, such as those that occur during interventional
procedures, in acute settings such as acute myocardial infarction, drug toxicity.
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
p.74
BRADYARRHYTHMIAS: Treatment (1) 5.3
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Permanent pacemaker is indicated in the following settings:
• Documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms • Symptomatic chronotropic incompetence • Symptomatic sinus bradycardia that results from required drug therapy for medical conditions
Permanent pacemaker is not recommended in the following settings:
• Asymptomatic patients • Patients for whom the symptoms suggestive of bradycardia have been clearly documented to occur
in the absence of bradycardia • Symptomatic bradycardia due to nonessential drug therapy
p.75
BRADYARRHYTHMIAS: Treatment (2)Pacemaker therapies in sinus node dysfunction 5.3
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Permanent pacemaker therapy is indicated in the following settings regardless of associated symptoms:
• Third-degree AV block • Advanced second-degree AV block • Symptomatic Mobitz I or Mobitz II second-degree AV block • Mobitz II second-degree AV block with a wide QRS or chronic bifascicular block • Exercise-induced second- or third-degree AV block • Neuromuscular diseases with third- or second-degree AV block • Third- or second-degree (Mobitz I or II) AV block after catheter ablation or valve surgery when block
is not expected to resolve
Permanent pacemaker is not recommended in the following settings:
• Asymptomatic patients • Patients for whom the symptoms suggestive of bradycardia have been clearly documented to occur
in the absence of bradycardia • Symptomatic bradycardia due to nonessential drug therapy
p.76
BRADYARRHYTHMIAS: Treatment (3)Pacemaker therapies in atrioventricular blocks 5.3
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CHAPTER 6: ACUTE VASCULAR SYNDROMES
6.1 ACUTE AORTIC SYNDROMES ��������������������������������������������������������������������������������� p�78A� Evangelista
6.2 ACUTE PULMONARY EMBOLISM ����������������������������������������������������������������������� p�88A� Torbicki
TITRETITRETITRE
6p.77
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Classic aortic dissectionSeparation of the aorta media with presence
of extraluminal blood within the layers of the aortic wall�Theintimalflapdividestheaortaintotwolumina,thetrueandthefalse
Penetrating aortic ulcer (PAU)Atherosclerotic lesion penetrates
the internal elastic lamina of the aorta wall
Aortic aneurysm rupture (contained or not contained)
Intramural hematoma (IMH)Aortic wall hematoma with no entry tear andnotwo-lumenflow
ACUTE AORTIC SYNDROMES: Concept and classifi cation (1)Types of presentation 6.1
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DeBakey’s Classifi cation• Type I and type II dissections both originate in the ascending aorta IntypeI,thedissectionextendsdistallytothedescendingaorta IntypeII,itisconfinedtotheascendingaorta• Type III dissections originate in the descending aorta
Stanford Classifi cation• Type A includes all dissections involving the ascending aorta regardless of entry site location• Type B dissections include all those distal to the brachiocephalictrunk,sparingtheascendingaorta
Time course• Acute: < 14 days• Subacute: 15-90 days• Chronic: > 90 days
Copyright:NienaberCA,EagleKA.Aorticdissection:newfrontiersindiagnosisandmanagement:PartII:therapeuticmanagementandfollow-up.Circulation(2003);108(6),772-778.
AdaptedwithpermissionfromNienaberCA,EagleKA,Circulation2003;108(6):772-778.Allrightsreserved.
ACUTE AORTIC SYNDROMES: Concept and classifi cation (2)Anatomic classifi cation and time course 6.1
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SYMPTOMS AND SIGNS SUGGESTIVE OF AAS
• Abrupt and severe chest/back pain with maximum intensity at onset• Pulse/pressuredeficit - Peripheral or visceral ischemia -Neurologicaldeficit• Widened mediastinum on chest X -ray• Risk factors for dissection• Other - Acute aortic regurgitation - Pericardial effusion - Hemomediastinum/hemothorax
DIFFERENTIAL DIAGNOSIS
• Acute coronary syndrome (with/without ST-segment elevation)• Aortic regurgitation without dissection• Aortic aneurysms without dissection• Musculoskeletal pain• Pericarditis• Pleuritis• Mediastinal tumours• Pulmonary embolism• Cholecystitis• Atherosclerosis or cholesterol embolism
ACUTE AORTIC SYNDROME: Clinical suspicion and differential diagnosis 6.1
p.80
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Copyright:Hiratzkaetal.2010GuidelinesonThoracicAorticDisease.Circulation.(2010);121:page-310(fig25step2).
Consider acute aortic dissection in all patients presenting with:
• Chest, back or abdominal pain• Syncope• Symptoms consistent with perfusion deficit (central nervous system, visceral myocardial or limb ischemia)
Pre-test risk assessment for acute aortic dissection
• Marfan’s syndrome• Connective tissue disease• Family history of aortic disease• Aortic valve disease• Thoracic aortic aneurysm
• Perfusion deficit: - Pulse deficit - SBP differential - Focal neurological deficit• Aortic regurgitation murmur• Hypotension or shock
Chest, back or abdominal paindescribed as:
Abrupt at onset, severe in intensity, and ripping/sharp or stabbing quality
High-risk conditions High-risk pain features High-risk exam features
General approach to the patient with suspectedACUTE AORTIC SYNDROME 6.1
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Laboratory tests required for patients with ACUTE AORTIC dissection 6.1
Laboratory tests To detect signs of:
Red blood cell count Bloodloss,bleeding,anaemia
White blood cell count Infection,inflammation(SIRS*)
C-reactive protein Inflammatoryresponse
ProCalcitonin DifferentialdiagnosisbetweenSIRS*andsepsis
Creatine kinase Reperfusioninjury,rhabdomyolysis
TroponinIorT Myocardialischaemia,myocardialinfarction
D-dimer Aorticdissection,pulmonaryembolism,thrombosis
Creatinine Renal failure (existing or developing)
Aspartate transaminase/ alanine aminotransferase
Liverischaemia,liverdisease
Lactate Bowelischaemia,metabolicdisorder
Glucose Diabetes mellitus
Blood gases Metabolicdisorder,oxygenation
*SIRS=systemicinflammatoryresponsesyndrome.
Reference:EurHeartJ2014;eurheartj.ehu281.
p.82
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ACUTE CHEST PAIN 6.1ACUTE CHEST PAIN
High probability (score 2-3)or typical chest pain
Medical history + clinic al examination + ECG STEMIa : see ESC guidelines169
HAEMODYNAMIC STATEUNSTABLE
Low probability (score 0-1)TTE + TOE/CT°
STABLE
AASconfirmed
AASexcludedConsideralternatediagnosis
D-dimersd,e + TTE + Chest X-ray TTE
Consideralternatediagnosis
No argumentfor AD
Signsof AD
Widenedmedia- stinum
DefiniteType A -AD c
Inconclusive
Refer on emergencyto surgical team andpre-operative TOE
CT (or TOE)
AASconfirmed
Consideralternatediagnosisrepeat CT
if necessaryAAS
confirmedConsideralternatediagnosis
CT (MRI or TOE)b
a STEMI can be associated with AAS in rare cases�bPendinglocalavailability,patientcharacteristics,
and physician experience�cProofoftype-AADbythepresenceofflap,aorticregurgitation,and/orpericardialeffusion.
dPreferablypoint-of-care,otherwiseclassical.e Also troponin to detect non–ST-segment elevation
myocardial infarction�
Flowchart for decision-making based on pre-test sensitivity of acute aortic syndrome� Reference:EurHeartJ2014;eurheartj.ehu281.
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Details required from imaging in ACUTE AORTIC dissection 6.1
Aortic dissection •Visualizationofintimalflap• Extent of the disease according to the aortic anatomic segmentation•Identificationofthefalseandtruelumens(ifpresent)• Localization of entry and re-entry tears (if present)•Identificationofantegradeand/orretrogradeaorticdissection•Identificationgrading,andmechanismofaorticvalveregurgitation• Involvement of side branches•Detectionofmalperfusion(lowflowornoflow)•Detectionoforganischaemia(brain,myocardium,bowels,kidneys,etc.)• Detection of pericardial effusion and its severity• Detection and extent of pleural effusion• Detection of peri-aortic bleeding• Signs of mediastinal bleeding
Intramural haematoma
• Localization and extent of aortic wall thickening• Co-existence of atheromatous disease (calcium shift)• Presence of small intimal tears
Penetrating aortic ulcer
• Localization of the lesion (length and depth)• Co-existence of intramural haematoma• Involvement of the peri-aortic tissue and bleeding• Thickness of the residual wall
In all cases •Co-existenceofotheraorticlesions:aneurysms,plaques,signsofinflammatorydisease,etc.
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ACUTE AORTIC SYNDROMES MANAGEMENT: GENERAL APPROACH
ACUTE AORTIC DISSECTION
Type A(Ascending aorta
involvement)
Type B(No ascending
aorta involvement)
Uncomplicated
Medical treatment
Open Surgery with/without Endovascular
Therapy
Endovascular Therapy or
Open Surgery(TEVAR*)
Complicated(malperfusion,
rupture)
*TEVARThoracicEndovascularAorticRepair.
ACUTE AORTIC SYNDROMES MANAGEMENT: General approach 6.1p.85
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1 • Detailed medical history and complete physical examination (when possible)
2 • Standard 12-lead ECG:Rule-outACS,documentationofmyocardialischemia
3 • Intravenous line, blood sample(CK,Tn,myoglobin,whitebloodcount,D-dimer,hematocrit,LDH)
4 • Monitoring: HR and BP
5 • Pain relief (morphine sulphate) (see chapter 3)
6 • Noninvasive imaging (see previous page)
7 • Transfer to ICU
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
ACUTE AORTIC SYNDROMES: Initial management 6.1p.86
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URGENT SURGERY (<24h)
Emergency Surgery
Graft replacement of ascending aorta +/- arch with/without aortic valve or aortic root
replacement/repair (depending on aortic regurgitation and aortic root involvement)
ACUTE AORTIC SYNDROMES: SURGICAL MANAGEMENT
TYPE A ACUTE AORTIC DISSECTION TYPE B ACUTE AORTIC DISSECTION
• Haemodynamic instability (hypotension/shock) • Tamponade• Severe acute aortic regurgitation• Impending rupture• Flap in aortic root• Malperfusion syndrome
Elective/individualisedSurgery
• Non-complicated intramural hematoma• Comorbidities• Age >80 years
Definitive diagnosis
COMPLICATEDdefined as:
by clinical presentation and imaging
• Impending rupture • Malperfusion • Refractory HTN • SBP <90 mmHg) • Shock
UNCOMPLICATEDdefined as:
No features ofcomplicated dissection
MEDICALMANAGEMENT
and imagingsurveillance protocol• On admission• At 7 days• At discharge• Every 6 months thereafter
MEDICALMANAGEMENT
andTEVAR
MEDICALMANAGEMENT
and OPEN SURGERY
REPAIRif TEVAR
contraindicated
Yes No
ACUTE AORTIC SYNDROMES: Surgical management 6.1p.87
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p.88
Risk-adjusted management strategies in ACUTE PULMONARY EMBOLISM 6.2
Shock / hypotension?
Clinical suspicion
Assess clinical risk (PESI or SPESI)
Diagnostic algorithmas for suspected not high-risk PE
Diagnostic algorithm
as for suspected high-risk PE
Intermediate risk
Yes
PEconfirmed
Consider further riskstratificaiton
PESI Class III-IVor sPESI ≥ I
PESI Class I-IIorsPESI=0
PEconfirmed
No
RV function (echo or CT)a
Laboratory testingb
Both positive One positiveor both negative
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p.896.2
Intermediate-high risk Low riskc
A/C;monitoringconsider rescue
reperfusiond
HospitalizationA/Ce
Consider early discharge and
home treatment if feasiblef
Primary reperfusion
Intermediate-low riskHigh-risk
Reference:EurHeartJ2014;35:3033-3073.
aIfechocardiographyhasalreadybeenperformedduringdiagnosticwork-upforPEanddetectedRVdysfunction,oriftheCTalreadyperformedfordiagnosticwork–uphasshown RV enlargement (RV/LV (left ventricular) ratio ≥0.9,acardiactroponintestshouldbeperformedexceptforcasesinwhichprimaryreperfusionisnotatherapeuticoption (e�g� due to severe comorbidity or limited life expectancy of the patient)�
bMarkersofmyocardialinjury(e.g.elevatedcardiactroponinIorTconcentrationsinplasma),orofheartfailureasaresultof(right)ventriculardysfunction (elevated natriuretic peptide concentrations in plasma)� If a laboratory test for a cardiac biomarker has already been performed during initial diagnostic work-up (e�g� in the chestpainunit)andwaspositive,thenanechocardiogramshouldbeconsideredtoassessRVfunction,orRVsizeshouldbe(re)assessedonCT.
cPatientsinthePESIClassI-II,orwithsPESIof0,andelevatedcardiacbiomarkersorsignsofRVdysfunctiononimagingtests,arealsotobeclassifiedintotheintermediate-low risk category� This might apply to situations in which imaging or biomarker results become available before calculation of the clinical severity index� These patients are probably no candidates for home treatment�
dThrombolysis,if(andassoonas)clinicalsignsofhaemodynamicdecompensationappear;surgicalpulmonaryembolectomyorpercutaneouscatheter-directedtreatmentmaybeconsideredasalternativeoptionstosystemicthrombolysis,particularlyifthebleedingriskishigh.
eMonitoringshouldbeconsideredforpatientswithconfirmedPEandapositivetroponintest,evenifthereisnoevidenceofRVdysfunctiononechocardiographyorCT.
fThesimplifiedversionofthePESIhasnotbeenvalidatedinprospectivehometreatmenttrials;inclusioncriteriaotherthanthePESIwereusedintwosingle-armed (non-randomized) management studies�
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p.90ACUTE PULMONARY EMBOLISM: Diagnosis 6.2
CARDIOVASCULARSymptoms/Signs
including but not limited to:
Shock? orSBP <90 mmHg?
orSBP fall by >40 mmHg?
persisting > 15 min, otherwise unexplained
RESPIRATORYSymptoms/Signs
including but not limited to:
ACUTE PULMONARY EMBOLISM: DIAGNOSIS
YES NO
Dyspnea
• Chest pain (angina)• Syncope • Tachycardia• ECG changes• NT-proBNP ↑• Troponin ↑
• Chest pain (pleural)• Pleural effusion• Tachypnea• Hemoptysis• Hypoxemia• Atelectasis
Suspectacute
PE
Management algorithmfor UNSTABLE patients
Management algorithmfor initially STABLE patients
Reference:IACCTextbook(2015)chapter66Pulmonaryembolism-page638-figure66.1
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Management algorithm for unstable patients with suspected ACUTE PULMONARY EMBOLISM 6.2MANAGEMENT ALGORITHM FOR UNSTABLE PATIENTS WITH
SUSPECTED ACUTE PULMONARY EMBOLISM
CT angiography immediately availableand patient stabilised
Primary PA reperfusion
Primary PA reperfusion not justified
patient stabilised
No further diagnostictests feasible
Right heart,pulmonary artery or
venous thrombi?
Echocardiography(bedside)
CT*
Angio
RV pressure overload
CUS
No Yes
Yes
Yes positive
negative
No
TEE
Search for other causes
Reference:IACCTextbook(2015)chapter66Pulmonaryembolism-page639-figure66.2
*Consideralsopulmonaryangiographyifunstablepatient in hemodynamic lab�
p.91
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p.92
ACUTE PE: Management strategy for initially unstable patients with confirmed high risk pulmonary embolism 6.2
Shock or hypotension YES
Contraindications for thrombolysis No Relative Absolute
Primary PAreperfusion strategy
Thrombolysis
Low- dose transcatheterthrombolysis /
clot fragmetation
Surgical orPercutaneous catheter
embolectomy(availability/experience)
Supportive treatment
i.v. UFH, STABILISE SYSTEMIC BLOOD PRESSURE,CORRECT HYPOXEMIA
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p.93
Management algorithm for initially stable patients with suspected ACUTE PULMONARY EMBOLISM 6.2MANAGEMENT ALGORITHM FOR INITIALLY STABLE PATIENTS WITH
SUSPECTED ACUTE PULMONARY EMBOLISM
Asses clinical (pre-test) probalility
Low or intermediate“PE unlikely“
positive
negative D-dimer
CT angiography
negative positivenegative
Confirm by CUSV/Q scan or angiography
positive
CT angiography
CUS
CUSpositive
High or“PE likely“
Anticoagulationnot justified
Anticoagulationrequired
Anticoagulationnot justified
Anticoagulationrequired
Reference:IACCTextbook(2015)chapter66Pulmonaryembolism-page640-figure66.3
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p.94
Suggested management strategy for initially stable patients with (non-high risk) confirmed PE 6.2
Markers for myocardial injury Positive Positive Negative
Markers for RV overload Positive Positive Negative
Clinical risk assessment score (PESI) Positive (class III-V) Positive (class III-V) Negative (class I-II)
Suggested initial anticoagulation UFH i.v /LMWH s.c. LMWH/Fonda/
apixaban/ rivaroxaban apixaban/rivaroxaban
STRATEGY Monitoring (ICU)*
rescue thrombolysisHospitalisation**
(telemonitoring)Early
discharge***
*Whenallmarkersarepositive. **Whenatleastonemarkerispositive. ***Whenallmarkersarenegative.
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
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p.95PULMONARY EMBOLISM: Pharmacological treatment 6.2
Key drugs for initial treatment of patients with confirmed PEU
nsta
ble
Alteplase (rtPA) (intravenous) 100mg/2hor0�6 mg/kg/15 min (max 50 mg)
Urokinase (intravenous) 3millionIUover2h
Streptokinase (intravenous) 1.5millionIUover2h
Unfractionated heparin (intravenous) 80 IU/kg bolus + 18 IU/kg/h
Stab
le
Enoxaparine (subcutaneous) 1�0 mg/kg BID or 1�5 mg/kg QD
Tinzaparin (subcutaneous) 175 U/kg QD
Fondaparinux (subcutaneous) 7.5mg(50-100Kgofbodyweight)5mgforpatients<50kg,10 mg for patients >100 kg
Rivaroxaban (oral) 15 mg BID (for3weeks,then20mgQD)
Apixaban (oral) 10mgbid(for7days,than5mgbid)
For more information on individual drug doses and indications, see chapter 8: Use of drugs in acute cardiovascular care.
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p.966.2
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Chapter 5RHYTHM DISTURBANCES
5.1 Supraventriculartachycardiasandatrialfibrillation
5.2 Ventricular tachycardias
5.3 Bradyarrhythmias
CHAPTER 7: ACUTE MYOCARDIAL /PERICARDIAL SYNDROMES
7.1 ACUTE MYOCARDITIS ...................................................................................................... p.98A.Keren,A.Caforio
7.2 ACUTE PERICARDITIS AND CARDIAC TAMPONADE .......................................................................................... p.103C. Vrints, S. Price
p.977
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MYOCARDITIS (WHO /ISFC):
CAUSES OF MYOCARDITIS
Inflammatory disease of the myocardium diagnosed by established histological, immunological and immunohistochemical criteria.
INFECTIOUS TOXICIMMUNE-MEDIATED
• Viral• Bacterial• Spirochaetal• Fungal • Protozoal• Parasitic• Rickettsial
• Drugs • Heavy Metals• Hormones, e.g. catecholamines (Pheochromocytoma)• Physical agents
• Allergens: Tetanus toxoid, vaccines, serum sickness, Drugs• Alloantigens: Heart transplant rejection• Autoantigens: Infection-negative lymphocytic, infection-negative giant cell, associated with autoimmune or immune oriented disorders
p.98ACUTE MYOCARDITIS: Definition and causes 7.1
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Reference:CaforioALPetal.EurHeartJ.(2013)Jul3(15).
Clinical presentationswith or without ancillary findings Diagnostic criteria
•Acutechestpain(pericarditicorpseudo-ischemic)•New-onset(daysupto3months)orworsening dyspneaorfatigue,withorwithoutleft/rightheart failuresigns
•Palpitation,unexplainedarrhythmiasymptoms,syncope, abortedsuddencardiacdeath
•Unexplainedcardiogenicshockand/orpulmonaryoedema
I. ECG/Holter/stress test features:NewlyabnormalECGand/orHolterand/orstresstesting,anyofthefollowing:•ItoIIIdegreeatrioventricularblock,orbundlebranchblock, ST/Twavechanges(STelevationornonSTelevation,Twaveinversion),
•Sinusarrest,ventriculartachycardiaorfibrillationandasystole, atrialfibrillation,frequentprematurebeats,supraventriculartachycardia
•ReducedRwaveheight,intraventricularconductiondelay (widenedQRScomplex),abnormalQwaves,lowvoltage
II. Myocardiocytolysis markers: Elevated TnT/TnI
III. Functional/structural abnormalities on echocardiography•New,otherwiseunexplainedLVand/orRVstructureandfunctionabnormality(includingincidentalfindinginapparentlyasymptomaticsubjects):regionalwallmotionorglobalsystolicordiastolicfunctionabnormality,withorwithoutventriculardilatation,withorwithoutincreasedwallthickness,withorwithoutpericardialeffusion,withorwithoutendocavitarythrombi
IV. Tissue characterisation by CMR: Edemaand/orLGEofclassicalmyocarditicpattern
Ancillary findings which support the clinical suspicion of myocarditis
• Fever ≥38.0°Cwithinthepreceding30days•Arespiratoryorgastrointestinalinfection•Previousclinicallysuspectedorbiopsyprovenmyocarditis
•Peri-partumperiod•Personaland/orfamilyhistoryofallergicasthma•Othertypesofallergy•Extra-cardiacautoimmunedisease•Toxicagents•Familyhistoryofdilatedcardiomyopathy,myocarditis
p.99
ACUTE MYOCARDITIS: Diagnostic criteria (1)Diagnostic criteria for clinically suspected myocarditis 7.1
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OneormoreoftheclinicalpresentationsshownintheDiagnosticCriteria*
withorwithoutAncillaryFeatures*
ANDOneormoreDiagnosticCriteriafromdifferentcategories(ItoIV)*
OR
whenthepatientisasymptomatic,twoormorediagnosticcriteriafromdifferentcategories(ItoIV)*
in the absence of:1)angiographicallydetectablecoronaryarterydisease
2)knownpre-existingcardiovasculardiseaseorextra-cardiaccausesthatcouldexplainthesyndrome(e.g.valvedisease,congenitalheartdisease,hyperthyroidism,etc.)
Suspicion is higher with higher number of fulfilled criteria*
Endomyocardialbiopsyisnecessaryto:1)confirmthediagnosisofclinicallysuspectedmyocarditis,
3)identifythetypeandaetiologyofinflammation,and2)providethebasisforsafeimmunosuppression (invirusnegativecases).
*Seechapter7.1page99.Reference:CaforioALPetal.EurHeartJ.(2013)Jul3(16).
p.100
ACUTE MYOCARDITIS: Diagnostic criteria (2) Acute myocarditis should be clinically suspected in the presence of: 7.1
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Hemodynamically stable Preserved LV function
No eosinophiliaNo significant rhythm or conduction disturbances
Not associated with systemic immune disease*
General supportive therapy
General supportive therapyImmunosuppression if
unresponsive and virus negative EMB
Hemodynamically unstable,decreased LV function, cardiogenic shock
Pharmacological and, if needed,mechanical circulatory support (ECMO, LVAD/Bi-VAD,
bridge to heart transplant or to recovery)
Lymphocytic Giant cell, eosinophilic,sarcoidosis (acute decompensation)
Immunosuppressionif infection-negative EMB
ACUTE MYOCARDITIS: DIAGNOSTIC AND MANAGEMENT PROTOCOLHistory, Physycal examination; ECG; Echocardiogram; Laboratory tests
(Troponin, CRP, ESR, blood cell count, BNP); CMR; If available, serum cardiac autoantibodies
Clinically suspected myocarditis
Consider coronary angiography and EMB
No coronary artery disease
*Ifmyocarditisisassociatedwithsystemicimmunediseaseexacerbation,therapyoverlapswithtreatmentofthebackgrounddisease(usuallyimmunosuppression).
p.101ACUTE MYOCARDITIS: Diagnostic and management protocol 7.1
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• Patientswithalife-threateningpresentationshouldbesenttospecialisedunitswithcapability forhemodynamicmonitoring,cardiaccatheterisationandexpertiseinendomyocardialbiopsy.
• Inpatientswithhemodynamicinstabilityamechanical cardio-pulmonary assist device maybeneededasabridgetorecoveryortohearttransplantation.
• Heart transplantshouldbedeferredintheacutephase,becauserecoverymayoccur,butcanbeconsidered forhemodynamicallyunstablemyocarditispatients,includingthosewithgiantcellmyocarditis, ifoptimalpharmacologicalsupportandmechanicalassistancecannotstabilisethepatient
• ICD implantationforcomplexarrhythmiasshouldbedeferreduntilresolutionoftheacuteepisode,withpossibleuseofalifevestduringtherecoveryperiod.
Reference:CaforioALPetal.EurHeartJ.2013Jul3(18).
p.102
Management of patients with life-threatening ACUTE MYOCARDITIS 7.1
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ACUTE PERICARDITIS: DIAGNOSIS
DIAGNOSIS (≥ 2 of the following):
• Chest pain (pleuritic) varying with position• Pericardial friction rub• Typical ECG changes (PR depression and/or diffuse concave ST-segment elevation)• Echocardiography: new pericardial effusion
Yes
Myopericarditis if:↑ TroponinEchocardiography: ↓ LV-function
Acutepericarditis
Equivocal or no
Consider cardiac
MRI
Delayedenhancementpericardium
Consider alternative diagnoses
p.103ACUTE PERICARDITIS: Diagnosis 7.2
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ACUTE PERICARDITIS: MANAGEMENT
Acute pericarditis
High-risk features? • Fever >38°C • Subacute onset • Anticoagulated • Trauma • Immunocompromised • Hypotension • Jugular venous distension • Large effusion
Other causes• Post cardiac injury syndrome• Post cardiac surgery• Post MI: Dressler syndrome• Uremic• Neoplastic• Collagen vascular diseases (e.g. SLE)• Bacterial• Tuberculous
Yes
Hospital admissionStable
Ibuprofen + colchicineFurther testing for underlying etiology
Tamponade?
Pericardiocentesis
No
Most frequent cause:Viral pericarditis
Outpatient treatment
Aspirin 800 mg orIbuprofen 600 mg BID - 2 weeks
If persisting or recurrent chest pain :Add colchicine 0.5 mg once (<70 kg) or 0.5 mg BID (≥70 kg) for 3 monthsAvoid corticosteroids!
p.104
ACUTE PERICARDITIS: Management 7.2
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CARDIAC TAMPONADE: DIAGNOSIS AND MANAGEMENT
Tamponade ?
Tamponade
Echocardiographywith respirometer
• Presence of a moderate to large pericardial effusion
• Diastolic collapses of right atrium and right ventricle
• Ventricular interdependence
• Increased tricuspid and pulmonary flow velocities (>50%) with decreased mitral and aortic flow velocities (>25%) during inspiration (predictive value >90%)
Physical examination• Distended neck veins• Shock• Pulsus paradoxus• Muffled heart sounds
ECG• Sinus tachycardia• Microvoltage QRS• Electrical alternans
Cardiac catheterization Early• Right atrial pressure ↑• Loss of X-descent
Late• Aortic pressure ↓• Pulsus paradoxus• Intracardiac diastolic pressure equilibration
Percutaneous pericardiocentesis & drainage
Consider surgical drainageAvoid PEEP ventilation
Not performed in routine p.105
CARDIAC TAMPONADE: Diagnosis and management 7.2
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p.1067.2
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DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Chapter 5RHYTHM DISTURBANCES
5.1 Supraventriculartachycardiasandatrialfibrillation
5.2 Ventricular tachycardias
5.3 Bradyarrhythmias
CHAPTER 8: DRUGS USED IN ACUTE CARDIOVASCULAR CARE
AnadeLorenzo
p.107p.107Titre 88
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Asp
irin Primary(notuniversallyapproved)and
secondarycardiovasculardiseasepreventionLD(ifACS): 150-300mgoralMD: 75-100 mg oralQD
- Majorcontraindications:GIbleeding-activepepticulcer
Tica
grel
or ACS(allpatientsatmoderate-to-highriskofischaemicevents,e.g.elevatedcardiactroponins)
LD:180mgoralMD:90mgoralBID
- Majorcontraindications:previousintracerebralhemorrhage
Secondaryprevention1-3yearspost-MI
MD:60mgoralBID - Majorcontraindications:previousintracerebralhemorrhage
Pras
ugre
l ACSwithplannedPCI LD:60mgoralMD:10mgoralQD
MD:5mgQDweight<60kg
Contraindication:previousstroke/TIA Prasugrelisgenerallynotrecommendedinelderly,andifpositivebenefit/risk5mgisrecommended
Clop
idog
rel ACS+PCIormedicalmanagement(patients
whocannotreceiveticagrelororprasugrel)andinACSpatientsathighbleedingrisk(e.g.patientswhorequireoralanticoagulation)
LD:300-600mgoralMD:75mgoralQD
- -
p.108Oral antiplatelets 8
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Clop
idog
rel STEMI
+fibrinolysis<75yearsLD:300mgoralMD:75mgoralQD
-
Prasugrelandticagrelorhavenotbeenstudiedasadjunctstofibrinolysisandoralanticoagulants
STEMI +fibrinolysis≥ 75 years
LD:75mgoral. MD:75mgoralQD
-
Secondaryprevention>12monthspost coronarystenting
MD:75mgoralQD -
Vora
paxa
r Co-administeredwithaspirinand,whereappropriate,clopidogrel,inpatientswithahistoryofMIorperipheralarterydisease
2.08mgoralQD - Initiatedatleast2weeksafteraMIandpreferablywithinthefirst12months Majorcontraindications:activepathologicbleedingorincreasedriskofbleeding,historyofstroke/TIAorintracranialbleeding,severehepaticdysfunction
p.1098Oral antiplatelets (Cont.)
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Abc
ixim
ab
AdjuncttoPCIforbailoutsituationsorthromboticcomplications
LD:0.25mg/Kgi.v.MD:0.125μg/Kg/mini.v.(max:10μg/min)for12h
- Contraindications:Activeinternalbleeding-HistoryofCVAwithin2years-Bleedingdiathesis-Preexistingthrombocytopenia-Recent(within2months)intracranialorintraspinalsurgeryortrauma-Recent(within2months)majorsurgery-Intracranialneoplasm,arteriovenousmalformation,oraneurysm-Severeuncontrolledhypertension-Presumedordocumentedhistoryofvasculitis-Severehepaticfailureorsevererenalfailurerequiringhaemodialysis-Hypertensiveretinopathy
Eptifi
batid
e
ACStreatedmedicallyorwithPCI LD:180μg/Kgi.v.(ata10mininterval)IfSTEMIandPCI:addasecond180mcg/kgi.v.bolusat 10 minMD:2μg/Kg/mini.v.infusion
Reduceinfusiondoseto1μg/kg/minifCrCl30-50ml/min
Contraindications:Bleedingdiathesisorbleedingwithintheprevious30days-Severeuncontrolledhypertension-Majorsurgerywithinthepreceding6weeks-Strokewithin30daysoranyhistoryofhemorrhagicstroke-CoadministrationofanotherparenteralGPIIb/IIIainhibitor-Dependencyonrenaldialysis-Knownhypersensitivitytoanycomponentoftheproduct
p.1108Intravenous Antiplatelets
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Tiro
fiban
ACStreatedmedicallyorwithPCI LD:25μg/Kgi.v.over5minMD:0.15μg/Kg/mini.v.Infusionto18hour
CrCl<30ml/min:decrease 50% bolusandinfusiondose
Contraindications:SeverehypersensitivityreactiontotirofibanAhistoryofthrombocytopeniafollowingpriorexposureActiveinternalbleedingorahistoryofbleedingdiathesis,majorsurgicalprocedureorseverephysicaltraumawithinthepreviousmonth
Cang
relo
r
AllpatientsundergoingPCI(elective+ACS)immediateonset+rapidoffset(plateletrecoveryin60min)
IVBolusof30μg/Kg+ IVinfusionof 4μg/kg/minForatleast2hoursfromstartofPCI
- Majorcontraindications:significantactivebleedingorstrokeTransitiontooralP2Y12inhibitorsvariableaccordingtotypeofagent
p.1118Intravenous Antiplatelets (Cont.)
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
War
farin
A
ceno
coum
arol Treatmentandprophylaxis
ofthrombosisINRgoalof2-3(INR:2.5-3.5formechanicalmitralvalveprosthesesordoublevalvereplacement)
Assessingindividualrisksforthromboembolismandbleeding
-
Dab
igat
ran
PreventionofstrokeandsystemicembolisminNVAF
150mgoralBID 110 mg BID (ifage≥80,increasedbleedingriskorconcomitantuseofverapamil)
ContraindicatedifCrCl<30ml/minorseverehepaticimpairmentActivepathologicalbleedingIdarucizumab: specificantidote(notyetavailable)
TreatmentofDVTandPEinpatientswhohavebeentreatedwithaparenteralanticoagulantfor5-10daysandpreventionofrecurrentDVTandPEinpatientswhohavebeenpreviouslytreated
150mgoralBID
p.112Oral Anticoagulants 8
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Riva
roxa
ban
PreventionofstrokeandsystemicembolisminNVAF
20mgoralQD CrCl<50ml/min:15mgQD ContraindicatedifCrCl<15ml/minorhepaticdiseaseassociatedwithcoagulopathyandclinically relevant bleedingrisk
TreatmentofDVTandPEandpreventionofrecurrentDVT and PE
15mgoralBIDforthefirst3weeksfollowedby20mgQD
Reducethemaintenancedoseto 15mgQDifbleedingriskoutweighstheriskforrecurrentDVTandPE(notformallyapproved)
PreventionofatherothromboticeventsafteranACS
2.5mgoralBID -
Api
xaba
n
PreventionofstrokeandsystemicembolisminNVAF
5mgoralBID 2.5mgoralBID1)whenatleast2ofthefollowingcharacteristics: age ≥80, Cr>1.5mg/dlorweight<60Kg2)whenCrCl15-29mL/min
ContraindicatedifCrCl<15ml/minorseverehepaticimpairment
TreatmentofDVTandPE 10mgoralBIDforthefirst7daysfollowedby5mgoralBID
-
PreventionofrecurrentDVT and PE
2.5mgoralBID -
p.1138Oral Anticoagulants (Cont.)
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
UFH
NSTE-ACS LD:4000IUi.v.MD:1000IU/hi.v. TargetaPTT:50-70sor1.5to2.0timesthatofcontroltobemonitoredat3,6,12and24h
Monitoringforheparin-induced thrombocytopenia(HIT)Dose-independentreaction
STEMI PrimaryPCI:70-100IU/Kgi.v.whennoGP-IIb/IIIainhibitorisplanned.50-60IU/Kgi.v.boluswithGP-IIb/IIIainhibitors-Fibrinolysis/Noreperfusion:60IU/kgi.v.bolus(max:4000IU)followedbyani.v.infusionof12IU/kg(max:1000IU/h)for24-48h
TargetaPTT:50-70sor1.5to2.0timesthatofcontroltobemonitoredat3,6,12and24h
TreatmentofDVTandPE 80IU/Kgi.v.bolusfollowedby18IU/Kg/h
AccordingtoaPTT,thromboembolicandbleedingrisk
Fond
apar
inux
NSTE-ACS 2.5mgQDs.c. - Severe hepatic impairment:cautionadvisedContraindicatedifCrCl<20ml/minContraindicatedforDVT/PEtreatmentifCrCl<30ml/min
STEMI Fibrinolysis/Noreperfusion:2.5mgi.v.bolusfollowedby2.5mgQDs.c.upto8daysorhospitaldischarge
-
TreatmentofDVTandPE 5mgQDs.c.(<50kg);7.5mgQDs.c.(50-100kg);10mgQDs.c.(>100kg)
If>100KgandCrCl30-50ml/min:10mgfollowedby7.5mg/24hs.c.
PreventionofVTE 2.5mgQDs.c. CrCl20-50ml/min:1.5mgQDs.c.
p.114Intravenous/Subcutaneous Anticoagulants 8
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Drug Indications Dose Dose adjustments Comments
Biva
lirud
in
PCIforNSTE-ACS 0.75mg/kgi.v.bolusfollowedimmediatellyby1.75mg/kg/hinfusionwhichmaybecontinuedforupto4hpostPCIasclinicallywarrantedandfurthercontinuedatareducedinfusiondoseof0.25mg/kg/hfor4-12hasclinicallynecessary
PatientsundergoingPCIwithCrCl30-50ml/minshouldreceivealowerinfusionrateof1.4mg/kg/h.Nochangeforthebolusdose.
ContraindicatedifCrCl<30ml/min
PCIforSTEMI 0.75mg/kgi.v.bolusfollowedimmediatellyby1.75mg/kg/hinfusionwhichshouldbecontinuedforupto4haftertheprocedureAftercessationofthe1.75mg/kg/hinfusion,areducedinfusiondoseof0.25mg/kg/hmaybecontinuedfor4-12h
PCIforelectivecases 0.75mg/kgi.v.bolusfollowedimmediatellyby1.75mg/kg/hinfusionwhichmaybecontinuedforupto4hpostPCIasclinicallywaranted
p.1158Intravenous/Subcutaneous Anticoagulants (Cont.)
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Drug Indications Dose Dose adjustments Comments
Enox
apar
in
NSTE-ACS 30mgi.v.+1mg/kgs.c.BID If>75years:noLDandMD 0.75mg/KgBIDs.c.CrCl<30ml/min:noLDandMD1mg/KgQDs.c.If>75yearsandCrCl<30ml/min:noLDand0.75mg/KgQDs.c.
MonitoringforHIT-AntiXamonitoringduringtreatmentwithLMWHmightbehelpfulinpregnancy,extremebodyweightsandrenal impairment.
STEMI PrimaryPCI:0.5mg/Kgi.v.bolusFibrinolysis/Noreperfusion:a)Age<75y:30mgi.v.bolusfollowedby1mg/KgBIDs.c.untilhospitaldischargeforamaxof8days-Thefirsttwodosesshouldnotexceed100mgb)Age>75y:nobolus;0.75mg/KgBIDs.c.-Thefirsttwodosesshouldnotexceed 75 mg
InpatientswithCrCl<30ml/min:regardlessofage,thes.c.dosesaregivenoncedaily
TreatmentofDVTandPE 1mg/Kgs.c.BIDor1.5mg/Kgs.c.QD CrCl<30ml/min:1mg/Kg/24hs.c.
PreventionofVTE 40mgs.c.QD CrCl<30ml/min:20mgs.c.QD
Intravenous/Subcutaneous Anticoagulants (Cont.)p.116
8
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Drug Indications Dose Dose adjustments Comments
Tinz
apar
in
PreventionofVTE 3500IUs.c.QD(moderaterisk)4500IUs.c.QD(highrisk)
- MonitoringforHIT-AntiXamonitoringduringtreatmentwithLMWHmightbehelpfulinpregnancy,extremebodyweightsandrenal impairment - Dalteparin: Incancerpatients,doseof200IU/kg(max:18000IU)/24hfor1month,followedby150IU/kg/24hfor5months-Afterthisperiod,vitaminKantagoraLMWHshouldbecontinuedindefinitelyoruntilthecancerisconsideredcured
TreatmentofDVTandPE 175IU/Kgs.c.QD -
Dal
tepa
rin
PreventionofVTE 2500IUs.c.QD(moderaterisk)5000IUs.c.QD(highrisk)
-
TreatmentofDVTandPE 200IU/KgQDor100IU/KgBIDs.c. AntiXamonitoringifrenalimpairment
Arg
atro
ban Anticoagulantinpatients
withHITInitiali.v.infusiondose:2μg/kg/min(nottoexceed10μg/kg/min)PatientsundergoingPCI:350μg/kgi.v.followedby25μg/kg/mini.v.
Renal and hepatic impairment: cautionadvised
MonitoredusingaPTTgoal: 1.5to3.0timestheinitialbaselinevaluePCI:ACTgoal:300-450s
Intravenous/Subcutaneous Anticoagulants (Cont.)p.117
8
DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
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Drug Indications Dose Dose adjustments Comments
Stre
ptok
inas
e (S
K) STEMI 1.5millionunitsover30-60mini.v. - Absolute contraindications to
fibrinolytics:
PreviousintracranialhaemorrhageorstrokeofunknownoriginatanytimeIschaemicstrokeinthepreceding6monthsCentralnervoussystemdamageorneoplasmsoratrioventricularmalformationRecentmajortrauma/surgery/headinjury(withinthepreceding3weeks)GastrointestinalbleedingwithinthepastmonthKnownbleedingdisorder(excludingmenses)AorticdissectionNon-compressiblepuncturesinthepast24h(e.g.liverbiopsy,lumbarpuncture)
TreatmentofPE 250000IUasaLDover30min,followedby100000IU/hover12-24h
-
Alte
plas
e (t
PA)
STEMI 15mgi.v.bolus:0.75mg/kgover30min(upto50mg)then0.5mg/kgover60mini.v.(upto35mg)
-
TreatmentofPE Totaldoseof100mg:10mgi.v.bolusfollowedby90mgi.v.for2h
Ifweight<65Kg:maxdose<1.5mg/kg
p.118Fibrinolytics 8
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Drug Indications Dose Dose adjustments Comments
Rete
plas
e
(rt-
PA)
STEMI 10units+10unitsi.v.bolusgiven 30 min apart
Renal and hepatic impairment: cautionadvised
Absolute contraindications to fibrinolytics:
PreviousintracranialhaemorrhageorstrokeofunknownoriginatanytimeIschaemicstrokeinthepreceding6monthsCentralnervoussystemdamageorneoplasmsoratrioventricularmalformationRecentmajortrauma/surgery/headinjury(withinthepreceding3weeks)GastrointestinalbleedingwithinthepastmonthKnownbleedingdisorder(excludingmenses)AorticdissectionNon-compressiblepuncturesinthepast24h(e.g.liverbiopsy,lumbarpuncture)
Tene
ctep
lase
(T
NK
-tPA
)
STEMI Over10seconds;Singlei.v.bolus:30mgif<60kg35mgif60to<70kg40mgif70to<80kg45mgif80to<90kg50mgif≥90kg
-
p.1198Fibrinolytics (Cont.)
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Drug Indications Dose Dose adjustments Comments
Beta-blockers:Preferredovercalciumchannelblockers-Contraindicatedifcoronaryspasm,severebradycardia,AVblock,severebronchospasm
Ate
nolo
l NSTE-ACS LD:25-100mgoral MD:25-100mgQD
Elderly: start at alowerdoseCrCl:15-35ml/min:maxdose50mg/day;CrCl<15ml/min:maxdose25mg/day
OnlyifnormalLVEF
STEMI 25-100mgQD,titrateastoleratedupto100mgQDonlyifnoLVSDorCHF
Carv
edilo
l NSTE-ACS LD:3.125-25mgoral MD: 3.125-25 mg BID
Cautioninelderlyandhepatic impairment
PreferredifLVSD/HF
STEMI 3.125-6.25mgBID,titratedastoleratedupto50mgBID
Biso
prol
ol NSTE-ACS LD:1.25-10mgoral MD:1.25-10mgQD
Cautioninrenalorhepatic impairment
PreferredifLVSD/HF
STEMI 1.25-5mgQD,titrateastoleratedupto10mgQD
p.120Antiischemic drugs 8
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Drug Indications Dose Dose adjustments Comments
Beta-blockers:Preferredovercalciumchannelblockers-Contraindicatedifcoronaryspasm,severebradycardia,AVblock,severebronchospasm
Met
opro
lol NSTE-ACS LD:25-100mgoral
MD: 25-100 mg BIDCautioninhepaticimpairment
PreferredifLVSD/HF
STEMI 5-25mgBID,titrateastoleratedupto200mgQD
Calcium antagonists: Considerifbeta-blockersarecontraindicated.Firstoptioninvasospasticangina
Vera
pam
il ACS LD:80-120mgoralMD:80-240mgTID-QD
Cautioninelderly,renalorhepaticimpairment
Contraindicatedifbradycardia,HF,LVSD
Dilt
iaze
m ACS LD:60-120mgoralMD:60-300mgTID-QD
Cautioninelderlyandhepatic impairment
Contraindicatedifbradycardia,HF,LVSD
p.1218Antiischemic drugs (Cont.)
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DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Calcium antagonists: Considerifbeta-blockersarecontraindicated.Firstoptioninvasospasticangina
Am
lodi
pine ACS LD:5-10mgoral,MD:5-10mgQD Cautioninhepatic
impairmentContraindicatedifhypotension
Nitrates
Nitr
ogly
cerin
i.v.
ACS Ifintolerantorunresponsivetonitroglycerins.l.5μg/min-Increaseby5mcg/minq3-5minupto20μg/min-If20mcg/minisinadequate,increaseby10to20μg/minevery3to5min-Maxdose:400μg/min
- Contraindicatedifseverehypotensionandco-administrationwithphosphodiesteraseinhibitorsThemostcommonadverseeffectsareheadacheanddizziness
Useglassbottlesfornitroglycerini.v.administration
spra
y Angina 1-2puffs.l.every5minasneeded,upto3puffin15min
-
subl
ingu
al
tabl
et
Angina 0.3to0.6mgs.l.orinthebuccalpouchevery5minasneeded,upto3dosesin15min
-
p.122Antiischemic drugs (Cont.) 8
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Drug Indications Dose Dose adjustments Comments
Isos
orbi
de
mon
onitr
ate
Angina 5-10mgBIDwiththetwodosesgiven7hapart(8amand3pm)todecreasetolerancedevelopment-thentitrateto10mgBIDinfirst2-3daysExtended release tablet: Initial: 30-60 mg given inthemorningasasingledose Titrateupwardasneeded,givingatleast3daysbetweenincreasesMaxdailysingledose:240mg
- Contraindicatedifseverehypotensionandco-administrationwithphosphodiesteraseinhibitorsThemostcommonadverseeffectsareheadacheanddizziness
Isos
orbi
de
dini
trat
e
Angina Initialdose:5to20mgorally2or3times/dayMD:10to40mgorally2or3timesadayExtendedrelease:40to160mg/dayorally
-
Nitr
ogly
cerin
tr
ansd
erm
al
pat
ch
Angina 0.2to0.4mg/hpatchappliedtopicallyonceadayfor12to14hperday;titrateasneededandtoleratedupto0.8mg/h
-
p.1238Antiischemic drugs (Cont.)
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Drug Indications Dose Dose adjustments Comments
Other antiishemic drugs
Ivab
radi
ne
Stableangina
5-7.5mgoralBID CautioninelderlyandCrCl<15ml/min
Contraindicatedifseverehepaticimpairment
Rano
lazi
ne
Stableangina
Initialdose:375mgoralBIDAfter2-4weeks,thedoseshouldbetitratedto500mgBIDand,accordingtothepatient’sresponse,furthertitratedtoarecommendedmaxdoseof750mgBID
Usewithcautioninrenal and hepatic impairment,CHF,elderly,lowweight
ContraindicatedifCrCl<30ml/min,concomitantadministrationofpotentCYP3A4inhibitors,moderateorseverehepaticimpairment
Trim
etaz
idin
e Stableangina
Modified-release:35mgoralBID Cautioninelderlyand30<CrCl<60ml/min
Contraindicatedinparkinsondisease,parkinsoniansymptoms,tremors,restlesslegsyndrome,movementdisorders,severerenalimpairment
p.1248Antiischemic drugs (Cont.)
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Drug Indications Dose Dose adjustments Comments
Statins: Secondary prevention of cardiovascular disease: startwithhighdosesanddowntitrateifsideeffectsTargetLDL-Clevels<70mg/dlinitiatedearlyafteradmission
Atorvastatin - Contraindicatedinpatientswithactiveliverdiseaseorwithunexplainedelevationofliverfunctionenzymelevels
Rosuvastatin CrCl<30ml/min:start5mgQD,max:10mgQD
PitavastatinCrCl30-59ml/min:start1mgQD,max2mg/day;CrCl10-29ml/min:notdefined
Simvastatin Severe renal impairment: start5mgQPM
Fluvastatin Cautioninsevererenalimpairment
Pravastatin Significantrenalimpairment:start10mgQD
Lovastatin CrCl<30ml/min: cautionifdose>20mgQD
LDL-C reduction
<30% 30-40% 40-50% >50%
Simva 10 mg Simva 20-40 mg Simva 40 mg Ator80mg
Lova20mg Ator10mg Ator20-40 mg
Simva/ezet40/10mg
Prava 20-40 mg
Prava 40 mg Rosu10-20 mg
Rosu40mg
Fluva 40 mg Fluva 80 mg Pita 4 mg
Pita 1 mg Rosu5mg Simva/ezet20/10mg
Pita 2 mg
p.125Hypolipidemic drugs 8
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Drug Indications Dose Dose adjustments Comments
Others
Ezetimibe Hyperlipidemia 10mgoralQD Avoiduseifmoderate-severe hepatic impairment
-
FenofibrateHyperlipidemia 48-160mgoralQD
Mayadjustdoseq4-8weeksCrCl50-90ml/min: start48-54mgQD
ContraindicatedifCrCl<50ml/minorhepatic impairment
Gemfibrozil
Hyperlipidemia 900-1200mg/dayoral ContraindicatedifsevererenalimpairmentorhepaticdysfunctionStatins may increase muscletoxicity:avoidconcomitantuse
Evolocumab PCSK9inhibitor(notyetavailable).Mostcommonsideeffects:nasopharyngitis,upperrespiratorytractinfection,headacheandbackpain
p.1268Hypolipidemic drugs (Cont.)
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Drug Indications Dose Dose adjustments Comments
ACEI
Capt
opril
HF Start:6.25mgoralTID Targetdose:50mgTID
CrCl>50ml/min:75-100%ofthenormaldoseCrCl10-50ml/min:25-50%CrCl<10ml/min:12.5%
Checkrenalfunction,electrolytes,druginteractions
Majorcontraindications:Historyofangioedema,knownbilateralrenalarterystenosis,pregnancy(risk)
HTN Start:12.5mgoralBID Targetdose:25-50mgTID Max450mg/day
Enal
april HF,HTN Start:2.5mgoralBID
Targetdose:10-20mgBIDCrCl30-80ml/min:start5mg/dayCrCl10-30ml/min:start2.5mg/day
Lisin
opril
HF Start:2.5-5.0mgoralQD Targetdose:20-35mgQD
CrCl31-80ml/min:start5-10mg/dayCrCl10-30ml/min:start2.5-5mg/dayCrCl<10ml/min:start2.5mg/day
HTN 10-20mgoralQD Max:80mgQD
p.127Heart failure & hypertension 8
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Drug Indications Dose Dose adjustments Comments
Perin
dopr
il HF Start:2.5mgoralQDMax:5mgQD
CrCl>60ml/min:start5mg/dayCrCl31-60ml/min:start2.5mg/dayCrCl15-30ml/min:start2.5mgalternatedaysCrCl<15ml/min:start2.5mg/dayonthedayofdialysis
Checkrenalfunction,electrolytes,druginteractions
Majorcontraindications:Historyofangioedema,knownbilateralrenalarterystenosis,pregnancy(risk)
HTN Start:2.5-5mgQDTargetdose:10mgQD
Ram
ipril HF,HTN Start:2.5mgoralQD
Targetdose:5mgBIDCrCl<40ml/min:start1.25mgQD,max5mg/dayCautioninelderlyandhepaticimpairment
Tran
dola
pril HF Start:0.5mgoralQD
Targetdose:4mgQDCrCl<30ml/minorseverehepaticimpairment:start 0.5 mg
HTN 2-4mgoralQD CrCl<30ml/minorseverehepaticimpairment:start 0.5 mg
p.1288Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
ARB
Cand
esar
tan HF,HTN Start:4-8mgoralQD
Targetdose:32mgQDIfrenalorhepaticimpairment:start4mg/day
IfACEIisnottolerated.Checkrenalfunction,electrolytes,druginteractions
Majorcontraindications:Historyofangioedema,knownbilateralrenalarterystenosis,pregnancy(risk)
Losa
rtan
HF Start:50mgoralQDTargetdose:150mgQD
CrCl<20ml/min:25mgQDCautionifhepaticimpairment
HTN 50-100mgoralQD CrCl<20ml/min:25mgQDCautionifhepaticimpairment
Valsa
rtan
HF Start:40mgoralBIDTargetdose:160mgBID
Ifmild-moderatehepaticimpairment:maxdose80mg/day
HTN 80-160mgQD Ifmild-moderatehepaticimpairment:maxdose80mg/day
p.1298Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Beta-blockers:Check12-leadECG
Card
iose
lect
ive
Ate
nolo
l HTN Start:25mgoralQD Usualdose:50-100mgQD
CrCl10-50ml/min: decreasedose50% CrCl<10ml/min: decreasedose75%
Majorcontraindications:asthma,2ndor3rddegreeAVblock
Biso
prol
ol
HF Start:1.25mgoralQD Targetdose:10mgQD
CrCl<20ml/min: maxdose10mgQD Hepaticimpairment:avoiduse
HTN Start:2.5-5mgoralQD Usualdose:5-10mgQD Maxdose:20mgQD
Met
opro
lol HF Start:12.5-25mgoralQD Targetdose:200mgQD
Hepaticimpairment:startwithlowdosesand titrate gradually
HTN 100-400mgQD Maxdose:400mgQD
p.130Heart failure & hypertension (Cont.) 8
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Drug Indications Dose Dose adjustments Comments
Beta-blockers:Check12-leadECG
Card
iose
lect
ive
Neb
ivol
ol
HF Start:1.25mgoralQD Targetdose:10mgQD
Renalimpairmentorelderly: startdose2.5mgQD,titrateto5mgQD Hepaticimpairment:contraindicated
Majorcontraindications:asthma,2ndor3rddegreeAVblock
HTN Start:2.5mgoralQD Usualdose:5mgQD
Non
-car
dios
elec
tive
Carv
edilo
l
HF Start:3.125mgoralBID Targetdose:25-50mgBID
Cautioninelderly Contraindicatedifhepaticimpairment
HTN Start:12.5mgoralQD Usualdose:25mgQD andmaxdose:25mgBID or50mgQD
p.1318Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Other vasodilators
Am
lodi
pine
HTN Start:5mgoralQD,increaseafter 1-2weeks Max:10mg/day
Elderlyorsecondaryagent: start2.5mgQD Hepatic impairment: start2.5mgQD
Contraindicatedifcardiogenicshock,2ndor3rddegreeAVblock,severehypotension
Nife
dipi
ne
HTN Extended-releaseform: Start20mgoralBIDorTID Max: 60 mg BID
Renal and hepatic impairment: cautionadvised
Clev
idip
ine HTN InitiatetheIVinfusionat4ml/h(2mg/h);
thedosemaybedoubledevery90seconds UptitrationuntildesiredBPrange is achieved Halflifeof1-2min
Thedesiredtherapeuticresponseformostpatientsoccursatdosesof8-12ml/h (4-6mg/h) Themaxrecommendeddoseis64ml/h(32mg/h)
Hypersensitivitytosoy,peanut,oreggproducts CriticalAorticstenosis,mitralstenosis,HOCM
p.1328Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Other vasodilators
Vera
pam
il HTN Immediate-release form: Dose:80-120mgoralTID; Start:80mgTID; Max:480mg/day
Start40mgoralTIDinelderlyorsmallstature patients
Contraindicatedifbradycardia,HF,LVSD
Loop diuretics
Furo
sem
ide HF 20-40mgi.v.bolus,continuous100mg/6h
(adjustbasedonkidneyfunctionandclinicalfindings;monitorcreatinine)
Anuria:contraindicated Cirrhosis/ascites:cautionadvised
-
HTN 10-40mgoralBID
Tors
emid
e HF 10-20mgoralori.v.QD Hepaticimpairment:initialdoseshouldbereducedby50%anddosageadjustmentsmadecautiously
-
HTN 5mgoralori.v.QD Max10mgQD
p.1338Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Thiazides
Chlo
rtha
lidon
e HF 50-100mgoralQD MD:25-50mgQD
Elderly:maxdose25mg/day CrCl<25ml/min:avoiduse
-
HTN Start12.5-25mgoralQD; Max:50mg/day
Elderly:maxdose25mg/day CrCl<25ml/min:avoiduse
-
Hyd
roch
loro
thia
zide HF 25-200mgoral/day CrCl<25ml/min:avoiduse
Hepaticimpairment:cautionadvised-
HTN Start12.5-25mgoralQD MD:mayincreaseto50mgoralasasingleor2divideddoses
CrCl<25ml/min:avoiduse Hepaticimpairment:cautionadvised
-
p.1348Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Thiazides
Inda
pam
ide HTN Start1.25mgPOQAMx4weeks,
thenincreasedoseifnoresponse Max:5mg/day
CrCl<25ml/min:avoiduse Hepaticimpairment:cautionadvised
-
Aldosterone-antagonists
Spiro
nola
cton
e HF Start25mgoralQD Targetdose:25-50mgQD
CrCl<10ml/min,anuriaoracuterenalimpairment:contraindicated Severe hepatic impairment and elderly: cautionadvised
Checkrenalfunction,electrolytes, druginteractions ProducesgynecomastiaHTN 50-100mg/dayoral
p.1358Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Aldosterone-antagonists
Eple
reno
ne
HF Start25mgoralQD Targetdose:50mgQD
Elderly:cautionadvised CrCl<50ml/min:contraindicated
Checkrenalfunction,electrolytes,druginteractions Majorcontraindications: strongCYP3A4inhibitorsHTN 50mgoralQD-BID
Max:100mg/day
Others
Ivab
radi
ne HF 5-7.5mgoralBID CautioninelderlyandCrCl<15ml/min Contraindicatedifseverehepatic impairment
p.1368Heart failure & hypertension (Cont.)
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Drug Indications Dose Dose adjustments Comments
Levo
simen
dan HF/cardiogenic
shockLD:6to12μg/kgi.v.over10min(givenonlyifimmediateeffectisneeded)followedby0.05to0.2μg/kg/minasacontinuousinfusionfor24h
AvoiduseifCrCl<30ml/minorsevere hepatic impairment
CalciumsensitizerandATP-dependentpotassiumchannelopener
Milr
inon
e
HF/cardiogenicshock
50μg/kgi.v.in10-20min,continuous 0.375-0.75μg/kg/min
Renal:Samebolus.Adjustinfusion:CrCl50ml/min:start0.43μg/kg/minCrCl40ml/min:start0.38μg/kg/minCrCl30ml/min:start0.33μg/kg/minCrCl20ml/min:start0.28μg/kg/minCrCl10ml/min:start0.23μg/kg/minCrCl5ml/min:start0.20μg/kg/min
Phosphodiesteraseinhibitor
Cautionifatrialflutter
Hypotensivedrug
Isop
rena
line/
Is
opro
tere
nol Cardiogenic
shock0.5-5μg/min(0.25-2.5mlofa1:250,000dilution)i.v.infusion
- ß1,ß2agonist.Contraindicatedinpatientswithtachyarrhythmia,tachycardiaorheartblockcausedbydigitalisintoxication,ventriculararrhythmiaswhichrequireinotropictherapy,anginapectoris,recentACS,hyperthyroidism
Bradyarrhythmias Bolus:20-40μgi.v.Infusion:0.5μg/minof2mg/100mlnormalsaline
p.137Inotropics & vasopressors 8
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Drug Indications Dose Dose adjustments Comments
Dob
utam
ine Cardiogenic
shock2-20μg/kg/mini.v. - ß1,a1/ß2agonist.
Increasescontractilitywithlittleeffectonheartrateandbloodpressure.ReducespulmonaryandsystemicVR,PCP
Dop
amin
e Cardiogenicshock
Dopaminergiceffect: 2-5μg/Kg/mini.v.ßeffect:5-15μg/Kg/mini.v.aeffect:15-40μg/Kg/mini.v.
- ß,a,dopaminergicagonistIncreasesBP,PAP,heartrate,cardiacoutputandpulmonaryandsystemicVRMorearrhythmogenicthandobutamineandnoradrenaline
Nor
adre
nalin
e Cardiogenicshock
0.05-0.2μg/kg/mini.v.titratetoeffect
- a 1,ß1agonistIncreases BP and PAPLittlearrhythmogenic
p.1388Inotropics & vasopressors (Cont.)
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Drug Indications Dose Dose adjustments Comments
Group I
Proc
aina
mid
e i.v
.
AF (termination);stableVT(withapulse)
15-18mg/kgi.v.over60min,followedbyinfusionof1-4mg/min
ReduceLDto12mg/kginsevererenalimpairmentReduceMDbyone-thirdinmoderaterenalimpairmentandbytwo-thirdsinsevererenal impairmentCautioninelderlyandasthma
Hypotension(negativeinotropicagent)Lupus-likesyndromeContraindicatedifmyastheniagravis,AVblock,severerenalimpairment
Lido
cain
e i.v
.
PulselessVT/VF 1-1.5mg/kgi.v./i.o.bolus(cangiveadditional0.5-0.75mg/kgi.v./i.o.pushevery5-10minifpersistentVT/VF,maxcumulativedose=3mg/kg),followedbyinfusionof1-4mg/min
1-2mg/mininfusionifliverdiseaseorHF ContraindicatedifadvancedAVblock,bradycardia,hypersensitivitytolocalanestheticsCautioninHF,renalimpairmentand elderlyMaycauseseizures,psychosis.StopifQRSwidens>50%
StableVT(withapulse)
1-1.5mg/kgi.v.bolus(cangiveadditional0.5-0.75mg/kgi.v.pushevery5-10minifpersistentVT,maxcumulativedose=3mg/kg),followedbyinfusionof1-4mg/min
1-2mg/mininfusionifliverdiseaseorHF
p.139Antiarrhythmics 8
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Drug Indications Dose Dose adjustments Comments
Group I
Flec
aini
de i.
v.
SVT,ventricular arrhythmias
2mg/kg(max150mg)i.v.over30minThismaybefollowedbyaninfusionatarateof1.5mg/kg/hfor1h,reducedto0.1-0.25mg/kg/hforupto24h,maxcumulativedose=600mg
Severe renal impairment: cautionadvised
Contraindicatedifcardiogenicshock,recentMI,2ndor3rddegreeAVblock
Prop
afen
one
i.v. PSVT,
ventricular arrhythmias
LD:0.5-2mg/kgi.v.directoveraminimumof3-5minMD:0.5-2.5mg/kgi.v.directq8h(max560mg/day)orcontinuousinfusionupto23mg/h
Mayneedtoreducedoseinrenalorhepaticfailure
ContraindicatedifunstableHF,cardiogenicshock,AVblock,bradycardia,myastheniagravisseverehypotension,bronchospasticdisorders,Brugadasyndrome
p.1408Antiarrhythmics (Cont.)
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Drug Indications Dose Dose adjustments Comments
Group II
Ate
nolo
l i.v
.
Arrhythmias 2.5mgi.v.over2.5minevery5min(max10mg)
Cautioninelderlyand/orsevererenal impairment
Contraindicatedifcardiogenicshock,bradycardiaandgreaterthanfirst-degreeblock,unstableHF
Met
opro
lol
i.v.
Arrhythmias 2.5-5mgi.v.over5min,may repeat every 5 min (max15mg)
Cautionifsevere hepatic impairment
Contraindicatedifcardiogenicshock,bradycardiaandgreaterthanfirst-degreeblock,unstableHF
Prop
rano
lol
i.v.
Arrhythmias Initiallygivenasslowi.v.bolusesof1mg,repeated at 2 min intervals (max:10mginconsciouspatientsand5mgifunderanesthesia)
- Contraindicatedifcardiogenicshock,bradycardiaandgreaterthanfirst-degreeblock,asthma,unstableHF
p.141Antiarrhythmics (Cont.) 8
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Drug Indications Dose Dose adjustments Comments
Group III
Am
ioda
rone
i.v.
AF(termination) 5mg/Kgi.v.over30min,followedbyinfusionof1mg/minfor6h,then0.5mg/min
- Reduceinfusionrateifbradycardia,AVblock,hypotension
BolusshouldbeavoidedifhypotensionorsevereLVdysfunction
Highly vesicant agent
StableVT(withapulse)
150mgi.v.over10minfollowedbyinfusionof1mg/minfor6h,then0.5mg/min
-
PulselessVT/VF 300mgbolusi.v.(cangiveadditional150mgi.v.bolusifVF/VTpersists)followedbyinfusionof900mgover24h
-
Dro
neda
rone
ParoxysmalorpersistentAFprevention
400mgoralBID - Contraindicatedifsevererenalorliverdysfunction,LVSD,symptomaticHF,permanentAF,bradycardia…(multiplecontraindications)
p.1428Antiarrhythmics (Cont.)
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Drug Indications Dose Dose adjustments Comments
Group IV
Dilt
iaze
m
i.v.
PSVT;AF(ratecontrol) 0.25mg/kgi.v.over2min(mayrepeatwith0.35mg/kgi.v.over2min),followedbyinfusionof5-15mg/h
Hepatic impairment: cautionadvised
-
Vera
pam
il i.v
.
PSVT;AF(ratecontrol) 2.5-5mgi.v.over2min(mayrepeatuptomaxcumulativedoseof20mg);canfollowwithinfusionof2.5-10mg/h
- ContraindicatedifAF+WPW,tachycardiasQRS(exceptRVOT-VT),fascicularVT,bronchospasm,age>70Antidote:-LVD:Calciumgluconate,dobutamine-Bradycardia/AVblock:Atropine,Isoproterenol
Ade
nosin
e i.v
.
RapidconversiontoanormalsinusrhythmofPSVTincludingthoseassociatedwithaccessoryby-passtracts(WPWsyndrome)
Rapidi.v.bolusesseparatedby2min:
6 mg → 6 mg → 12 mg
- Contraindicatedifsicksinussyndrome,secondorthirddegreeAtrio-Ventricular(AV)block(exceptinpatientswithafunctioningartificialpacemaker),chronicobstructivelungdiseasewithevidenceofbronchospasm(e.g.asthmabronchiale),longQTsyndrome,severehypotension;decompensatedstatesofheartfailure-AdenosinecancauseAF
p.1438Antiarrhythmics (Cont.)
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 143 16/06/2016 10:14
DISCLAIMER:Theguidancesuggestedinthisdocumentdoesnotoverridetheindividualresponsibilityofthehealthcareprofessionaltomakeappropriatedecisionsaccordingtoeachpatient’scircumstancesandprofile,aswellaslocalregulationsandlicenses.
Drug Indications Dose Dose adjustments Comments
Others
Mag
nesiu
m
sulfa
te
VT-TorsadesdePointes Bolus:1-2gi.v./i.o.over5minPerfusion:5-20mg/mini.v.
Cautionifsevererenalfailure
Contraindicatedifmyastheniagravis
Vern
akal
ant Acuteatrialfibrillation 3mg/kgi.v.over10min.IfAFpersists,
asecond10-min-infusionof2mg/kg,15minlatermaybeadministered
- ContraindicatedifACSwithinthelast30days,severeaorticstenosis,SBP<100mmHg,HFclassNYHAIII/IV,severebradycardia,sinusnodedysfunctionor2ndor3rddegreeheartblock
p.1448Antiarrhythmics (Cont.)
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 144 16/06/2016 10:14
APTT = Activated partial thromboplastin timeAB = Airway and breathingABG = Arterial blood gasAADs = Antiarrhythmic drugsAAS = Acute aortic syndromeACEI = Angiotensin converting enzyme inhibitorACLS = Advanced cardiovascular life supportACS = Acute coronary syndromeACT = Activated clotting timeAD = Aortic DissectionAED = Automated external defibrillator AF = Atrial fibrillationAo = Aortic aPRR = Activated partial thromboplastin timeARB = Angiotensin receptor blockersAS = Aortic stenosisAV = Atrioventricular AVN = Atrioventricular nodeAVNRT = Atrioventricular nodal re-entrant tachycardiaAVNT = Atrioventricular nodal tachycardiaBID = Twice a day
BBB = Bundle branch blockBLS = Basic life support BNP = Brain natriuretic peptideBP = Blood pressureCABG = Coronary artery bypass graftingCAD = Coronary artery diseaseCath Lab = Catheterisation laboratoryCCU = Coronary care unitCHF = Congestive heart failureCMR = Cardiovascular magnetic resonanceCOPD = Chronic obstructive pulmonary diseaseCPAP = Continuous positive airway pressure CPR = Cardiopulmonary resuscitationCrCI = Creatinine clearanceCS = Cardiogenic shockCSM = Carotid sinus massage CSNRT = Corrected sinus node recovery timeCSS = Carotid sinus syndromeCT = Computed tomographyCT-angio = Computed tomography angiographyCUS = Compression venous ultrasound
p.145
Abbreviations
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 145 16/06/2016 10:14
CV = Cardiovascular CXR = Chest X-rayDD = Dyastolic dysfunctionDM = Diabetes mellitusDVT = Deep vein thrombosis ECG = ElectrocardiogramED = Emergency department EG = ElectrogramsEMB = Endomyocardial biopsyEMS = Emergency medical servicesEPS = Electrophysiological study ERC = European Resuscitation CouncilESR = Erythrocyte sedimentation rate ETT = Exercice treadmill testing FMC = First medical contactGER = Gastroesophageal refluxGFR = Glomerular flow rateGI = GastrointestinalGP = GlycoproteinHF = Heart failureHTN = Hypertension
HR = Heart ratehsTn = High-sensitive troponinIABP = Intra-aortic balloon pump ICC = Intensive cardiac careICCU = Intensive cardiac care unitICD = Implantable cardioverter defibrillatorIHD = Ischemic heart diseaseIMH = Intramural hematomaISFC = International Society and Federation of Cardiologyi.o. = Intraosseous IV = Invasive ventilationi.v. = IntravenousKD = Kidney diseaseLBBB = Left bundle branch blockLD = Loading doseLGE = Late gadolinium enhancement LMWH = Low-molecular weight heparinLOC = Loss of consciousness LV = Left ventricularLVD = Left ventricular dysfunctionLVEF = Left ventricular ejection fraction
p.146
Abbreviations
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 146 16/06/2016 10:14
LVH = Left ventricular hypertrophyLVSD = Left ventricular systolic dysfunctionMCS = Mechanical circulatory support MD = Maintenance doseMDCT = Computed tomography with >4 elementsMI = Myocardial infarctionMRI = Magnetic resonance imagingMvo = Microvascular obstructionNIV = Non-invasive ventilationNOAC = New oral anticoagulantsNSAID = Non-steroidal anti-inflammatory drugsNSTEACS = Non-ST-elevation ACSNSTEMI = Non ST-segment elevation myocardial infarction NTG = NitroglycerinNT-proBNP = N-terminal pro brain natriuretic peptideNVAF = Non-valvular atrial fibrillationNYHA = New York Heart AssociationOH = Orthostatic hypotensionPAP = Pulmonary arterial pressurePAU = Penetrating aortic ulcer PCI = Percutaneous coronary intervention
PCM = Physical counter-measures PCP = Pulmonary capillary pressurePE = Pulmonary embolismPEA = Pulmonary endarterectomyPEEP = Positive end expiratory pressurePR = Pulmonary regurgitation ProCT = ProcalcitoninPRN = Pro re nata PSVT = Paroxysmal supraventricular tachycardiaQD = Once a dayQPM = Every eveningrtPA = Recombinant tissue plasminogen activatorRV = Right ventricularRVOT-VT = Right ventricular outflow tract ventricular tachycardiaSBP = Systemic blood pressures.c = SubcutaneousSLE = Systemic lupus erythematosusSMU = Syncope management unitsSTE-ACS = ST-segment elevation acute coronary syndromeSTEMI = ST-segment elevation myocardial infarction
p.147
Abbreviations
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 147 16/06/2016 10:14
SVT = Supraventricular tachycardiaSpO2 = Oxygen saturation TEE = Transesophageal echocardiographyTEVAR = Thoracic endovascular aortic aneurysm repairTIA = Transient ischemic attack TID = Three times a dayTLOC = Transient loss of consciousnessTn = TroponinTOE = Transoesopageal echocardiographyTSH = Thyroid-stimulating hormone TTE = Transthoracic echocardiographyUFH = Unfractionated heparinULN = Upper limit of normalVF = Ventricular fibrillationVR = Vascular resistanceVT = Ventricular tachycardia VTE = Venous thromboembolismVVS = Vasovagal syncopeWHO = World Health OrganizationWPW = Wolff-Parkinson-White
p.148
Abbreviations
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 148 16/06/2016 10:14
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p.149
Notes
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 149 16/06/2016 10:14
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p.150
Notes
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 150 16/06/2016 10:14
�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
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Notes
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Notes
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�����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
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Notes
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A Registered Branch of the ESC
AcuteCardiovascularCare AssociationUNITED IN QUALITY CARE - JOIN ACCA
livre_assemble-TOOLKIT_V2-148x105-ENG.indb 154 16/06/2016 10:14
Reproduced With permission of Oxford University Press (UK) © European Society of Cardiology
Habib G, et al. 2015 ESC Guidelines for the management of infective endocarditis. European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv319
Priori, SG, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv316
Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases. European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv318
Roffi M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv320
Erbel R, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases. European Heart Journal Aug 2014, DOI: 10.1093/eurheartj/ehu281
Konstantinides SV, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism. European Heart Journal Nov 2014, 35 (43) 3033-3073; DOI: 10.1093/eurheartj/ehu283
Lip GYH, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI) and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS) and Asia-Pacific Heart Rhythm Society (APHRS). European Heart Journal Dec 2014, 35 (45) 3155-3179; DOI: 10.1093/eurheartj/ehu298
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References and copyright acknowledgments
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Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal Oct 2014, 35 (37) 2541-2619; DOI: 10.1093/eurheartj/ehu278
Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European Heart Journal (2013); July 3. DOI: 10.1093/eurheartj/eht210
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European Heart Journal (2012) DOI: 10.1093/eurheartj/ehs104
Steg G, James SK Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal (2012); DOI: 10.1093/eurheartj/ehs215
Steg PG, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. European Heart Journal Oct 2012, 33 (20) 2569-2619; DOI: 10.1093/eurheartj/ehs215
Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. ESC Guidelines for the diagnosis and management of syncope. European Heart Journal (2009); DOI:10.1093/eurheartj/ehp298
Reproduced with permission from John Wiley & Sons © European Society of Cardiology
Mebazaa A et al. Eur J Heart Fail. (2015); Recommendations on pre-hospital and early hospital management of acute heart failure. DOI:10.1093/eurheartj/ehv066
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Disclaimer and CopyrightsThis is a publication of the Acute Cardiovascular Care Association (ACCA), a Registered Branch of the European Society of Cardiology. Its content reflects the opinion of the authors based on the evidence available at the time it was written and does not necessarily imply an endorsement by ACCA or the ESC.The guidance suggested in the Toolkit does not override the individual responsibility of the healthcare professional to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.Some content, illustrations/tables/figures were inspired and/or adapted from ESC Guidelines and other existing sources, with permission granted by the original publishers.
AcknowledgementsWe are indebted to all the authors for their commitment and for the strong effort to synthesise their wide scientific knowledge and clinical experience into simple algorithms and schemes using the aim to help clinicians in everyday clinical practice in the easiest possible manner as the main driver of their work.
The support of this initiative by the ACCA board members was essential to launch this initiative as was the hard work of the ESC staff to make this project move forward.
The financial support of the sponsors, AstraZeneca and Novartis Pharma AG, made the development of the Toolkit easier. We appreciate the generous unrestricted educational grants and the independence to develop the Toolkit with no influence whatsoever in the selection of faculty, topics, clinical or scientific content.
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A Registered Branch of the ESC
AcuteCardiovascularCare Association
TOOLKIT ONLINE VERSION
Acute Cardiovascular Care Association Clinical Decision-Making
TOOLKIT
European Society of CardiologyAcute Cardiovascular Care Association (ACCA)
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Tel.: +33 (0)4 92 94 76 00 - Fax: +33 (0)4 92 94 86 46Email: [email protected]
FLASH ME www.escardio.org/ACCA
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