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Clinical Practice Guidelines

for Acute Coronary Syndrome General System of Social Security in Health -‐ Colombia

For health professionals GPC-‐2013-‐17

National Research Center on Evidence and Health Technology CINETS

© Ministry of Health and Social Protection -‐ Colciencias

Quick Reference Guide. Guidelines for Acute Coronary Syndrome GSSS – CPG-‐2013-‐17

ISBN: 978-‐958-‐8838-‐16-‐8 Bogotá, Colombia

Legal Note: In all cases in which this ACS-‐CPG is to be used for the management of health sector organizations in Colombia, both copyright ownership belonging to the Ministry and the University of Antioquia co-‐authorship, represented by the ACS-‐CPG Development Group, should be disclosed. No partial or complete reproduction of the ACS-‐CPG is allowed without the authorization of the Ministry of Health and Social Protection.

This document should be cited as follows: Colombia. Ministry of Health and Social Protection, Colciencias, University of Antioquia. Quick Reference Guide. Guidelines for Acute Coronary Syndrome. ACS-‐CPG. Bogotá, 2013. CPG-‐2013-‐17

MINISTRY OF HEALTH AND SOCIAL PROTECTION Alejandro Gaviria Uribe Minister of Health and Social Protection

Fernando Ruiz Gómez Deputy Minister of Health and Services

Norman Julio Muñoz Muñoz Deputy Minister of Social Protection

Burgos Gerardo Bernal Secretary General

José Luis Ortiz Hoyos Head of the Office of Quality

COLCIENCIAS

Carlos Fonseca Zárate General Director

Paula Marcela Arias Pulgarín Deputy General Director

Arleys Cuesta Simanca Secretary General

Alicia Rios Hurtado Director of Knowledge Networks

Carlos Caicedo Escobar Director of Research Development

Vianney Motavita García Health Program Manager in Science, Technology and Innovation

INSTITUTE OF TECHNOLOGY ASSESSMENT IN HEALTHCARE Héctor Eduardo Castro Jaramillo Executive Director

Aurelio Mejía Mejía Deputy Director of Health Technology Assessment

Iván Darío Flórez Gómez Assistant Production Director of Clinical Practice Guidelines

Diana Esperanza Rivera Rodríguez Assistant Director of Participation and Deliberation

Raquel Sofía Amaya Arias Dissemination and Communication Branch

Guide Development Group

Coronary Syndrome CCG Leader JUAN MANUEL SÉNIOR SÁNCHEZ Medical Doctor, specialist in Internal Medicine, specialist in Clinical Cardiology University of Antioquia

CCG Coordinator U of A LUZ HELENA LUGO AGUDELO Medical, physiatrist, Master in Clinical Epidemiology University of Antioquia

Development Team NATALIA ACOSTA BAENA Medical Doctor, Master in Clinical Sciences University of Antioquia JORGE LUIS ACOSTA REYES Medical Doctor, Master in Clinical Sciences University of Antioquia JAMES DÍAZ BETANCUR Medical Doctor, specialist in Internal Medicine, Master in Clinical Sciences University of Antioquia OSCAR HORACIO OSÍO URIBE Medical Doctor, specialist in Internal Medicine, Master in Clinical Epidemiology University of Antioquia JESÚS ALBERTO PLATA CONTRERAS Medical Doctor, specialist in Physical Medicine and Rehabilitation, Master in Clinical Sciences University of Antioquia CLARA INÉS SALDARRIAGA GIRALDO Medical Doctor, specialist in Internal Medicine, specialist in Cardiology University of Antioquia ERIK JAVIER TRESPALACIOS ALIES Medical doctor specialist in Internal Medicine, specialist in Cardiology Universidad de Antioquia JUAN MANUEL TORO ESCOBAR Medical Doctor, specialist in Internal Medicine, specialist in Cardiology

University of Antioquia

CCG Implementation MARÍA DEL PILAR PASTOR Nurse, MA in Public Health, Ph.D. in Public Health Sciences

International Reviewer AGUSTIN CIAPPONI Cochrane Center Coordinator Argentina Scientific Secretary of the Association of Family Medicine in Argentina

Economic Group AURELIO ENRIQUE MEJÍA MEJÍA SARA ATEHORTÚA BECERRA MATEO CEBALLOS GONZÁLEZ MARÍA ELENA MEJÍA PASCUALES CAROLINA RAMÍREZ ZULUAGA

Patient guide MARÍA STELLA MORENO VÉLEZ Bachelor Degree in Nutrition and Dietetics Antioquia University CLAUDIA MARCELA VÉLEZ Medical Doctor, specialist in Public Health and Social Security management, MA in Clinical Sciences University of Antioquia

Support Group PAULA ANDREA CASTRO GARCÍA GILMA HERNÁNDEZ HERRERA ÁNGELA MARÍA OROZCO GIRALDO JESENIA AVENDAÑO RAMÍREZ PAOLA ANDREA RAMÍREZ PÉREZ

Editorial Board JUAN MANUEL SENIOR SÁNCHEZ LUZ HELENA LUGO AGUDELO NATALIA ACOSTA BAENA PAOLA ANDREA RAMÍREZ PÉREZ

Design and Illustrations MAURICIO RODRIGUEZ SOTO

External subject experts and representatives of scientific societies

WILSON RICARDO BOHÓRQUEZ RODRÍGUEZ Medical Doctor, specialist in Internal Medicine, specialist in Cardiology Pontificia Javierana University

FERNÁN DEL CRISTO MENDOZA Medical Doctor, specialist in Internal Medicine, specialist in Cardiology, and specialist in Critical and Intensive Care Medicine, specialist in Bioethics, specialist in Clinical Epidemiology Colombian Society of Cardiology and Cardiovascular Surgery

EDUARDO RAMÍREZ VALLEJO Medical Doctor, specialist in Internal Medicine, specialist in Cardiology Colombian Association of Internal Medicine

MANUEL URINA TRIANA Medical Doctor, specialist in Internal Medicine, specialist in Cardiology, specialist in Hemodynamics and Interventional Cardiology, MA in Clinical Epidemiology Pontificia Javierana University

JUAN JOSÉ VÉLEZ CADAVID Medical Doctor, specialist in Emergency Medicine, specialist in Critical and Intensive Care Medicine

SEBASTIÁN VÉLEZ PELÁEZ Medical Doctor, specialist in Internal Medicine, specialist in Cardiology, specialist in Echocardiography Colombian Association of Internal Medicine

Participating Entities Colombian Association of Internal Medicine (ACMI, for its initials in Spanish) Colombian Society of Cardiology and Cardiovascular Surgery Colombian Association of Physical Medicine and Rehabilitation Academic Clinical Epidemiology Group of the University of Antioquia (GRAEPIC, for its initials in Spanish) Health Rehabilitation Research Group (GRS, for its initials in Spanish) Sustainability Strategy U of A 2013-‐2014 Cardiovascular Disease Study Group Health Economics Research Group at the University of Antioquia (GES, for its initials in Spanish) CINETS Alliance

39

Content

7 Introduction

11 Initial care and pre-‐hospital treatment 1. Pre-‐hospital drug therapy 12 2. Pre-‐hospital fibrinolysis 12

13 Emergency care and hospitalization 3. Risk classification 13 4. Diagnostic methods with non-‐diagnostic electrocardiogram 14

and negative biomarkers of myocardial necrosis 5. Drug therapy in Acute Coronary Syndrome 14

with and without ST-‐segment elevation 6. ACS revascularization therapy without ST elevation 30 7. ACS revascularization therapy with ST elevation 33 8. Three vessel or left main coronary artery disease 38

Secondary prevention 9. Drug therapy in secondary prevention 39 10. Controlling cardiovascular risk factors 41 11. Nutritional program 42 12. Cardiopulmonary exercise testing 42 13. Cardiac rehabilitation 42

6 I University of Antioquia

Ministry of Health and SociaL Protection -‐ Colciencias 7

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Introduction

In Colombia, ischemic heart disease in the last decade has been the leading cause of death in people over 55 years of age, surpassing cancer and violence. Understanding this priority in our country, as part of the call 500 of 2009, there was a need to develop the first Clinical Practice Guideline (CPG) for patients with acute coronary syndrome (ACS) in Colombia.

Despite the effects caused by atherosclerotic disease and, particularly, its manifestation in ACS, there is sufficient evidence to demonstrate that an appropriate intervention, backed by a specific CPG, can modify disease progression and minimize damage with a subsequent decrease in mortality and an improvement in the quality of life.

The preparation of this CPG was conducted by the University of Antioquia in conjunction with CINETS Alliance, formed by two other universities: Pontificia Javeriana University and the National University of Colombia. Other participating organizations were the Colombian Association of Internal Medicine and the Colombian Society of Cardiology and Cardiovascular Surgery, the Colombian Association of Physical Medicine and Rehabilitation, the Health Rehabilitation Research Group, the Academic Group of Clinical Epidemiology of the University of Antioquia (GRAEPIC, for its initials in Spanish), the Health Rehabilitation Research Group, the Cardiovascular Disease Study Group, and the Research Group on Health Economics at the University of Antioquia.

8 University of Antioquia

Introduction

The Comprehensive Care Guide (CCG) of patients with ACS aims to standardize comprehensive treatment with the highest possible clinical consensus from the current available scientific evidence, considering the knowledge and experience of the development group and taking into account patient preferences.

The development of the CPG for ACS was an integrative research project to prepare recommendations based on evidence or proof of published scientific studies with explicit evaluation of the effectiveness, harm, and cost-‐benefit ratio. Each recommendation answers a scientific question aimed at improving the management of an acute coronary event. These questions were posed in each area of the health care process, where users of the guide and patients must make decisions regarding specific interventions. To answer each question, it was necessary to conduct a systematic review of the literature of previous clinical practice guidelines, systematic reviews, and primary studies published worldwide. The process included the search, selection and extraction of information, the critical appraisal of the quality, evidence charting, and consensus in the formulation of recommendations. According to the specificities of certain questions, it was necessary to also conduct a systematic literature review (SLR) for economic studies and evaluations.

The recommendations were classified according to the methodology described by the GRADE Working Group. This system includes two concepts: evidence quality and the strength of the given recommendations. See Table 1. GRADE Classification System.

The quality can be "high," "intermediate," "low," or "very low” based on the methodological characteristics and the risk of bias of the available evidence defining each outcome. While the evidence quality in some outcomes may be low or intermediate, the quality of the overall evidence is based on the summary of all important outcomes for the clinical setting.

The recommendations are graded as "strong" or "weak," and each can be positive or negative regarding an intervention. The implications of a strong or weak recommendation are described in Table 1.

The population considered for this guide: Adult men and women over 18 years of age with an ACS diagnosis with or without ST-‐segment elevation.

Ministry of Health and SociaL Protection -‐ Colciencias 9

Quick Reference Guide. Guidelines for Acute Coronary Syndrome Groups that were not considered: • Chronic, stable angina • Variant or Prinzmetal's angina • Chest pain of non-‐cardiac origin

Users: The recommendations of this CCG are aimed at pre-‐hospital care staff, general practitioners, nurses, and specialists in the following areas: Emergency Medicine, Internal Medicine, Cardiology, Hemodynamics, Cardiovascular Surgery, Critical Care, Physical Medicine and Rehabilitation, Sports Medicine, Cardiac Rehabilitation and caregivers.

Objectives

General Objectives • To systematically develop a Clinical Practice Guide based

on evidence to reduce mortality and morbidity and to improve the functionality and quality of life of people with ACS through an interdisciplinary team with the participation of patients and stakeholders involved in the care of this condition.

Specific Objectives • To make recommendations based on the evidence for pre-‐hospital, hospital,

and outpatient care of people with ACS with ST and ACS without ST to improve the effectiveness and safety of the interventions.

• To develop safe and effective recommendations based on the evidence for secondary prevention for people who have had ACS.

• To provide evidence-‐based recommendations for the diagnosis, pharmacological, interventional, and rehabilitation interventions to improve mortality, morbidity, functionality, and quality of life of people with ACS.

• To perform economic evaluations of treatment alternatives based on certain Guideline recommendations, when appropriate and in accordance with strict prioritization criteria.

• To propose strategies and performance indicators to monitor implementation and compliance by different users.

• To engage patients and users in the development of the Guide through dissemination and socialization strategies in each of the Guide’s development phases.

Clinical aspects covered by the Guide: 1. Pre-‐hospital Care 2. Emergency Care Management 3. Hospital and Interventional Care 4. Secondary Prevention

Introduction


⊕ �� D

Clinical aspects not covered by the Guide: 1. Primary prevention 2. Nonspecific chest pain 3. Percutaneous revascularization technique 4. Surgical revascularization techniques 5. Mechanical complications of acute coronary syndromes 6. Rhythm complications during an acute coronary syndrome

Table 1. GRADE classification system

Quality of Evidence

High High confidence: It is highly unlikely that new studies would change confidence in the estimated effect. �� A

Moderate

Moderate confidence: It is likely that further research would have a significant impact on the confidence of the

estimated effect, and the results may change.

�� B

Low

Limited confidence in the estimated effect: It is very likely that new studies would have an important impact on the

confidence in the estimated effect and likely change the results.

��

C

Very Low Confidence is very low in the estimated effect: Any estimated effect is uncertain.

Strength of Recommendations

Strong positive

Most well-‐informed people would agree with the

recommended action; only a small proportion would not.

The recommendations may be accepted as a health care policy in most cases.

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1

Strong negative

"" 1

Weak positive

Most well-‐informed people would agree with the recommended action, but a significant number would

not.

The values and preferences may vary widely.

The decision as a health policy deserves important debate and discussion with all stakeholders.

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2

Weak negative

"?

2

Ministry of Health and Social Protection-‐ Colciencias 11

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Typical angina

EKG diagnostic Elevation ST

Initial care and pre-‐hospital treatment

Figure 1. Initial diagnosis of probable ACS

Probable ACS

• Angina at rest over 20-‐30 min

• New grade III angina; according to CCS

• Angina In Crescendo

Non-‐diagnostic ECG

No ST elevation

Enzymes -‐

Monitor 12 hours

Positive enzymes

ACS

with ST

Negative troponin

Unstable Angina

Positive troponin

ACS no ST

Non-‐diagnostic ECG Negative enzymatic control

• Positive stress SPECT • Another non-‐invasive positive test

CCS = Canadian Cardiovascular Society classification of angina class III with

symptoms in activities of daily living.

In the first medical contact with a patient consulting for chest pain and typical angina, it becomes necessary to determine the ACS diagnosis and classify it as ACS with or without ST by performing an electrocardiogram and measuring cardiac

enzymes.

Patients with atypical symptoms and suspected ACS who present to the emergency department and whose initial studies are negative could benefit from further testing: tomographic angiography; myocardial perfusion imaging; or stress echocardiography. Similarly, clinical, ECG, and enzymatic monitoring for short periods (6-‐8 hours) in chest pain units provide important data for diagnosis.

Initial care and prehospital treatment


1. Pre-‐hospital drug treatment In patients older than 18 years with ACS, does the administration of acetylsalicylic acid (ASA), clopidogrel, morphine, nitrates, or glycoprotein IIb/IIIa inhibitors by the pre-‐hospital care (PHC) staff decrease myocardial revascularization, heart failure, cardiogenic shock, overall death, cardiovascular death, reinfarction, and major bleeding at 30 days compared with not using them?

Recommendations

!!

��## We recommend the use of ASA by pre-‐hospital care staff in patients with ACS without ST. Strong positive recommendation, moderate quality evidence in patients with ACS without ST. We recommend the use of ASA by pre-‐hospital care staff

!! in patients with ACS with ST. Strong positive recommendation, high quality evidence in patients with �� ACS with ST. We suggest the use of nitrates by pre-‐hospital care staff in patients with ACS. Weak positive recommendation, low quality evidence.

!? ��#

We do not recommend the use of clopidogrel by pre-‐hospital care staff in patients with ACS. Strong negative recommendation, low quality evidence.

""

��## We do not recommend the use of glycoprotein IIb/IIIa inhibitors by pre-‐hospital care staff in patients with ACS. Strong negative recommendation, low quality evidence.

""

��## We do not recommend the use of morphine by pre-‐hospital care staff in patients with ACS. Strong negative recommendation, low quality evidence.

""

��##

2. Pre-‐hospital fibrinolysis In patients older than 18 years with ACS with ST of less than 12 hours of evolution, does the use of pre-‐hospital fibrinolysis reduce the risk of urgent myocardial revascularization, heart failure, cardiogenic shock, overall death, and major bleeding at 30 days compared with not using it?

Recommendations

We recommend using pre-‐hospital fibrinolysis in patients older than 18 years with ACS and ST of less than 12 hours of evolution, when the patient cannot be transferred to a center providing percutaneous intervention within 90 minutes of first presentation. Strong positive recommendation, low quality evidence. We recommend using pre-‐hospital fibrinolysis, provided pre-‐hospital care staff are trained and skilled in the application of fibrinolytic agents and are coordinated by a specialized center. Strong positive recommendation, very low quality evidence. .

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We recommend utilizing the GRACE risk score to stratify risk of hospital death and nonfatal reinfarction. If the GRACE score is not available, we suggest using the TIMI risk score. Strong positive recommendation, moderate quality evidence.

Emergency care and hospitalization

3. Risk Classification

In patients older than 18 years with ACS, does the Global Registry of Acute Coronary Events (GRACE) scale, compared with the Thrombolysis In Myocardial Infarction (TIMI) scale, better classify mortality risk and nonfatal reinfarction in the first 30 days?

Recommendation

Figure 2. GRACE risk score

ACS with ST/no ST

GRACE score

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��#

In-‐hospital death or myocardial reinfarction

High Moderate Low

It is important to determine the risk to choose the best treatment. This score can be downloaded directly from the

following link: http://www.outcomes-‐umassmed.org/grace/acs_risk/acs_risk_content.html

Ministry of Health and Social Protection -‐ Colciencias 13



4. Diagnostic methods with non-‐diagnostic electrocardiogram and negative biomarkers of myocardial necrosis

4.1. Baseline echocardiography compared with coronary

angiography In patients older than 18 years with suspected ACS with a non-‐diagnostic electrocardiogram and negative biomarkers of myocardial necrosis, what is the diagnostic accuracy of baseline echocardiography compared with coronary angiography in terms of positive and negative likelihood ratio (LR), sensitivity, and specificity?

Recommendation

We do not recommend the use of echocardiography for the diagnosis of ACS in patients older than 18 years with suspected ACS with a non-‐diagnostic electrocardiogram, and negative biomarkers of myocardial necrosis Strong negative recommendation, low quality evidence.

"" ��#

4.2. SPECT compared with coronary

angiography In patients older than 18 years with suspected ACS, a non-‐diagnostic electrocardiogram, and negative biomarkers of myocardial necrosis, what is the diagnostic accuracy of stress SPECT myocardial perfusion compared with coronary angiography?

Recommendation We recommend the use of stress SPECT myocardial perfusion in patients with suspected ACS with a non-‐diagnostic ECG and negative biomarkers of myocardial necrosis. Strong positive recommendation, low quality evidence.

!! ⊕⊕##

5. Drug therapy in ACS with and without ST-‐segment elevation 5.1. Antiplatelet therapy

a. Acetyl salicylic acid

In patients older than 18 years who present to the emergency department with ACS, does ASA administration at high maintenance doses (> 150 mg/day) compared with low doses (< 150 mg/day) reduce the incidence of death, cerebrovascular event, nonfatal reinfarction, and major bleeding at 30 days?

Quick Reference Guide. Guidelines for Acute Coronary Syndrome


Recommendation We recommend a maintenance dose of ASA between 75 and 100 mg daily after the loading dose of 300 mg for ACS patients. Strong positive recommendation, high quality evidence.

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a. Clopidogrel

Clopidogrel loading dose

In patients older than 18 years who present to the emergency department with ACS, does the administration of a loading dose of 300 mg compared with 600 mg of clopidogrel reduce the incidence of death, nonfatal reinfarction, cerebrovascular event, and major bleeding at 30 days?

Recommendation We recommend, preferably administered in the emergency department, a 300-‐mg loading dose of clopidogrel to all ACS patients. Add 300 mg if the patient is to undergo percutaneous coronary intervention (PCI) Strong positive recommendation, high quality evidence.

!! ⊕⊕⊕⊕

Maintenance dose of clopidogrel

In adult patients presenting to the emergency department with ACS, does the administration of a maintenance dose of 75 mg/day compared with 150 mg/day of clopidogrel reduce the incidence of death, nonfatal reinfarction, cerebrovascular event, and major bleeding at 30 days?

Recommendation

The administration of a 150-‐mg/day maintenance dose of clopidogrel in ACS patients is not recommended Strong negative recommendation, low quality evidence.

""

��##

The administration of a 75-‐mg/day maintenance dose of clopidogrel in patients with ACS is recommended. Strong positive recommendation, low quality evidence.

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��###



c. Dual antiplatelet therapy

Figure 3. Dual therapy

ACS with and without ST

ASA Loading dose 300 mg

Maintenance 100 mg/day

Add P2Y12 receptor inhibitor

for 12 months

Ticagrelor Prasugrel Clopidogrel

Figure 4. Indications for antiplatelet agents

Ticagrelor Prasugrel

High or Intermediate Risk

Clopidogrel

1. Low-‐risk patients 2. Contraindication for another P2Y12 inhibitor 3. Oral anticoagulation requirement 4. Fibrinolysis 5. Unavailability of other P2Y12 inhibitor

ACS

High or Intermediate Risk

Clopidogrel

Prior Revascularization Unplanned

intervention

Ticagrelor PCI Fibrinolysis Ticagrelor

Known

anatomy Clopidogrel

Yes No

PCI: Percutaneous coronary intervention * Prasugrel: Diabetes, no history of stroke/TIA, > 60 Kg, < 75 years

*Prasugrel Ticagrelor



ASA + clopidogrel compared with ASA alone

In patients older than 18 years who present to the emergency department with ACS, does the early administration of ASA + clopidogrel reduce the incidence of nonfatal myocardial infarction, death, cerebrovascular event, and major bleeding at one year compared with ASA alone?

Recommendations

We recommend the early administration of dual antiplatelet therapy with ASA plus clopidogrel in patients with ACS without ST. Strong positive recommendation, moderate quality evidence.

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We recommend the early administration of dual antiplatelet therapy with ASA plus clopidogrel in patients with ACS with ST, regardless of the reperfusion strategy (fibrinolysis or primary angioplasty). Strong positive recommendation, high quality evidence.

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Dual antiplatelet therapy in the emergency room

In patients older than 18 years who present with ACS, does the early administration of dual antiplatelet therapy in the emergency room compared with the cardiac catheterization laboratory reduce the incidence of nonfatal myocardial infarction, death, and bleeding at 30 days?

Recommendation We recommend administering the loading dose of clopidogrel at the emergency room to all patients with ACS with ST and to patients with ACS without ST of moderate and high risk. Strong positive recommendation, low quality evidence.

!! ��

ASA + clopidogrel compared with ASA + ticagrelor

In patients older than 18 years who present to the emergency department with ACS, does the early administration of ASA + clopidogrel compared with ASA + ticagrelor reduce the incidence of nonfatal myocardial infarction, death, cerebrovascular events, and major bleeding after one year?

Recommendation

We recommend the use of ticagrelor + ASA in patients with ACS without ST of moderate or high risk, regardless of the initial treatment strategy, including those who previously received clopidogrel, which should be stopped once ticagrelor is initiated. Strong positive recommendation, high quality evidence. .

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We recommend the use of ticagrelor + ASA in patients with ACS with ST who have not received fibrinolytic therapy within the previous 24 hours and with a planned primary percutaneous coronary intervention.

Strong positive recommendation, high quality evidence.

!!

��

ASA + clopidogrel compared with ASA + prasugrel

In patients older than 18 years who present to the emergency department with ACS, does the early administration of ASA + clopidogrel compared with ASA + prasugrel reduce the incidence of nonfatal myocardial infarction, death, cerebrovascular events, and major bleeding after one year?

Recommendation

We recommend the use of prasugrel + aspirin in patients with known coronary anatomy, with an indication for percutaneous revascularization who have not received clopidogrel, in the absence of predictors for high risk of bleeding: a previous cerebrovascular event or transient ischemic attack, weighing less than 60 kg, or older than 75 years. Strong positive recommendation, high quality evidence.

!! ��

Proton pump inhibitors

In patients older than 18 years who present to the emergency department with ACS receiving double antiplatelet therapy (ASA + clopidogrel), does the administration of proton pump inhibitors reduce the incidence of gastrointestinal bleeding, cerebrovascular events, nonfatal reinfarction, or death compared with no administration?

Recommendation We recommend administering proton pump inhibitors to all patients at high risk of bleeding who are being treated with dual antiplatelet therapy with ASA and clopidogrel. Strong positive recommendation, low quality evidence.

!! ��



FONDAPARINUX

Riesgo sangrado

5.2. Anticoagulant therapy

Figure 5. Indications for anticoagulants in patients with ACS without ST

ACS no ST

Anticoagulation

ENOXAPARIN UFH *BIVALIRUDIN

Choice If

fondaparinux

is unavailable

If fondaparinux or enoxaparin

are unavailable

In percutaneous intervention

and High bleeding risk

ACS no ST

Anticoagulation

Fondaparinux

Yes No PCI

HIGH LOW In-‐hospital fondaparinux

*Bivalirudin UFH or Bivalirudin alone with

or without GP IIb/IIIA Inh.

*Bivalirudin: not marketed in Colombia

PCI: Percutaneous Coronary Intervention UFH: Unfractionated Heparin GP IIb/IIIa Inh. : Glycoprotein IIb/IIIa Inhibitor

a. Unfractionated heparin compared with low-‐molecular-‐

weight heparins In adult patients presenting with ACS, does the initiation of anticoagulation with unfractionated heparin compared with low-‐molecular-‐weight heparins (enoxaparin, dalteparin, fraxiparine, reviparin) reduce the incidence of nonfatal myocardial infarction, death, and major bleeding at 30 days?



Recommendations The use of anticoagulation with enoxaparin instead of unfractionated heparin in patients with ACS without ST is recommended. If enoxaparin is unavailable, unfractionated heparin can be administered. Strong positive recommendation, high quality evidence.

!! ��

The use of enoxaparin in patients with ACS with ST instead of unfractionated heparin is recommended, regardless of the reperfusion strategy (primary angioplasty or fibrinolysis). In case of unavailability of enoxaparin, unfractionated heparin can be administered. Strong positive recommendation, moderate quality evidence.

!! ��

b. Fondaparinux vs. enoxaparin compared with unfractionated heparin

In patients older than 18 years who present with ACS, does the administration of fondaparinux compared with enoxaparin or unfractionated heparin reduce the incidence of nonfatal myocardial infarction, refractory ischemia, death, and major bleeding at 30 days?

Recommendations

The use of fondaparinux in patients with ACS without ST instead of enoxaparin is recommended. An additional dose of unfractionated heparin should be administered during percutaneous intervention to prevent catheter thrombosis. Strong positive recommendation, high quality evidence.

!! ��

The use of fondaparinux in patients with ACS without ST in medical treatment or reperfusion non-‐fibrin specific drugs as an alternative to unfractionated heparin. Strong positive recommendation moderate quality evidence.

!!

��## c. Bivalirudin

In patients older than 18 years who present to the emergency department with ACS, does the administration of bivalirudin compared with enoxaparin reduce the incidence of nonfatal myocardial infarction, major bleeding, cerebrovascular event, and death at 30 days?

Recommendation The use of bivalirudin in patients with ACS who will undergo percutaneous intervention and have a high risk of bleeding is recommended. Strong positive recommendation, moderate quality evidence.

!! ��#



5.3. Beta blockers

In patients older than 18 years who present with ACS, does the use of oral and intravenous betablockers in the emergency room reduce the incidence of death, nonfatal reinfarction, cardiac arrest, heart failure, re-‐hospitalization, and cardiogenic shock at 30 days and one year compared with not using them?

Recommendation

We recommend the administration of oral betablockers in patients with ACS with no contraindications for use. Strong positive recommendation, moderate quality evidence.

!!

��#

We do not recommend the administration of betablockers in patients with ACS at risk for cardiogenic shock until their clinical condition is stable. Strong negative recommendation, moderate quality evidence.

""

��# 5.4. Inhibitors of the renin-‐angiotensin-‐aldosterone system and angiotensin II receptor antagonists

In patients older than 18 years who present with ACS, does the administration of ACE/ARA II inhibitors in the emergency room reduce the incidence of death, nonfatal reinfarction, and heart failure at 30 days compared with not doing so?

Recommendations

!! ��

We recommend the administration of angiotensin-‐converting enzyme inhibitors Inhibitors in the first 36 hours of hospitalization in patients with ACS and ejection fraction less than 40% in the absence of hypotension (systolic blood pressure less than 100 mm Hg). Strong recommendation for, with high quality of evidence. We recommend the administration of angiotensin-‐converting enzyme inhibitors

!? enzyme inhibitors in the first 36 hours of hospitalization in patients

with ACS and ejection fraction greater than 40% in the absence of hypotension (systolic blood pressure less than 100 mm Hg). ��# Weak positive recommendation, low quality evidence. We recommend the use of angiotensin II receptor antagonists

!! in patients who would not tolerate angiotensin-‐converting enzyme inhibitors. ��## Strong positive recommendation, low quality evidence.



4.1. Glycoprotein IIb/IIIa inhibitors

In patients older than 18 years who present with ACS, does the administration of glycoprotein IIb/IIIa inhibitors reduce the incidence of nonfatal myocardial infarction, death, major bleeding, refractory ischemia, and rehospitalization at 30 days compared with not doing so?

Recommendations

!!

We recommend the use of glycoprotein IIb/IIIa inhibitors in the catheterization laboratory in patients with ACS without ST with high Ischemic risk and low bleeding risk when a high risk ⊕⊕⊕⊕ percutaneous coronary intervention is to be performed Strong positive recommendation, high quality evidence. We recommend the use of glycoprotein IIb/IIIa inhibitors only in the

!?

catheterization laboratory , in patients with ACS with ST and low bleeding risk, who are to undergo primary coronary percutaneous intervention and in whom there is a high thrombotic load. ⊕⊕⊕# Weak positive recommendation, moderate quality evidence. We do not recommend the routine use of glycoprotein IIb/IIIa inhibitors in the emergency department in ACS patients. Strong negative recommendation, high quality evidence.

""

⊕⊕⊕⊕

4.2. Eplerenone In patients older than 18 years who present with ACS with ST, does the administration of eplerenone in the emergency room reduce the incidence of death and hospitalization at 30 days compared with not doing so?

Recommendation

We recommend the administration of eplerenone in patients with ACS with ST with an ejection fraction less than 40% and at least one of the following conditions: symptoms of heart failure or diabetes mellitus. Strong positive recommendation, high quality evidence.

!! ⊕⊕⊕⊕

5.5. Statins in the emergency room In patients older than 18 years who present to the emergency department with ACS, does the administration of statins plus standard therapy reduce the incidence of nonfatal reinfarction and death at 30 days compared with standard treatment only?

Recommendation

We recommend administering statins after an ACS in the emergency room. Strong positive recommendation, moderate quality evidence.

!!

⊕⊕⊕#



5.6. Calcium channel blockers

In patients older than 18 years who present with ACS, does the administration of calcium channel blockers in the emergency room reduce the incidence of nonfatal reinfarction and death at 30 days compared with not doing so?

Recommendation

We recommend the use of non-‐dihydropyridine-‐type calcium channel blockers for controlling the symptoms of continuous or recurrent ischemia in patients with ACS with contraindication to the use of betablockers and having no systolic dysfunction. Weak positive recommendation, low quality evidence.

We suggest the use of long-‐acting, non-‐dihydropyridine-‐type calcium-‐channel blockers with the same purpose in patients with ACS who are receiving betablockers and nitrates in full doses. Weak positive recommendation, low quality evidence.

!? ⊕⊕##

Table 2. ACS drug therapy with and without ST elevation.

ACS drug therapy summary Drug

Indication Initial medical treatment

During PCI

After PCI

At discharge

Antiplatelet Aspirin

All ACS patients

Loading dose,

300 mg; maintenance, 75-‐100 mg/day

Continue maintenance dose

Continue maintenance dose

75-‐100 mg/day

indefinitely

Nitrates Isosorbide dinitrate

Management of

pain and ischemia

5 mg sublingual every 5

minutes until 3 doses

No indication

No indication

No indication



Nitrogly cerin

10 mcg/min infusion

Titrated to 200

mcg/min

Decrease dose until discontinu

ation

No indication



Antiplatelet agents (P2Y12 Inhibitors) Clopido-‐ grel

In low-‐risk patients;

when there is contraindication to

another P2Y12 inhibitor; when there is unavailability of another P2Y12

inhibitor; when oral anticoagulation is required in patients

with ACS with ST who will receive fibrinolysis.

300 mg loading dose

300 mg additional if PCI

75 mg every day 75 mg every 12 hours at high risk of stent throm bosis

75 mg/day

for 12 months

Ticagre-‐

At high or

180 mg Continue Continue 90 mg every loading dose with dose with dose 12 hours

lor Intermediate risk 90 mg every 12 of main-‐ of main-‐ for 12 hours tenance tenance months

Prasu-‐ grel

At high or moderate risk; in patients with diabetes and no

history of ECV/ICT, > 60 kg, <

75 years, with known

coronary anatomy.

No indication

60 mg loading dose in the catheterization lab

10 mg daily

10 mg/ day for 12 months

Anticoagulants Fondapa-‐ rinux

Of choice in ACS without ST,

in patients with ACS with ST with no reperfusion or reperfusion with streptokinase.

2.5 mg SC /day

Add UFH

Until discharge

Not for

outpatients

Enoxapa-‐ rin

Of choice in ACS with ST,

if there is no availability of

fondaparinux in ACS without ST.

1 mg/Kg/ SC/12 h

En >75 years: 0.75 mg/Kg/

SC/12 h

Depuration < 30 mL/min:

1 mg/Kg/SC/day

Adjust dose proc.: last dose > 16 h or did not receive it: 0.75 mg/kg; last dose between 8-‐16 hours: 0.3 mg/kg. No additional UFH.

Until discharge

Not for

outpatients



Unfractionated heparin (UFH)

If there is no availability of

fondaparinux or enoxaparin

Without GP IIb/IIIa

inhibitor: 85 IU/Kg/IV bolus,

12 IU/kg/h infusion

With GP IIb/IIIa inhibitor: 60 IU/Kg/IV

bolus

Continue initial dose

Until discharge

Not for

outpatients

Bivaliru-‐ din

Of choice in patients

at high risk of bleeding.

Initial

0.1 mg/kg/IV bolus, 0.25 mg/kg/h infusion

Pre-‐PCI: 0.75 mg/ Kg/IV bolus, 1.75 mg/ Kg/hour infusion

Continue until 4 hours after PCI, at the discretion of the treating physician. After 4 hours, an IV infusion of additional bivalirudin may be initiated at a rate of 0.2 or 0.25 mg/kg/h for up to 20 hours, if necessary

Not for

outpatients



Beta blockers: No intrinsic sympathomimetic activity Metoprolol succinate

In all patients without contraindications and no risk factors for cardiogenic shock

12.5-‐25 mg oral daily; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 200 mg daily

Carve-‐ dilol

Nebivo-‐ lol

3.125 mg every 12 hours orally; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 25 mg given every 12 hours

1.25 mg every day orally; titration to maximum dose.

-‐

-‐


Bisopro-‐ lol

1.25 mg every day orally; titration to maximum dose.

-‐

-‐




ACEIs Captopril

In all ACS patients

6.25 mg each 8 hours; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 50 mg every 8 hours

Enalapril

2.5 mg every 12 hours; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 10-‐20 mg every 12 hours

Lisinopril

2.5-‐5 mg daily; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 20-‐35 mg daily

Ramipril

2.5 mg daily; titration to maximum dose.

-‐

-‐


Trando-‐ lapril

0.5 mg daily; titration to maximum dose.

-‐

-‐




ARBs Can-‐ desartan

Patient intolerance to ACE

4-‐8 mg daily; titration to maximum dose.

-‐

-‐


Valsartan

40 mg every 12 hours; titration to maximum dose.

-‐

-‐

Continue to maximum tolerated dose or up to 160 mg every 12 hours

Losartan

50 mg daily; titration to maximum dose.

-‐

-‐


Glycoprotein IIb/IIIa inhibitors Tirofiban

Patients with high thrombus burden or

reflux in the catheterization

laboratory

No indication

25 mcg/kg IV bolus or IC infusion 0.15 mcg/kg/minute for 18-‐24 hours

50% bolus and infusion if clearance < 30 mL/minute

No indication

Eptifiba-‐ tide

No indication

180 mcg/ Kg/minute bolo Infusion 2 mcg/kg/ minute for 18-‐24 hours

Contraindicated when clearance is < 30 mL/min; infusion 1 mcg/Kg/min when clearance is < 50 mL/minute

No indication



Abcixi-‐ mab

No indication

0.25 mg/kg bolus IV infusion, 0.125 mcg/Kg/min for 12 hours

No change in renal failure.

No indication



Anti-‐aldosterone agents Eplere-‐ none

In patients with EF < 40% and symptoms of heart failure. In patients with diabetes mellitus, no renal failure


Titration dose

No changes


Espiro-‐ nolacto-‐ ne


Titration dose

No changes

Continue to maximum tolerated dose or up to 25-‐50 mg daily

Statins Atorvas-‐ tatin

In all patients to achieve

LDL <100 mg/dL

40-‐80 mg daily

No changes

No changes

40 mg daily

Simvas-‐ tatin

40 mg daily 40 mg daily

Rosuvas-‐ tatin

20 mg daily 20 mg daily

Lovasta-‐ tin

40 mg daily

40 mg daily

Calcium antagonists Long-‐acting diltiazem

Non-‐dihydropyridine agent for ischemia control in patients

with contraindications to beta-‐ blockers with

EF > 40%

30-‐60 mg daily

-‐

-‐


Long-‐acting nifedipine

Dihydropyridine agent for ischemia control in patients treated with beta-‐blockers with EF >

40%

20-‐30 mg daily

-‐

-‐




6. Revascularization therapy in ACS without ST elevation

Figure 6. Types of revascularization therapy in ACS without ST

ACS no ST

Invasive strategy

Early Selective

1. Routine cardiac catheterization for all patients

2. Revascularization according to findings 3. Within the first 72 hours of admission

1. If no response to standard medical treatment

2. Recurrent ischemia 3. Positive for inducible ischemia

Urgent Immediate Deferred

<2 hours after

admission

<24 hours after

admission

24 -‐ 72 hours after

admission

6.1. Early invasive strategy compared with selective invasive strategy

In patients older than 18 years who present with ACS without ST, does an early invasive strategy reduce the incidence of refractory angina, re-‐hospitalization, nonfatal reinfarction, cerebrovascular event, and death at 30 days compared with a selective invasive strategy?

Recommendation We recommend starting an early invasive strategy (< 72 hours) after admission rather than selective for patients with ACS without ST of

intermediate and high risk Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕#

6.2 Early invasive strategy for patients with intermediate-‐

and high-‐risk scores In patients older than 18 years with ACS without ST and with a TIMI or GRACE score of intermediate and high risk, does conducting early invasive strategy (< 72 hours) reduce the incidence of death, re-‐infarction, cerebrovascular events, and bleeding compared with standard medical therapy?

Recommendation

We recommend starting an early invasive strategy (< 72 hours) after admission instead of standard medical treatment in patients with ACS without ST of intermediate and high risk. Strong positive recommendation, low quality evidence.

!! ⊕⊕##



6.3. Early percutaneous coronary intervention with high-‐risk markers compared with standard medical treatment In patients older than 18 years with ACS without ST with high-‐risk AHCPR markers or high-‐risk biomarkers (troponin, brain natriuretic peptide, and high-‐sensitivity C-‐reactive protein), does performing early PCI reduce the incidence of death, reinfarction, cerebrovascular event and bleeding compared with standard medical therapy?

Recommendations

!! ⊕⊕

We recommend using an early invasive strategy (< 72 hours) in patients with ACS without ST at high risk according to the Agency for Health Care Policy and Research (AHCPR) classification (> 75 years, presence of mitral insufficiency murmur, ejection fraction less than 40%, pulmonary edema, prolonged angina > 20 minutes at rest, dynamic changes of the ST segment > 0.05 mV, or presumed new bundle branch block left bundle branch block). Strong positive recommendation, low quality evidence. We recommend using an early invasive strategy (within 72

!! hours) in patients with ACS without ST, with positive biomarkers (Troponin-‐CPK MB elevation). ⊕⊕⊕# Strong positive recommendation, moderate quality evidence. We suggest using an early invasive strategy in patients with ACS

!? without ST with elevated brain natriuretic peptide or high-‐sensitivity C-‐reactive protein reactive protein. ⊕⊕## Weak positive recommendation, low quality evidence.

6.4. Immediate-‐early invasive strategy vs. deferred In patients older than 18 years with ACS without ST, does the immediate early invasive strategy (< 24 hours) compared with deferred (24-‐72 hours) reduce the incidence of refractory ischemia, nonfatal reinfarction, cerebrovascular event, and death at 30 days?

Recommendation

The immediate-‐early invasive strategy (< 24 hours) in patients with ACS without ST is suggested in high-‐risk patients by the GRACE (> 140) or TIMI (> 4) score. Weak positive recommendation, low quality evidence.

!? ⊕⊕#



Figure 7. Selection of revascularization therapy in ACS patients without ST

ACS no ST

6.2.1 Hemodynamic

or electrical instability 6.2.2 Recurrent

ischemia 6.2.3 Heart failure

Risk Stratification

Very High High Intermediate Low

Urgent

EIS

Immediate EIS

Deferred EIS

Selective Invasive Strategy

EIS: Early Invasive Strategy.

6.5 Urgent-‐invasive strategy compared with standard medical

therapy In patients older than 18 years with ACS without ST with hemodynamic or electrical instability, recurrent ischemia, or heart failure, does an urgent-‐invasive strategy (first 2 hours) reduce the incidence of death, reinfarction, cerebrovascular event, cardiogenic shock, and bleeding compared with standard medical therapy?

Recommendation

We recommend an urgent-‐invasive strategy (first 2 hours of admission) in patients with ACS without ST, with hemodynamic or electrical instability, recurrent ischemia, or heart failure. Strong positive recommendation, low quality evidence.

!! ⊕⊕#

6.6 Coronary intervention with positive stress test before discharge In patients older than 18 years with ACS without ST with initial medical treatment (no invasive strategy) and a positive stress test prior to discharge, does performing a coronary intervention (catheterization and revascularization according to findings) reduce the incidence of death, reinfarction, cerebrovascular events, and bleeding compared with standard medical therapy?

Recommendation We recommend performing a coronary intervention in patients with ACS without ST who received initial medical treatment (no invasive strategy) and had a positive stress test, prior to discharge. Strong positive recommendation, very low quality evidence.

!! ⊕###



6.7 Statins prior to early invasive strategy

In patients older than 18 years who present with ACS without ST with an indication for early invasive strategy, does the administration of high doses of statins before the procedure reduce the incidence of death, myocardial infarction, or target vessel revascularization at 30 days?

Recommendation

We recommend administering a high loading dose of atorvastatin, simvastatin, or rosuvastatin before percutaneous coronary intervention (PCI) to patients with ACS without ST with no contraindications for use. Strong positive recommendation, low quality evidence.

!! ⊕⊕##

7. Revascularization therapy for ACS with ST elevation

Figure 8. Reperfusion Strategies for ACS with ST

ACS no ST

Symptoms < 12 hours 12-‐72 hours > 72 hours

PCI availability < 90

MIN

Medical treatment. *PCI

Medical treatment *PCI

YES NO

+ Primary PCI ** Fibrinolysis

Failed Successful

Rescue PCI ++PCI < 24 hours

* PCI: useful in special situations ** Door-‐to-‐needle time < 30

minutes + Choice treatment. Door-‐to-‐

balloon time < 90 minutes ++If available

PCI scenarios

Primary PCI (PPCI): PCI performed within 12 hours of symptom onset as a reperfusion strategy of the target vessel without having received prior fibrinolytic therapy

Rescue PCI: After failed thrombolysis.

Failed thrombolysis:: Electrocardiographic findings at 90 minutes after completion of thrombolytic therapy with less than 50% resolution of ST segment elevation.

PCI after successful thrombolysis: PCI routinely to all patients after successful thrombolysis (first 24 hours).

Facilitated PCI: PCI immediately after administration of any of the following drugs: heparin at high doses; glycoprotein IIb/IIIa inhibitors; thrombolytic agents (low dose); or the combination of inhibitors of platelet glycoprotein IIb/IIIa and a reduced dose of a thrombolytic.

Farmacoinvasive strategy: PCI performed within the first hours (6-‐12 hours) after receiving full dose fibrinolysis as a combined strategy established from the start of reperfusion.



7.1. Primary percutaneous coronary intervention compared with

fibrinolysis In patients older than 18 years who present with ACS with ST with less than 12 hours of evolution, does primary mechanical reperfusion with angioplasty and stenting reduce the incidence of death, nonfatal reinfarction, cerebrovascular event, and heart failure compared with the administration of fibrinolysis?

Recommendation We recommend primary percutaneous coronary intervention with angioplasty and stenting in patients with ACS with ST with less than 12 hours of progression. For the implementation of this recommendation, the patient should be taken to the catheterization laboratory within 90 minutes of the first medical contact. Strong positive recommendation, high quality evidence.

!! ⊕⊕⊕⊕

7.2. Fibrinolytic reperfusion therapy in the first 12 hours

In patients older than 18 years who present with ACS with ST, does the administration of fibrinolytic reperfusion therapy within 12 hours of the onset of symptoms reduce the incidence of nonfatal reinfarction, death, cerebrovascular event, ventricular dysfunction, and bleeding at 30 days compared with the administration after the first 12 hours?

Recommendation

We recommend the administration of fibrinolytic therapy in patients with ACS with ST during the first 12 hours of the onset of symptoms, ideally in the first 30 minutes of first medical contact. Strong positive recommendation, high quality evidence.

!! ⊕⊕⊕⊕

Table 3. Contraindications to fibrinolytic therapy

Contraindications to fibrinolytic therapy (Adapted from Braunwald’s Heart Disease)

Absolute

Intracranial hemorrhage history Known structural cerebral vascular lesion (e.g., arteriovenous malformation) Known malignant intracranial neoplasm (primary or metastatic) Ischemic stroke in last 3 months, except when occurring in last 3 hours Suspected aortic dissection Active bleeding or bleeding diathesis (excluding menses) Severe head or facial trauma in the last 3 months



Drug Indication

Initial medical

treatment

During PCI

After PCI

At discharge

Streptokinase

Primary reperfusion in case of no

1.500,000 U in 30 minutes No

indication

No indicatio

n No

Indication

disponer de

minutos

angioplastia en < 90 mi-‐ nutos

Un solo bolo IV 30 mg si peso < 60 Kg

Relative

Poorly controlled chronic hypertension Uncontrolled systemic hypertension at the time of presentation (SBP ≥ 180 mmHg, DBP ≥ 110 mmHg. History of ischemic stroke of more than 3 months duration, dementia, or other intracranial pathology not covered in the absolute contraindications Traumatic or prolonged CPR (10 min) and/or major surgery in the past 3 weeks

Recent internal bleeding (2-‐4 weeks) Non-‐compressible vascular puncture Prior exposure to streptokinase or ASPAC (> 5 days) or allergic reactions to these.

7.3. Non-‐fibrin specific vs. fibrin specific

In patients older than 18 years who present with ACS with ST and with an indication for pharmacological reperfusion, does the use of non-‐fibrin-‐specific thrombolytic agents (streptokinase) compared with the use of fibrin-‐specific drugs (tecnecteplase, alteplase and reteplase) improve the efficiency and safety of pharmacological reperfusion?

Recommendation

We recommend the use of fibrin-‐specific thrombolytic agents in patients with ACS with ST with an indication for fibrinolysis. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕

Table 4. Fibrinolytic drug doses

Tissue plasminogen activator

15 mg IV bolus, 0.75 mg/Kg (50 mg) in 30 minutes; 0.5 mg/Kg (35 mg) in 60 minutes

No indicatio

n

No indicatio

n

No indication



7.4. Percutaneous coronary intervention after successful fibrinolysis

In patients older than 18 years who present with ACS with ST who underwent successful fibrinolysis, does the routine performance of percutaneous coronary intervention with angioplasty and stenting reduce the incidence of death, nonfatal reinfarction, recurrent ischemia, and bleeding compared with guidance by ischemia induction?

Recommendation

We recommend routine early percutaneous coronary intervention rather than percutaneous coronary intervention guided by induction of ischemia in patients with ACS with ST who received successful fibrinolysis. Strong positive recommendation, low quality evidence.

!! ⊕###

7.5. Rescue percutaneous coronary intervention

In patients older than 18 years who present with ACS with ST with failed fibrinolysis, does conducting rescue percutaneous coronary intervention reduce the incidence of death, nonfatal reinfarction, cerebrovascular events, and heart failure compared with continued medical treatment or a new dose of fibrinolysis?

Recommendation

We recommend using rescue percutaneous coronary intervention instead of repeated thrombolysis or continuation of medical treatment in patients with ACS with ST after failed fibrinolysis. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕#

7.6. Facilitated percutaneous coronary intervention

In patients older than 18 years who present with ACS with ST, does conducting facilitated PCI reduce the incidence of death, nonfatal reinfarction, cerebrovascular events, and heart failure compared with primary percutaneous coronary intervention?

Recommendation

We do not recommend facilitated percutaneous coronary intervention in patients with ACS with ST requiring percutaneous coronary intervention. Strong negative recommendation, high quality evidence.

"" ⊕⊕⊕⊕



7.7. Percutaneous coronary intervention after 12 hours of evolution

In patients older than 18 years who present with ACS with ST with 12-‐72 hours of evolution, does performing percutaneous coronary intervention with angioplasty and stenting reduce the incidence of death, nonfatal reinfarction, cerebrovascular events, and heart failure compared with continued medical therapy?

Recommendation

We suggest not performing routine PCI to the culprit vessel in patients with ACS with ST with 12 to 72 hours of evolution. Weak negative recommendation, low quality evidence.

"? ⊕⊕

In patients older than 18 years who present with ACS with ST with more than 72 hours of evolution, does performing percutaneous coronary intervention with angioplasty and stenting reduce the incidence of death, non-‐fatal reinfarction, cerebrovascular events, and heart failure compared with continued medical treatment?

Recommendation We do not recommend routine percutaneous coronary intervention for the culprit vessel in patients with ACS with ST with more than 72 hours of evolution. Strong negative recommendation, moderate quality evidence.

"" ⊕⊕⊕#

# 7.8. Farmacoinvasive strategy

In patients older than 18 years who present with ACS with ST, in whom it is not possible to perform primary percutaneous coronary intervention, does farmacoinvasive strategy (angiography and routine percutaneous coronary intervention after fibrinolysis) compared with standard treatment (angiography and need-‐based percutaneous coronary intervention after fibrinolysis) reduce the incidence of nonfatal reinfarction, cerebrovascular events, death, and bleeding at 30 days?

Recommendation We recommend farmacoinvasive strategy instead of the standard medical treatment in patients with ACS with ST undergoing fibrinolysis with reteplase, tenecteplase, or tissue plasminogen activator. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕



7.9. Drug-‐eluting stents compared with conventional stents

In patients older than 18 years who present with ACS, does the implantation of a drug-‐eluting stent reduce the rate of reinfarction, need for vessel revascularization, and death at one year compared with conventional stent?

Recommendation We recommend using a drug eluting stent only to decrease the rate of repeat revascularization, particularly in patients with small vessels (< 3 mm in diameter) and/or long lesions (> 15 mm in length). There are no differences between bare metal and drug eluting stents in mortality rate, reinfarction, or stent thrombosis. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕

8. Three-‐vessel or left main coronary artery disease

In patients older than 18 years presenting with ACS and 3-‐vessel or left main trunk disease, does percutaneous coronary intervention improve the quality of life and reduce the incidence of nonfatal myocardial infarction, repeat revascularization, cerebrovascular events, and death at one year compared with bypass surgery?

Recommendations

We recommend coronary artery bypass graft surgery (CABG) in patients with ACS with 3-‐vessel or left main coronary artery disease with high SYNTAX score, with or without diabetes mellitus. Strong positive recommendation, low quality evidence.

!! ⊕⊕##

We recommend individualizing the myocardial revascularization strategy (CABG vs PCI) in patients with ACS with 3-‐vessel or left main disease with low or moderate SYNTAX score, based on clinical judgment and patient preference. Strong positive recommendation, low quality evidence.

!! ⊕⊕##

Ministry of Health and Social Protectionl -‐ Colciencias 39

ome Coronario Agudo

uía para el Síndr

referencia rápida. G

Guía de

Secondary prevention 9. Drug therapy in secondary prevention

9.1. Beta blockers

In patients older than 18 years with a history of an acute coronary event, does treatment with beta blockers reduce the likelihood of a new coronary event, the rate of re-‐hospitalization, heart failure, and mortality at one year compared with not administering them?

Recommendation

We recommend continuing long-‐term treatment with betablockers after an ACS. Strong positive recommendation, moderate quality evidence.

!!

⊕⊕⊕#

9.2. Inhibitors of the renin-‐angiotensin-‐aldosterone system, ACE inhibitors In patients older than 18 years with a history of an acute coronary event, does treatment with ACE inhibitors reduce the likelihood of a new coronary event, the rate of re-‐hospitalization, heart failure, and mortality at one year compared with not administering them?

Recommendation

We recommend long-‐term treatment with angiotensin-‐converting enzyme inhibitors after an ACS. Strong positive recommendation, moderate quality evidence.

!!

⊕⊕⊕# #


Secondary prevention

9.3. Angiotensin II receptor blockers, ARBs

In patients older than 18 years with a history of an acute coronary event, does administering treatment with ARBs reduce the likelihood of a new coronary event, the rate of re-‐hospitalization, heart failure, and mortality at one year compared with not administering them?

Recommendation

We recommend using angiotensin II receptor blockers after an ACS only when there is intolerance to angiotensin-‐converting enzyme inhibitors. Strong positive recommendation, low quality evidence.

!! ⊕##

9.4. Statins a. Consumption of statins irrespective of cholesterol levels

In patients older than 18 years with a history of an acute coronary event, does statin use (regardless of cholesterol levels) reduce the possibility of having a new coronary event compared with not using them?

Recommendation

We recommend the use of statins to achieve LDL < 100 mg/dl (ideally in high-‐risk patients, less than 70 mg/dl) or reach at least 30% decrease in LDL (low-‐density lipoprotein cholesterol) in patients with a history of ACS provided there are no documented contraindications or adverse effects. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕#

a. Combination of statins with nicotinic acid and/or fibrates In patients older than 18 years with ACS and dyslipidemia that, despite having reached the LDL goal with statins, continue to present with low high-‐density lipoprotein (HDL) cholesterol and high triglycerides, does the combination of statins with nicotinic acid and/or fibrates reduce the likelihood of having a new coronary event compared with statins alone?

Recommendation

We suggest not administering niacin or fibrates to patients with ACS with dyslipidemia that, despite having reached the LDL goal with statins, continue to present with low HDL and high triglycerides. Weak negative recommendation with moderate quality evidence.

"? ⊕⊕⊕#

Ministry of Health and Social Protectionl -‐ Colciencias 41


We suggest administering fibrates as an alternative to administering statins in patients with a history of ACS and dyslipidemia but with an intolerance to statins. Weak positive recommendation, moderate quality evidence.

!?

⊕⊕⊕##

9.5. Dual antiplatelet medicated stent In patients older than 18 years with ACS, is there a difference between the dual antiplatelet time of those who have a medicated stent to reduce the risk of late thrombosis and/or death compared with those receiving a conventional stent?

Recommendations We recommend dual antiplatelet therapy for at least 12 months in patients with a history of ACS who have a stent, regardless of whether it is a drug eluting stent or bare metal stent. Strong positive recommendation, low quality evidence.

We recommend 6 months of dual antiplatelet therapy in patients who received a new generation drug eluting stent if there is a high risk of bleeding and/or non-‐cardiac surgery is required that cannot be postponed. Strong positive recommendation, low quality evidence. We recommend 3 months of dual antiplatelet therapy in patients who received a bare metal (conventional) stent if there is high risk of bleeding and/or surgery is required that cannot be postponed. Strong positive recommendation, low quality evidence.

!!

⊕⊕##

10. Controlling cardiovascular risk factors

In patients older than 18 years with a history of an acute coronary event, does the control of cardiovascular risk factors based on targets (blood pressure, LDL, HDL, triglycerides, glycosylated hemoglobin in diabetics, and smoking control) reduce the probability of having a new coronary event compared with the lack of control?

Recommendation

We recommend controlling risk factors based on targets in patients with ACS: blood pressure < 140/90; LDL <100 mg/dl (ideally less than 70 mg/dL in patients at very high risk); non-‐HDL cholesterol (total cholesterol minus HDL cholesterol) < 130 mg/dl, triglycerides < 150 mg/dl; glycated hemoglobin in diabetics < 7%; and smoking cessation. Strong positive recommendation, low quality evidence.

!! ⊕##

Secondary prevention


2

11. Nutritional program In patients older than 18 years with a history of an acute coronary event, does attending a nutrition program result in patients quickly acquiring targets to control cardiovascular risk and reduce the probability of a new coronary event compared with those receiving only the recommendations given by the physician at discharge?

Recommendation

We recommend decreasing and controlling fat intake and increasing fruit and vegetable consumption in patients with ACS. Strong positive recommendation, low quality evidence.

!!

⊕⊕##

12. Cardiopulmonary exercise testing

In patients older than 18 years with ACS, for cardiopulmonary exercise testing with direct determination of O2 consumption, is it more accurate to evaluate oxygen consumption, functional capacity, and having a lower risk of heart attack and death compared with the conventional test?

Recommendation

We suggest not using routine cardiopulmonary exercise testing with direct measurement of peak O2 consumption instead of the conventional stress test in patients with a history of an acute coronary event. Weak negative recommendation, very low quality evidence.

!! ⊕##

13. Cardiac rehabilitation 13.1. Electrocardiographic monitoring during exercise

In patients older than 18 years with a history of ACS, undergoing a cardiac rehabilitation program, does performing electrocardiographic monitoring during exercise compared with not doing so improve patient safety during surgery by avoiding reinfarction, re-‐hospitalization rate, and/or death?

Recommendation We suggest electrocardiographic monitoring during exercise in patients with a history of ACS at intermediate and high risk. Weak positive recommendation, low quality evidence.

!!

⊕⊕##



13.2. Cardiac rehabilitation program

In patients older than 18 years with ACS, is a comprehensive cardiac rehabilitation program, directed and requiring classroom attendance (therapeutic exercise, ergonomic and psychological support indications), compared with a program at home or with no exercise, more effective in improving the level of fitness, health-‐related quality of life, exercise adherence and decreasing the rate of re-‐hospitalization, and death in the first year post-‐event?

Recommendation

We recommend a comprehensive cardiac rehabilitation program conducted in ACS patients. Strong positive recommendation, moderate quality evidence.

!! ⊕⊕⊕

Documents

Clinical Practice Guideines for Acute Coronary syndrome · 2015-10-29 · 39’ Content’ 7(Introduction’ 11(Initial(care(and(preMhospital(treatment’ 1. Pre4hospital’drugtherapy’