Recommendations for invasive evaluation and revascularization in non-ST-elevation acute coronary syndrome. Likewise, the prognostic role of FFR and iwFR in guiding myocardial revascularization needs additional clarification. After reviewing the subsequent literature, the current Task Force endorses most recommendations of these Guidelines. Delays in the timely implementation of reperfusion therapy are key issues in the management of STEMI.
Thus, high-risk STEMI patients with cardiogenic shock or out-of-hospital cardiac arrest are those who benefit most from expediting all steps of the care pathway. Primary PCI, defined as percutaneous catheter intervention in the setting of STEMI without previous fibrinolysis, is the preferred reperfusion strategy. If first medical contact FMC is out-of-hospital, lysis should be implemented pre-hospital e. The infarct-related artery IRA should be systematically treated during the initial intervention.
A recent meta-analysis of 10 trials has shown that complete revascularization was associated with a lower risk of MACE RR 0. Yet, similar to earlier studies, the benefit of complete revascularization over culprit-only revascularization seen in Compare-Acute was driven by a lower need for unplanned reintervention, whereas the incidences of death and recurrent MI were similar between the two strategies. Most of the studies support the concept of full revascularization either during the initial hospital stay for STEMI or a staged admission, but it remains to be determined how clinicians can identify lesions that should be revascularized beyond the culprit lesion and whether complete revascularization should be performed in single- or multi-stage procedures.
Moreover, there is a lack of evidence on the optimal timing of staged procedures. In most of the studies, staged procedures were performed during the initial hospital stay. At present, one-stage multivessel PCI during STEMI without cardiogenic shock should be considered in patients in the presence of multiple, critical stenoses or highly unstable lesions angiographic signs of possible thrombus or lesion disruption , and if there is persistent ischaemia after PCI on the supposed culprit lesion.
These findings need to be interpreted in light of a low Based on these findings, culprit lesion-only PCI is recommended as the default strategy in patients with AMI with cardiogenic shock. A more detailed discussion of the revascularization strategy in MI patients with cardiogenic shock is found in the Supplementary Data. As discussed in section Delaying stenting in primary PCI has been investigated as an option to reduce microvascular obstruction MVO and preserve microcirculatory function in two small trials with conflicting results.
Thrombus aspiration has been proposed as an adjunct during primary PCI to further improve epicardial and myocardial reperfusion by the prevention of distal embolization of thrombotic material and plaque debris. The benefits of early, routine PCI after thrombolysis were seen in the absence of an increased risk of adverse events stroke or major bleeding.
Based on data from the four most recent trials, all of which had a median delay between the start of thrombolysis and angiography of 2—6 h, a time frame of 2—24 h after successful lysis is recommended. Patients undergoing primary PCI benefit from full revascularization, but the optimal timing of treatment of the non-culprit lesion is not known. Future trials of improved thrombus aspiration technologies may address the role of this strategy in patients with high-risk features, such as large thrombus burden.
Primary percutaneous coronary intervention for myocardial reperfusion in ST-elevation myocardial infarction: indications and logistics. Primary percutaneous coronary intervention for myocardial reperfusion in ST-elevation myocardial infarction: procedural aspects strategy and technique. When compared with medical therapy alone, coronary revascularization is superior in improving survival in patients with HF of ischaemic origin and is recommended in clinical practice.
Considerations relating to the need for viability testing prior to revascularization are discussed in section 3. There are currently no dedicated randomized clinical trials comparing PCI vs. In addition, CABG vs. PCI randomized trials have excluded patients with severe HF.
In one prospective registry including patients with multivessel disease and severe HFrEF, propensity score-matched comparison revealed similar survival mean follow-up 2. CABG was associated with a higher risk of stroke. The conclusion of the study was that multivessel PCI can be a valuable option in HF patients if complete revascularization is possible. Event curves separated early during the first year and continued to separate out to 12 years.
PCI should be considered in older patients without diabetes in whom complete revascularization can be achieved, whereas CABG is preferred in younger patients with more extensive CAD or those with diabetes. The aim of surgical ventricular reconstruction SVR is to restore physiological volume, and achieve an elliptical shape of the LV, by scar resection and LV wall reconstruction on a mannequin of predefined size.
The aim of ventricular aneurysmectomy is to remove fibrous scars in cases of severe dilatation, thrombus formation, or as a source of life-threatening ventricular arrhythmias. Acute myocardial ischaemia in the setting of AMI is the antecedent event for the majority of patients with cardiogenic shock undergoing percutaneous revascularization.
Mechanical complications—such as papillary muscle rupture with severe mitral valve regurgitation, ventricular septal defect, or free wall rupture—are additional precipitating causes. All-cause mortality at 6 months was lower in the group assigned to revascularization than in the medically treated patients The revascularization strategy for patients with cardiogenic shock and multivessel disease is addressed in section 7.
The findings of this non-randomized comparison suggest that CABG should be considered in patients with cardiogenic shock who have suitable anatomy, particularly if successful PCI is not feasible. Short-term MCS may be considered in refractory cardiogenic shock depending on patient age, comorbidities, neurological function, and the prospects for long-term survival and quality of life.
IABPs are low-cost devices that are easy to insert and remove. They moderately increase cardiac output and coronary and cerebral perfusion, while decreasing ventricular workload. It decompresses the venous system; increases coronary, cerebral, and peripheral perfusion; and also provides supplementary blood oxygenation. When performed percutaneously, it does not allow for LV decompression and leads to increasing LV afterload. In patients with cardiac arrest, evidence from observational trials supports better survival in patients treated with VA-ECMO compared with those without.
The majority of clinical experience with currently available pLVADs is limited to two types of device: i a transaortic microaxial pump Impella that directly unloads the LV providing 2. IABP, and demonstrated similar short-term mortality despite initial beneficial effects on arterial blood pressure and peripheral perfusion, measured by serum lactate levels.
The 30 day incidence of major adverse events was not different for patients with pLVAD vs. In summary, the evidence for pLVAD is insufficient to provide a recommendation on its clinical use in cardiogenic shock. A suggested algorithm for the management of patients with cardiogenic shock is shown in Figure 6.
There is limited evidence on the role of active MCS in patients with cardiogenic shock compared with standard therapy. Patients with diabetes mellitus have a higher prevalence of CAD, which often manifests earlier in life and confers a substantially worse prognosis than for patients without diabetes. The anatomical pattern of CAD in patients with diabetes clearly influences their prognosis and response to revascularization.
Angiographic studies have demonstrated that patients with diabetes are more likely to have LM disease and multivessel CAD, with more diffuse disease involving smaller vessels. In patients with diabetes, the indications for myocardial revascularization are the same as those in patients without diabetes see sections 5, 6, and 7. A meta-analysis of nine RCTs with ACS patients did not show an interaction between diabetic status and the benefit from invasive management and revascularization.
Consistent with the findings in the absence of diabetes, the adverse impact of incomplete revascularization in patients with diabetes was also demonstrated in the BARI-2D Bypass Angioplasty Revascularization Investigation 2 Diabetes trial. Data from randomized trials on revascularization in patients with diabetes are summarized in Supplementary Table 5. The selection of the optimal myocardial revascularization strategy for patients with diabetes and multivessel CAD requires particular consideration.
The recommendations are provided in section 5. The incidences of death PCI to prevent one event was The combined risk of death or non-fatal MI was In the subset of patients with diabetes and multivessel CAD who were enrolled in the SYNTAX trial, there were no differences in the composite safety endpoint of all-cause death, stroke, and MI at 5 year follow-up. Further analyses according to treatment with either oral hypoglycaemic agents or insulin showed that the MACCE rate was significantly greater after PCI in both the oral hypoglycaemic agent group PCI CABG 7.
When patients present with a comorbidity that increases surgical risk, the choice of revascularization method is best decided by multidisciplinary individualized risk assessment. For the reasons discussed above, PCI in patients with diabetes is often more complex than PCI in the absence of diabetes. Nevertheless, irrespective of diabetic status, the same principles apply as discussed in section Placement of a new-generation DES is the default strategy. In the current context of the use of oral P2Y 12 -inhibitors, there is no indication that antithrombotic pharmacotherapy should differ between diabetics and patients without diabetes who are undergoing revascularization.
For detailed discussion refer to section There is a theoretical risk of lactic acidosis and deteriorating renal function in patients treated with metformin who are exposed to iodinated contrast media. However, clinical experience suggests that the actual risk of lactate acidosis is very small, and that checking renal function after angiography in patients on metformin and withholding the drug when renal function deteriorates appears to be an acceptable alternative.
Following successful revascularization, the rate of events during follow-up remains high in patients with diabetes, independent of the mode of revascularization. Future research should be focused on identifying new disease-modifying therapies to influence the progression of vascular disease in this high-risk cohort. After reviewing the subsequent literature, the current Task Force has not found any evidence to support a major update. The risk of contrast-induced nephropathy CIN depends on patient-related factors, such as CKD, diabetes mellitus, congestive HF, haemodynamic instability, reduced plasma volume, female sex, advanced age, anaemia, and periprocedural bleeding, as well as on the type and volume of contrast administered.
Adequate hydration remains the mainstay of CIN prevention. Thus far, patients with CKD have been excluded from randomized trials on myocardial revascularization, hence current data are based on observational studies only. Moreover, additional randomized evidence on optimal strategies for CIN prevention is needed. Options are: infusion of normal saline adjusted to central venous pressure or furosemide with matched infusion of normal saline , for details see the Supplementary Data.
After reviewing the subsequent literature, the current Task Force endorses the recommendations of the Guidelines and has not found any evidence to support a major update. These recommendations are included below for ease of reference. Of note, the available evidence on invasive functional assessment of CAD with FFR or iwFR in patients with severe aortic stenosis AS is limited to a few small-scale observational studies.
The recommendations for patients undergoing CABG for the clinically leading problem of CAD, who also have coexisting severe aortic stenosis or regurgitation, remain unchanged from those of the Guidelines and support replacement of the aortic valve. Patients with concomitant severe primary mitral regurgitation MR should undergo mitral valve repair at the time of CABG in keeping with guidance for the surgical repair of primary MR.
The CTSN trial showed that addition of surgical mitral valve repair to CABG made no significant difference to survival, overall reduction of adverse events, or LV reverse remodelling at 2 years. For a more detailed discussion of this issue, please refer to the Supplementary Data.
In patients with concomitant valvular and coronary disease, the possibility of future transcatheter therapy for the aortic and mitral valves has made a significant impact on decision-making for patients with predominantly coronary disease with moderate valve lesions.
However, there is currently little evidence on this topic. The long-term outcomes of patients with concomitant surgical repair of ischaemic MR are also awaited. Ischaemic stroke after CABG is multifactorial: thrombo-embolism from the aorta, its branches, or the heart; atrial arrhythmias; inflammatory pro-thrombogenic milieu; lower levels of antiplatelet therapy perioperatively; and haemodynamic instability.
However, the most consistent predictor of perioperative stroke is previous stroke or TIA. There is no strong evidence that carotid artery stenosis is a significant cause of perioperative stroke except for bilateral severe carotid bifurcation stenosis.
It may be reasonable to restrict prophylactic carotid revascularization to patients at highest risk of post-operative stroke, i. The Guidelines on the diagnosis and treatment of peripheral arterial diseases in collaboration with the European Society of Vascular Surgery cover the screening for and management of carotid artery disease in patients scheduled for CABG, including screening, indications, and the timing and type of carotid revascularization.
Its management is discussed in section In addition, inter-arm blood pressure asymmetry should lead to the investigation of subclavian artery stenosis. Further details are provided in the peripheral arterial diseases Guidelines. Recommendations on the management of carotid stenosis in patients undergoing coronary artery bypass grafting.
Preoperative strategies to reduce the incidence of stroke in patients undergoing coronary artery bypass grafting. Graft failure can be due to conduit defects, anastomotic technical errors, poor native vessel run-off, or competitive flow with the native vessel. When clinically relevant, acute graft failure may result in MI with consequently increased mortality and major cardiac events.
The suspicion of early graft failure should arise in the presence of ECG signs of ischaemia, ventricular arrhythmias, biomarker changes, new wall motion abnormalities, or haemodynamic instability. Perioperative angiography is recommended in cases of suspected severe myocardial ischaemia to detect its cause and aid decision-making on the most appropriate treatment. In the case of early post-operative graft failure, emergency ad hoc PCI may limit the extent of infarction, if technically feasible.
The target for PCI is the native vessel or the internal mammary artery IMA graft, while the acutely occluded saphenous vein graft SVG and any anastomotic site should be avoided, if possible, due to concerns regarding embolization or perforation. Redo surgery should be favoured if the anatomy is unsuitable for PCI, if several important grafts are occluded, or in the case of clear anastomotic errors.
In asymptomatic patients, repeat revascularization should be considered if the artery is of an appropriate size and supplies a large territory of myocardium. Further details on the diagnosis and management of perioperative MI are provided in a recent ESC position paper. Ischaemia after CABG may be due to the progression of disease in native vessels or de novo disease of bypass grafts.
In view of the higher risk of procedural mortality with redo CABG and the similar long-term outcome, PCI is the preferred revascularization strategy in patients with amenable anatomy. CABG should be considered for patients with extensively diseased or occluded bypass grafts and diffuse native vessel disease, especially in the absence of patent arterial grafts.
Distal protection devices using filters have shown the most encouraging results. However, although a single randomized trial supports the use of distal embolic protection during SVG PCI, observational studies including data from large-scale registries are conflicting. Based on data from a small number of randomized trials, implantation of DES in SVG lesions is associated with a lower risk of repeat revascularization than with BMS at 1 year follow-up.
However, at 5 year follow-up, the advantage of DES over BMS was lost due to a higher incidence of target lesion revascularization between years 1 and 5 in patients treated with DES. Recurrence of symptoms or ischaemia after PCI is the result of restenosis, incomplete initial revascularization, or disease progression.
Restenosis associated with angina or ischaemia should be treated by repeat revascularization, and repeat PCI remains the strategy of choice for most of these patients. In this setting, the results from DES are superior to those obtained with balloon angioplasty, BMS implantation, or brachytherapy.
The use of intracoronary imaging provides unique insights into the underlying mechanisms of in-stent restenosis see section OCT is able to detect the presence of neoatherosclerosis in a significant number of these patients. Underexpanded stents should be aggressively tackled with high-pressure dilatations using non-compliant balloons.
The optimization of the final results remains crucial during reinterventions for in-stent restenosis and, in this regard, the use of intracoronary imaging may be particularly helpful. Outcomes of patients with in-stent restenosis after DES are poorer than those in patients with BMS in-stent restenosis, independently of the therapeutic modality. Although stent thrombosis is very rare, particularly since the advent of new-generation DES, it may have devastating clinical consequences.
Stent thrombosis usually presents as a large MI and patients should be treated according to the principles outlined in section 8. Although repeat stenting in patients with stent thrombosis may be avoided when satisfactory results are obtained with balloon dilation, a new stent may be required to overcome edge-related dissections and adjacent lesions, or to optimize final results.
There is no evidence that the post-interventional management of patients with stent thrombosis should differ from that of patients with thrombosis of a de novo lesion resulting in STEMI. Electrical storm is a life-threatening syndrome related to incessant ventricular arrhythmias, which is most frequently observed in patients with ischaemic heart disease, advanced systolic HF, valve disease, corrected congenital heart disease, and genetic disorders such as Brugada syndrome, early repolarization, and long QT syndrome.
Accordingly, the recommendation tables are taken from the Guidelines. For a detailed discussion, we refer to the previous Guidelines. The combination and duration of anticoagulation and antiplatelet therapy should be assessed according to the clinical situation, as outlined in section 17 as well as in the ESC Guidelines on Atrial Fibrillation and the ESC Focused Update on Dual Antiplatelet Therapy. Post-operative AF affects one-third of patients undergoing cardiac surgery. Post-operative AF is a common complication, in which prophylactic treatment has a moderate effect.
Pre-operative anti-arrhythmic drug treatment may be initiated but will have to be weighed against side effects. Patients with post-operative AF have an increased stroke risk post-operatively as well as during follow-up, , and warfarin medication at discharge has been associated with a reduced long-term mortality. Whether or not surgical left atrial appendage LAA obliteration reduces stroke risk has been studied in smaller trials and registry studies with conflicting results, — and is currently under investigation in a large randomized trial.
Recommendations for the prevention of ventricular arrhythmias by revascularization. Recommendations for the prevention and treatment of atrial fibrillation in the setting of myocardial revascularization. Likewise, the role of routine left atrial exclusion at surgery for the prevention of stroke is currently unclear.
CABG remains the most common cardiac surgical procedure, and the techniques have been refined during 50 years of evolution. Certainly, in some patients with a stenosis in small vessels with little myocardium at risk, complete revascularization may not be necessary. FFR-guided surgical revascularization has been associated with improved graft patency, but more studies are needed to investigate whether it improves clinical outcomes. In addition to patient-related factors, the outcome following CABG is related to the long-term patency of grafts and therefore is maximized with the use of arterial grafts, specifically the IMA.
Whether or not the use of additional arterial grafts can translate into prolonged survival remains debatable. Interim analysis showed no difference at 5 years in the rate of death or the composite of death, MI, or stroke, and 10 year results are warranted to draw final conclusions.
The radial artery constitutes an alternative as the second arterial graft in patients in whom BIMA grafting is not feasible, patients with a high risk of sternal wound complications, or as a third arterial graft.
While the skeletonized technique of harvesting the IMA has a higher theoretical potential for injury, the potential benefits include a longer conduit, more versatility sequential anastomosis , higher blood flow, and fewer wound-healing problems. Endoscopic radial harvesting is possible, but robust evidence concerning its safety and efficacy is scarce. Saphenous vein harvesting can be accomplished using open and minimally invasive techniques, which include interrupted incisions and partial or full endoscopic procedures.
Endoscopic vein graft harvesting leads to a reduced rate of leg wound complications, — but the short- and long-term patency of endoscopically harvested vein grafts, compared with openly harvested grafts, has been challenged. A single cross-clamp technique may be preferred to multiple manipulations of the aorta, with the aim of reducing atheroembolic events, but a strict no-touch technique most effectively reduces embolization of atherosclerotic material.
Besides continuous ECG monitoring and transoesophageal echocardiography immediately after revascularization, intraoperative quality control may also include graft flow measurement to confirm or exclude a technical graft problem. Two large, international randomized trials have shown no difference in 30 day or 1 year clinical outcomes between on- and off-pump surgery when performed by experienced surgeons.
A summary of these technical aspects can be found in Figure 8. Technical aspects of CABG. Minimally invasive coronary surgery with LIMA, harvested either directly or under video-assisted vision, may represent an attractive alternative to a sternotomy. Hybrid revascularization can be performed consecutively in a hybrid operating room, or sequentially on separate occasions in the conventional surgical and PCI environments.
Perioperative reporting of outcomes after CABG procedures should be done on a risk-adjusted basis. The early risk period after CABG extends up to 3 months, is multifactorial, and depends on the interface between technical variability and patient comorbidity. The role of FFR and iwFR in guiding surgical revascularization needs further investigation into whether it improves clinical outcomes. Likewise, there are insufficient data on the impact of intraoperative assessment of graft flow on outcomes.
Multiple Arterial Grafts trial is recruiting to answer the question of whether the use of additional arterial conduits either BIMA or radial artery translates into superior clinical outcomes when compared with SIMA supplemented by SVG only. Hybrid procedures, which combine minimally invasive arterial grafting with PCI, proved feasible and safe. However, multicentre studies are required to prove the efficacy and superiority of this approach in stable, multivessel coronary disease.
Particularly in patients with poor vein grafts. The radial artery should not be used if previously catheterized, if the Allen test is positive or if calcific degeneration is present. Patients with diabetes mellitus, chronic pulmonary obstructive disease, previous mediastinal radiation, and obesity, particularly when multiples of these are present. Plain balloon angioplasty has been superseded in the treatment of de novo coronary lesions after demonstration of the superiority of stenting in terms of the requirement for repeat revascularization.
Balloon angioplasty is no longer preferred to stenting with DES for patients who require urgent non-cardiac surgery as short-duration DAPT may be reasonable with both strategies. A major reduction in the risk of restenosis has been achieved with DES technology.
Biodegradable polymer and polymer-free DES offer the potential to reduce late adverse events after PCI by eliminating inflammatory reactions to permanent polymer coatings. A number of large-scale trials showed comparable efficacy and safety compared with permanent polymer stents.
New-generation DES should therefore be considered as the default stent type for PCI regardless of clinical presentation, lesion subtype, concomitant therapies, or comorbidities. Completely bioresorbable scaffolds BRS , which degrade to predominantly inert end products after fulfilling their scaffold function in the lesion site of the coronary vessel, have been developed with the goal of reducing or eliminating stent-related adverse events at long-term follow-up.
Current scaffold platforms to have reached clinical testing are based on two different technologies: bioresorbable, polymer-based scaffolds resorption up to 3—4 years and resorbable, metallic magnesium scaffolds resorption up to 1 year. Findings of these trials as well as meta-analyses consistently indicate the inferior efficacy and safety of Absorb BVS compared with contemporary DES during long-term follow-up.
Specifically, the Absorb BVS is associated with a significantly increased risk of target lesion revascularization and device thrombosis, with numbers needed to harm of 40— Available evidence on the magnesium scaffold is limited to small observational studies. Initial results appear encouraging, but further evaluation is needed.
The rationale for using DCBs is based on the concept that with highly lipophilic drugs, even short contact times between the balloon surface and the vessel wall are sufficient for effective drug delivery. There are various types of DCB that are approved for use in Europe and their main characteristics are listed in Supplementary Table 8. Although specifically designed comparative randomized trials are lacking, a class effect for all DCBs cannot be assumed. In terms of the use of DCB angioplasty for de novo disease, a number of small randomized trials have been reported with somewhat conflicting results.
Lesion preparation is critical for successful PCI. In addition to plain balloon angioplasty with standard or non-compliant balloons , cutting or scoring balloon angioplasty or rotational atherectomy may be required in selected lesions—particularly those with heavy calcification—in order to adequately dilate lesions prior to stent implantation. However, studies investigating the systematic use of these adjunctive technologies, such as rotational atherectomy, have failed to show clear clinical benefit.
Findings from one meta-analysis of randomized trials suggested better outcomes with IVUS guidance in terms of acute procedural results and reduced angiographic restenosis, repeat revascularization, and MACE, with no effect on death and MI. In cases of stent failure, including restenosis and stent thrombosis, the use of IVUS should be considered in order to identify and correct underlying mechanical factors see section Two observational studies show that while OCT imaging changes operator behaviour, its impact on clinical outcomes is unclear.
A number of observational studies have shown that OCT is feasible and safe in the assessment of stent failure due to thrombosis, and may yield information that may be clinically useful. A number of RCTs have investigated the optimal intervention strategy in patients with bifurcation lesions and showed no benefit for the systematic two-stent approach vs. Recently, a multicentre trial conducted in China directly compared a double-kissing crush two-stent strategy with provisional stenting of the main branch in patients with distal LM bifurcation disease.
Double-kissing crush resulted in a lower risk of the primary endpoint target lesion failure at 1 year compared with provisional stenting. When a two-stent strategy is necessary, which two-stent technique should be preferred is debated. The three most widely used contemporary two-stent techniques are culotte, crush classic or double-kissing crush , and T and protrusion TAP.
In non-LM bifurcation lesions, there is no compelling evidence that one technique is superior to the others in terms of major clinical endpoints. Dedicated RCTs examining the outcomes of patients with chronic total occlusion CTO allocated to revascularization or conservative therapy are scarce. Yet, MACE were comparable between the two groups.
A systematic review of 25 observational studies showed that at median follow-up of 3 years, successful CTO-PCI was associated with improved clinical outcomes in comparison with failed revascularization, including overall survival, angina burden, and the requirement for bypass surgery. In cases of regional wall motion abnormalities in the territory of the CTO, objective evidence of viability should be sought.
In ostial coronary lesions, additional judgement and caution is essential before proceeding to PCI. In particular, a catheter-induced coronary spasm must be rigorously excluded. FFR measurement may also be valuable in the assessment of ostial lesions of borderline significance, taking special care to avoid a wedge position of the guiding catheter and using i.
When performing an intervention, due to interaction between the guide catheter and the proximal stent edge, the risk of longitudinal stent deformation must be considered and avoided with careful catheter manipulation. The accurate positioning of the stent, precisely in the coronary ostium, may be technically challenging and some specialized techniques that may help to achieve optimal stent placement have been described.
Major BARC 3 or 5 bleeding was significantly reduced in the radial group 1. Treatment of restenotic and saphenous vein graft lesions are discussed in section Antithrombotic treatment is mandatory in CAD patients undergoing myocardial revascularization. CABG of revascularization. Both ischaemic and bleeding events significantly influence the outcome of CAD patients and their overall mortality risk during and after myocardial revascularization.
The recommended drugs Figure 9 and doses Table 7 for anticoagulant and antiplatelet drugs used in conjunction with myocardial revascularization are summarized below. Doses of antiplatelet and anticoagulant drugs used during and after myocardial revascularization. Antithrombotic treatment for myocardial revascularization and its pharmacological targets.
For routine clopidogrel pre-treatment administration of the drug when the coronary anatomy is unknown , there is no compelling evidence for a significant clinical benefit in SCAD patients. While aspirin and clopidogrel are indicated for elective stenting procedures, prasugrel or ticagrelor may only be considered in selected patients for specific high-risk situations of elective stenting e. In parallel with antiplatelet treatment, the use of anticoagulants is standard of care during elective PCI to inhibit thrombin generation and activity.
Different agents, including unfractionated heparin UFH and bivalirudin, have been evaluated for their use in clinical practice. UFH treatment. An algorithm for the use of antithrombotic drugs in patients undergoing PCI is shown in Figure Algorithm for the use of antithrombotic drugs in patients undergoing percutaneous coronary intervention.
High bleeding risk is considered as an increased risk of spontaneous bleeding during DAPT e. Following elective stenting, DAPT consisting of clopidogrel in addition to aspirin is generally recommended for 6 months, irrespective of the stent type. Recommendations for antithrombotic treatment in stable coronary artery disease patients undergoing percutaneous coronary intervention. These recommendations refer to stents that are supported by large-scale randomized trials with clinical endpoint evaluation leading to an unconditional CE mark.
The evidence supporting this recommendation comes from two studies where the zotarolimus-eluting Endeavour stent was investigated in conjunction with a 3 month DAPT regimen. The activation of blood platelets and the coagulation cascade plays a key role in the initial phase and evolution of an ACS.
These trials have been reviewed extensively in a number of meta-analyses. The study demonstrated similar risk patterns for both ischaemia and bleeding when comparing the two drugs. Of note, while prior studies reported a reduced bleeding risk with bivalirudin vs. Due to its short half-life and favourable results in some of the studies, bivalirudin may be considered as an alternative to UFH in selected cases. Patients may undergo cardiac catheterization after a conservative treatment phase and these patients are commonly treated with fondaparinux during the conservative treatment phase.
Enoxaparin should be considered as anticoagulant for PCI in patients pre-treated with subcutaneous enoxaparin. Nevertheless, it should be considered for bail-out situations or thrombotic complications, and may be used for high-risk PCI in patients without pre-treatment with P2Y 12 -inhibitors. The available evidence on cangrelor suggests that the potential benefit is independent of the clinical presentation.
Recently, the SMART-DATE Smart Angioplasty Research Team-safety of 6-month duration of Dual Antiplatelet Therapy after percutaneous coronary intervention in patients with acute coronary syndromes prospective multicentre randomized trial supported this notion in the setting of contemporary interventional practice. The authors stated that the increased risk of MI with 6 month DAPT and the wide non-inferiority margin prevented them from concluding that short-term DAPT was safe in this setting, and suggested that prolonged DAPT should remain the standard of care in patients with ACS without excessive risk of bleeding.
Further on, switching and especially a de-escalation of DAPT switching from potent P2Y 12 -inhibitors to clopidogrel was subject to a number of randomized clinical trials. Of note, rivaroxaban has not been investigated in a background of potent P2Y 12 -inhibitors. Recommendations for antithrombotic treatment in patients with non-ST-elevation acute coronary syndromes undergoing percutaneous coronary intervention.
Recommendations for post-interventional and maintenance treatment in patients with non-ST-elevation acute coronary syndromes and ST-elevation myocardial infarction undergoing percutaneous coronary intervention. Randomized data on a comparison of ticagrelor vs.
When potent P2Y 12 receptor inhibitors are contraindicated or are not available, clopidogrel should be given for primary PCI instead. Likewise, the incidence of a combined ischaemic endpoint death, MI, stroke, stent thrombosis, and urgent revascularization did not differ between the two treatment arms. A number of RCTs compared bivalirudin vs. Of note, the bail-out scenarios have never been addressed in randomized controlled trials. For reasons discussed above see sections Recommendations for antithrombotic treatment in ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention.
Accordingly, the recommendation tables in this section are taken from the Focused Update. For a detailed discussion, we refer the reader to the Focused Update. Compared with OAC therapy alone, the addition of DAPT to OAC therapy results in a two- to three-fold increase in bleeding complications, suggesting that every effort should be undertaken to avoid bleeding Table 8.
Of note, previous randomized studies evaluating the duration of triple therapy or the benefit of NOACs vs. The rate of bleeding events peaked within the first 30 days of initiation of triple therapy, and was twice as high when compared with the rate of acute coronary events including recurrent MI and stent thrombosis. For these reasons, the duration of triple therapy should be minimized depending on bleeding and ischaemic risks see Tables 8 to 10 for guidance in decision-making.
In stabilized event-free patients, discontinuation of any antiplatelet agent at 1 year after stenting is encouraged, while dual therapy may be continued beyond 1 year according to the stent-driven risk shown in Table 9. However, as compared with triple therapy, an increase in both MI 4. Although statistical significance was missed, these findings raise concern about the efficacy of the lower dabigatran dose in combination with single antiplatelet therapy in preventing coronary events.
Thus, the mg b. At present, evidence for a dual treatment approach is available for VKA, rivaroxaban, and dabigatran, but none of these studies were powered to assess the efficacy of preventing stent thrombosis or thrombo-embolic events and only RE-DUAL used a NOAC dose that was previously shown to be effective in the prevention of thrombo-embolic events.
Edoxaban is currently being investigated in a setting of triple treatment in the ENTRUST-AF-PCI Evaluation of the safety and efficacy of an edoxaban-based antithrombotic regimen in patients with atrial fibrillation following successful percutaneous coronary intervention trial ClinicalTrials. Adapted from Valgimigli et al. Unfavourable patient profile for a combination of oral anticoagulant and antiplatelet therapy. Dual antiplatelet therapy duration in patients with indication for oral anticoagulation.
Apixaban 5 mg b. Figure 11 illustrates applicable DAPT algorithms in patients with an indication for OAC undergoing PCI with the respective classes of recommendations for the different treatment regimens. Algorithm for dual antiplatelet therapy in patients with an indication for oral anticoagulation undergoing percutaneous coronary intervention.
See the Supplementary Data. The value of pre-hospital pre-treatment with prasugrel in STEMI patients, as well as the safety and efficacy of ticagrelor given at hospital admission in NSTE-ACS patients, has not been addressed in dedicated randomized studies. The clinical benefit of a short-term DAPT duration followed by long-term ticagrelor monotherapy and stopping aspirin remains unknown. Operator experience influences outcomes, particularly in critical, complex situations.
Greater total experience of an entire hospital team—consisting of the supporting members in the operating room or catheterization laboratory and those responsible for postoperative care—results in more favourable outcomes. Studies have suggested that the volume of CABG surgery in a hospital significantly impacts in-hospital mortality, although no consistent cut-offs for volume were used in these studies.
Apart from hospital volume, higher surgeon volume also appears to be inversely related to operative mortality. Birkmeyer et al. Several studies suggest that quality measures are more important than volume per se. Numerous studies have investigated the relationship between the volume of procedures and outcomes of PCI, suggesting a volume—outcome relationship at the operator level, as well as at the institutional level.
A large study in the USA reported that, in a cohort of 36 patients undergoing primary PCI, in-hospital mortality was significantly lower in institutions with higher primary PCI volumes 5. A European training programme in interventional cardiology has been proposed by the EAPCI in order to ensure the high quality of patient care and clinical excellence.
However, the pace at which proficiency reaches certain acceptable standards differs from trainee to trainee. Myocardial revascularization must be accompanied by medical therapy and other secondary prevention strategies for risk factor modification and permanent lifestyle changes. These measures are discussed in detail in the European Guidelines on Cardiovascular Disease Prevention that were published in The need to detect restenosis has reduced in the DES era.
Nevertheless, the recurrence of symptoms or ischaemia due to disease progression or restenosis deserves attention. Strategies for follow-up and management in patients after myocardial revascularization. In all studies to date on the optimal follow-up after PCI, the gain from discovering patients with restenosis is obscured by the high rate of false positive exercise ECG tests indicating ischaemia. Therefore, simple exercise ECG testing is not recommended for follow-up and a non-invasive imaging approach is preferred.
Specific studies to clarify which subset of patients benefits more from a specific follow-up approach are missing. More studies are needed to assess the role of CT angiography in patient surveillance after myocardial revascularization.
Myocardial revascularization is performed for the relief of symptoms of myocardial ischaemia and the improvement of prognosis. In SCAD, the prognostic benefit is dependent on the extent of myocardium subject to ischaemia.
The prognostic and symptomatic benefits of myocardial revascularization critically depend on the completeness of revascularization. Therefore, the ability to achieve complete revascularization is a key issue when choosing the appropriate treatment strategy. This calls for the Heart Team to be consulted to develop individualized treatment concepts, with respect for the preferences of the patient who has been informed about early and late outcomes.
Radial access is preferred for any PCI irrespective of clinical presentation, unless there are overriding procedural considerations. Based on this judgement, treatment durations for DAPT after DES that are as short as 1 month or even as long as lifelong may be reasonable. Off-pump surgery with no-touch aorta for high-risk patients should be considered when expertise exists.
The disclosure forms of all experts involved in the development of these Guidelines are available on the ESC website www. ESC entities having participated in the development of this document:. The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge and the evidence available at the time of their dating. Health professionals are encouraged to take the ESC Guidelines fully into account when exercising their clinical judgment as well as in the determination and the implementation of preventive, diagnostic or therapeutic medical strategies.
Eur Heart J ; 34 : — Google Scholar. Diagnostic accuracy of fractional flow reserve from anatomic CT angiography. JAMA ; : — J Am Coll Cardiol ; 63 : — Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. Eur Heart J ; 36 : — Eur Heart J ; 37 : — Ffluorodeoxyglucose positron emission tomography imaging-assisted management of patients with severe left ventricular dysfunction and suspected coronary disease: A randomized, controlled trial PARR J Am Coll Cardiol ; 50 : — The International Society for Heart Lung Transplantation listing criteria for heart transplantation: A year update.
J Heart Lung Transplant ; 35 : 1 — J Heart Lung Transplant ; 32 : — Myocardial viability and survival in ischemic left ventricular dysfunction. N Engl J Med ; : — Myocardial viability testing and impact of revascularization on prognosis in patients with coronary artery disease and left ventricular dysfunction: A meta-analysis.
J Am Coll Cardiol ; 39 : — Identification of therapeutic benefit from revascularization in patients with left ventricular systolic dysfunction: Inducible ischemia versus hibernating myocardium. Circ Cardiovasc Imaging ; 6 : — Circulation ; : — Long-term follow-up after deferral of percutaneous transluminal coronary angioplasty of intermediate stenosis on the basis of coronary pressure measurement.
SAR Saudi riyal. SGD Singapore dollar. ZAR South African rand. KRW South Korean won. SEK Swedish krona. CHF Swiss franc. TRY Turkish lira. UAH Ukrainian hryvnia. THB Thai baht. Hotel Orso Bruno Carate Urio ex. Check-in Check-out:. Adults: 1 adult 2 adults 3 adults 4 adults.
Ages of children:. Specify the age of a child. Specify the age of children. Request group booking. Based on reviews. Important information. Yes, guests of Hotel Orso Bruno can park their cars on site. Hotel Orso Bruno is situated 1 km from the centre of the city. Hotel Orso Bruno offers child care and children's menu for guests travelling with children.
Yes, guests can enjoy canoeing, hiking and horseback riding at Hotel Orso Bruno. Read reviews. Facilities Internet access. Shuttle service. Eating places. Business facilities. Children facilities. Leisure facilities. Room features. Bathroom features. General facilities. Great restaurants. Local attractions Carate. Find a cancellation policy that works for you. From 6 April , your chosen cancellation policy will apply, regardless of Coronavirus. We recommend booking a free cancellation option in case your travel plans need to change.
Read more. For bookings made on or after 6 April , we advise you to consider the risk of Coronavirus COVID and associated government measures. Your cancellation request will be handled by the property based on your chosen policy and mandatory consumer law, where applicable. During times of uncertainty, we recommend booking an option with free cancellation. If your plans change, you can cancel free of charge until free cancellation expires. Checking available rooms Searching rooms….
Checking available hotels Searching hotels…. Reviews Read reviews. Mary The great view of the lake. Within walking distance of the restaurant una finestra sul lago. The hotel had an excellent location in Carate Urio. Minutes from a ferry port;. What is your impression of this property?
|Online forex exchanges||Table 2 Levels of evidence. Subject: Choose subject… Are you a property owner who needs help? Within 2 weeks for high-risk patients b and within 6 weeks for all other patients. Patient information needs to be unbiased, evidence-based, up-to-date, reliable, accessible, relevant, and consistent with legal requirements. Acute Catheterization and Urgent Intervention Triage strategy. Consistent with the findings in the absence of diabetes, the adverse impact of incomplete revascularization in patients with diabetes was also demonstrated in the BARI-2D Bypass Angioplasty Revascularization Investigation 2 Diabetes trial.|
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|Bruno moltrasio forex converter||Hybrid procedures, which combine minimally invasive arterial grafting with PCI, proved feasible and safe. Following successful revascularization, the rate of events during follow-up remains high in patients with diabetes, independent of the mode of revascularization. CNY Chinese yuan. These versions are abridged and, thus, if needed, one should always refer to the full text version, which is freely available on the ESC and EACTS websites. Bruno moltrasio forex converter facilities are available only for people over the age of Please note that these are considered correct at the time of publishing, but may no longer be available. The early risk period after CABG extends up to 3 months, is multifactorial, and depends on the interface between technical variability and patient comorbidity.|
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|Download forexyard mt4||Adrian P Banning. These recommendations are included below for ease of reference. Likewise, there are insufficient data on the impact of intraoperative assessment of graft flow on outcomes. IABPs are low-cost devices that are easy to insert and remove. At present, one-stage multivessel PCI during STEMI without cardiogenic shock should be considered in patients in the presence of multiple, critical stenoses or highly unstable lesions angiographic signs of possible thrombus or lesion disruptionand if there is persistent ischaemia after PCI on the supposed culprit lesion. Important information.|
|Forexpf quote show php files||Myocardial revascularization must be accompanied by medical therapy and other secondary prevention strategies for risk factor modification and permanent lifestyle changes. FFR-guided surgical revascularization has been associated with improved graft patency, but more studies are needed to investigate whether it improves clinical outcomes. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. For PCI, the FAME study demonstrated that the more restrictive selection of target lesions by functional guidance conferred superior long-term outcomes compared with anatomically guided lesion selection see section 3. Some observational data exist to support the use of FFR in order to decide if revascularization should be deferred or performed. Guestrooms are fitted with all the amenities you need for a good night's sleep.|
|Large Russian forex companies||Minimally invasive coronary surgery with LIMA, harvested either directly or under video-assisted vision, may represent an attractive alternative to a sternotomy. CABG A single cross-clamp technique may be preferred to multiple manipulations of the aorta, with the aim of reducing atheroembolic events, but a strict no-touch technique most effectively reduces embolization of atherosclerotic material. After reviewing the subsequent literature, the bruno moltrasio forex converter Task Force has not found any evidence to support a major update. Lesion preparation is critical for successful PCI. A buffet breakfast is available each morning at the hotel. The level of evidence and the strength of recommendation of particular treatment options were weighed see more graded according to predefined scales, as outlined in Tables 1 and 2.|
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