2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: comments from the Dutch ACS working group
2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: comments from the Dutch ACS working group
F. Arslan 0 1 2 3 4 5 6 7 8
L. Bongartz 0 1 2 3 4 5 6 7 8
J. M. ten Berg 0 1 2 3 4 5 6 7 8
J. W. Jukema 0 1 2 3 4 5 6 7 8
Y. Appelman 0 1 2 3 4 5 6 7 8
A. H. Liem 0 1 2 3 4 5 6 7 8
R. J. de Winter 0 1 2 3 4 5 6 7 8
A. W. J. van 't Hof 0 1 2 3 4 5 6 7 8
P. Damman 0 1 2 3 4 5 6 7 8
0 Department of Cardiology, Haaglanden Medical Center , Den Haag , The Netherlands
1 Department of Cardiology, St. Antonius Hospital , Nieuwegein , The Netherlands
2 Department of Cardiology, Radboud University Medical Center , Nijmegen , The Netherlands
3 Department of Cardiology, Zuyderland Medical Center , Heerlen , The Netherlands
4 Department of Cardiology, Maastricht University Medical Center , Maastricht , The Netherlands
5 Department of Cardiology, Academic Medical Center , Amsterdam , The Netherlands
6 Department of Cardiology, Franciscus Gasthuis , Rotterdam , The Netherlands
7 Department of Cardiology, VU Medical Center , Amsterdam , The Netherlands
8 Department of Cardiology, Leiden University Medical Center , Leiden , The Netherlands
On behalf of the Dutch ACS working group, we discuss the most important changes in recommendations in the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation relevant for both the general and interventional cardiologist. The 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation (STEMI) were presented at the 2017 European Society of Cardiology (ESC) Conference in Barcelona and published in the European Heart Journal . Compared with the 2012 version, the new guidelines incorporate significant changes in recommendations. In this article, we focus on the changes most relevant for daily practice.
STEMI guidelines; NVVC ACS working group statement
The 2012 guideline based its ‘should be considered’
recommendation for routine thrombus aspiration on small trials
and single-centre studies. The current guideline does not
recommend routine manual thrombus aspiration, based on
the TOTAL [
] and TASTE [
] trials. These two studies
are the largest (10,064 and 7,244 patients respectively) and
most recent to investigate both the efficacy and safety of
manual thrombus aspiration.
In the TOTAL trial, a randomised trial of routine
aspiration thrombectomy with percutaneous coronary
intervention (PCI) versus PCI alone in patients with STEMI
undergoing primary PCI, a high (70%) retrieval of macroscopic
thrombus was achieved and a large proportion (nearly 80%)
of the patients included had a high thrombus burden (TIMI
(thrombolysis in myocardial infarction) thrombus grade 4
or 5). However, the trial did not show any effect on
cardiovascular death, recurrent MI, cardiogenic shock, or class
IV heart failure during 1 year follow-up. In addition, a
significantly higher rate of stroke, mainly within 180 days after
intervention, was observed in patients undergoing manual
thrombus aspiration (1.2%).
The TASTE (thrombus aspiration during STEMI) trial
showed no difference in all-cause mortality, cardiac death,
rehospitalisation for MI or stent thrombosis 1 year after
randomisation, even in subgroups with a high thrombotic
burden; approximately 30% of the study population was
classified as having TIMI thrombus grade 4 or 5. In a recent
meta-analysis incorporating these trials, the lack of benefit
for thrombus aspiration was confirmed [
]. In this
metaanalysis, a benefit of thrombus aspiration with regard to
death in patients with a high thrombus burden could not be
Given these concordant results in two high-powered,
large, randomised trials and confirmed by a large
metaanalysis, the ESC guideline correctly discourages the use
of routine manual thrombus aspiration. In cases of high
thrombus burden, the use of a thrombus aspiration device
is left to the discretion of the interventional cardiologist
according to the new guideline.
Multivessel coronary revascularisation
The 2017 guideline gives a class IIA recommendation
(‘should be considered’) for complete revascularisation in
patients presenting with STEMI and multivessel disease,
which is approximately 50% of the STEMI population [
]. Treatment of the infarct-related artery (IRA) improves
clinical outcomes, but evidence for improved prognosis
with immediate revascularisation (preventive PCI) of
remaining lesions is lacking. The new guideline summarises
recent trials investigating complete revascularisation
either during the index procedure [
] or staged during
]. All but the Preventive Angioplasty
in Acute Myocardial Infarction (PRAMI) trial show no
improvement in clinical outcomes such as mortality or
reinfarction, but a consistent and significant reduction in
repeat revascularisation with preventive PCI. In the PRAMI
trial, patients undergoing primary PCI were randomised to
preventive PCI or no preventive PCI. Subsequent PCI for
angina was recommended only for refractory angina with
objective evidence of ischaemia. A reduction was observed
with preventive PCI with regard to non-fatal MI,
refractory angina and the composite end-point, including cardiac
death. However, the group with incomplete
revascularisation included more diabetics with anterior wall MIs, both
important determinants of clinical outcomes after acute
MI. Recent meta-analyses confirm the lack of benefit for
clinical outcomes [
The end-point repeat revascularisation of non-IRAs is
determined by the treatment strategy itself and may not
reflect the clinical benefit of preventive PCI over no PCI.
Even with objective ischaemia such as evidenced by
fractional flow reserve (FFR), deferral of a significant lesion
that likely causes symptoms should not count as an
endpoint, since the occurrence of the event (revascularisation)
is related to the lesion and not to the treatment arm
(preventive PCI vs no PCI).
Complete revascularisation in STEMI patients with
cardiogenic shock is an area of great interest with little but
conflicting data in non-randomised studies [
recent Culprit Lesion Only PCI versus Multivessel PCI in
Cardiogenic Shock (CULPRIT-SHOCK) trial is the first
randomised study to assess culprit-only versus multivessel
PCI in 706 patients presenting with STEMI and cardiogenic
shock. The rate of composite death or renal-replacement
therapy was lower among patients who underwent
culpritonly PCI than in those who underwent multivessel PCI. The
better outcome was mainly driven by lower mortality in the
culprit-only PCI group .
Given the consistent results of recent trials and
metaanalyses, the Dutch ACS (acute coronary syndromes)
working group endorses the ESC recommendation by adding that
patient factors such as complaints, haemodynamic stability,
renal function, lesion complexity as well as local
facilities, logistics (working hours with more back-up available)
and economic considerations should also be taken into
account in the decision-making process. We believe that an
ischaemia-driven staged revascularisation (either during
hospitalisation or elective) is an effective alternative.
Early P2Y12 inhibitor administration
As stated in the ESC guidelines, the evidence for
pre-loading P2Y12 inhibitors in STEMI patients is not very
One small randomised trial (337 patients) was conducted
comparing the efficacy of a high loading dose of 600 mg
clopidogrel given in the pre-hospital phase versus
administration after coronary angiography. The results showed
a trend towards better outcomes with regard to death,
re-infarction or urgent target vessel revascularisation in favour of
pre-treatment, but no difference in vessel patency. In
addition, no difference in bleeding complications was observed
The ATLANTIC (Administration of Ticagrelor in the
Cath Lab or in the Ambulance for New ST-Elevation
Myocardial Infarction to Open the Coronary Artery) trial
investigated whether pre-treatment with ticagrelor
versus treatment in the catheterisation laboratory was
associated with better outcomes [
]. Patients with
ongoing STEMI of less than 6 h duration were randomised to
pre-hospital (in the ambulance) versus in-hospital (in the
catheterisation laboratory) treatment with ticagrelor. There
was no difference in the primary end-point of resolution
of ST-segment elevation or improved TIMI flow pre-PCI;
however ST resolution after PCI (pre-specified secondary
outcome) was significantly improved [
]. The study was
underpowered for clinical end-points, including mortality.
However, definite stent thrombosis at 30 days was
significantly less frequent in pre-treated patients (0.2% vs 1.2%;
p = 0.026). This difference was already apparent in the first
few days after PCI. The ATLANTIC trial shows that
prehospital ticagrelor administration a short time before PCI in
patients with ongoing STEMI is safe but does not improve
pre-PCI coronary reperfusion. It may, however, improve
ST resolution after PCI and reduce the risk of post-PCI
The following should be noted when interpreting the
ATLANTIC trial. The mean difference in time of
administration in the ATLANTIC trial between the two groups was
only 31 min. With regard to the pharmacokinetic data,
ticagrelor and prasugrel are deemed effective after 30 min up
to 4 h after administration. Furthermore, Valgimigli et al.
] showed that inhibition of platelet aggregation by
prasugrel in STEMI patients is suboptimal for at least 2 h after
administration. This is the primary reason why
pre-treatment during transport is standard practice in many
European countries. Of note, a small study by Parodi et al.. [
showed better platelet inhibition after ingestion of crushed
ticagrelor tablets than with whole tablets.
Based on the limited available data, the current ESC
guidelines state that the earliest possible administration may
be preferable to achieve early efficacy. In the Netherlands,
where pre-hospital diagnosis of STEMI has a high accuracy
owing to the digital transfer of electrocardiograms from the
ambulance for consultation, the Netherlands Society of
Cardiology (NVVC) ACS working group supports this
When there is doubt about the STEMI diagnosis, or there
is a high probability that cardiac surgery will be necessary
(for example in cases where a mechanical complication is
suspected), withholding the loading dose should be
considered by the cardiologist until a more definitive diagnosis is
Intravenous ß-blockers prior to primary PCI
The ESC guidelines give a class IIa, level of evidence A
recommendation for intravenous beta-blockade at the time of
presentation in patients without contra-indications, no signs
of acute heart failure, and with a systolic blood pressure of
more than 120 mm Hg.
In the Effect of Metoprolol in Cardioprotection
During an Acute Myocardial Infarction (METOCARD-CNIC)
trial, 270 patients with anterior STEMI without signs of
overt heart failure and a systolic blood pressure of more
than 120 mm Hg were randomised to receive either 15 mg
of intravenous metoprolol or nothing at time of diagnosis
]. The primary end-point was infarct size assessed by
MRI at 5–7 days. MRI was performed in 88% of patients.
Infarct size was significantly smaller in patients treated
with intravenous metoprolol, but the standard deviation
was large: 25.6 ± 15.3 g after intravenous metoprolol
versus 32.0 ± 22.2 g in controls; (p = 0.012). This resulted in
a higher ejection fraction at 6 months (48.7% vs 45.0%;
p = 0.018), and a significant decrease in patients with an
ejection fraction 35% and a class I indication for an
implantable cardioverter-defibrillator. Limitations of this
study are that only anterior STEMI was included, and that
it was not blinded or placebo-controlled.
The Early Intravenous Beta-Blockers in Patients with
ST-Segment Elevation Myocardial Infarction Before
Primary Percutaneous Coronary Intervention (EARLY-BAMI)
trial tried to confirm these findings by including all types
of STEMI patients in a randomised, placebo-controlled trial
]. The trial randomised 683 patients with STEMI within
12 h of onset to intravenous metoprolol (5 mg at
recruitment and an additional 5 mg immediately before PCI) or
placebo. No significant decrease was found in infarct size
measured by creatinine kinase release or by MRI, the
primary end-point. MRI data was, however, only available in
66% of patients, mainly due to logistical reasons. Early
intravenous metoprolol was associated with a borderline
reduction of malignant ventricular arrhythmias (3.6% vs
6.9%; p = 0.050).
Reasons for the lack of effect on infarct size might be
that, compared to the METOCARD-CNIC trial, infarct size
was smaller overall and that around 19% of patients were
already using a beta-blocker before inclusion. Furthermore,
the beta-blocker dose in the METOCARD-CNIC trial was
higher and administered in the ambulance. A subanalysis
of the METOCARD-CNIC trial suggests that the timing
of beta-blocker administration plays a role in determining
its effect on infarct size, with the greatest effect seen in
patients receiving beta-blockade earlier before reperfusion
]. However, with the strict inclusion and exclusion
criteria used, intravenous beta-blockade did not cause an
increase in adverse events.
The ESC guidelines give a class IIa, level of evidence
A recommendation for intravenous beta-blockers.
Summarising the above results, the use of intravenous
betablockers before primary PCI seems safe in patients without
hypotension, heart failure or cardiogenic shock. However,
no robust data is available with regard to a benefit of this
treatment, with one study showing a reduction in infarct
size. We believe there is currently no indication for
routine early intravenous beta-blockers in STEMI, even in the
absence of the above-mentioned contra-indications.
Specific interventional cardiology themes
In the 2017 guidelines, the radial artery is now
considered the preferred access site with a class I
recommendation (level of evidence A). The latest MATRIX
(Minimising Adverse Haemorrhagic Events by TRansradial Access
Site and Systemic Implementation of angioX) trial not only
showed reduced bleeding complications, but also confirmed
a significant survival benefit over transfemoral access as
observed in earlier studies such as the RIVAL (RadIal Vs
femorAL access for coronary intervention) and
RIFLESTEACS (Radial Versus Femoral Randomized
Investigation in ST-Elevation Acute Coronary Syndrome) trials. The
NVVC ACS working group endorses the recommendation
for the radial approach as the default access site in ACS
patients undergoing primary PCI by operators with experience
using this approach.
DES over BMS
The 2017 guidelines now also give a class I
recommendation for the use of drug-eluting stents (DES) over bare
metal stents (BMS), given the lower risk of re-infarction and
target vessel revascularisation with DES. The latest
generation of DES have also been shown to have a lower risk
of stent thrombosis and recurrent MI compared to the
Time delays and limits
The 2017 guidelines have replaced the term
‘door-to-balloon’ time by ‘first medical contact (FMC) to wire crossing’
as a clinical performance measure. FMC is defined as the
initial assessment of the patient by a physician, paramedic,
nurse or other trained emergency medical system
personnel who can obtain and interpret the electrocardiogram, and
perform the initial intervention (e. g. defibrillation). The
target for diagnosing STEMI is set at <10 min after FMC.
For the primary PCI strategy, the 2017 guidelines dictate
a < 90 min target from STEMI diagnosis to wire crossing.
The time limits for primary PCI after symptom onset have
also changed slightly. The 2017 guidelines give a class I
(level of evidence A) recommendation for reperfusion
therapy in all patients with symptoms of ischaemia of <12 h
duration and persistent ST-segment elevation. A class IIa
recommendation (‘should be considered’) is given for
routine primary PCI for patients presenting late (12–48 h) after
symptom onset. In asymptomatic patients, routine PCI of an
occluded IRA > 48 h after onset of STEMI is not indicated
(class III, level of evidence A).
Conflict of interest F. Arslan, L. Bongartz, J.M. tenBerg, J.W. Jukema,
Y. Appelman, A.H. Liem, R.J. de Winter, A.W.J. van ’t Hof and
P. Damman declare that they have no competing interests.
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