2. What Do the Guidelines Say ?
Acute Coronary Syndromes Guidelines :
Are the US and Europe in Harmony ?

3. STEMI

4. NSTEmi

5. Based on the ECG, two groups of patients should be
differentiated:
(1)Patients with acute chest pain and persistent (>20 min) ST-
segment elevation (ST-elevation ACS )
(2) Patients with acute chest pain but no persistent ST-
segment elevation (Non-ST-elevation ACS)
 ECG changes may include transient ST-segment elevation,
persistent or transient ST-segment depression, T-wave
inversion, flat T waves or pseudo-normalization of T waves
or the ECG may be normal.
The leading symptom that initiates the diagnostic and
therapeutic cascade in patients with suspected acute
coronary syndromes is chest pain.

6. Initial assessment of patients with suspected acute coronary syndromes
“Other cardiac” includes, among other, myocarditis, Tako-Tsubo cardiomyopathy, or
tachyarrhythmias. “Non-cardiac” refers to thoracic diseases such as pneumonia or
pneumothorax. . If the initial evaluation suggests aortic dissection or pulmonary embolism,
D-dimers and MDCT angiography are recommended

7. Differential diagnoses of acute coronary
syndromes in the setting of acute chest pain

8. Differential diagnoses of acute coronary
syndromes in the setting of acute chest pain

9. Reperfusion goals:
Door-to-balloon inflation(pPCI)goal of 90
minutes

10. STEMI time delays (Time is Myocardium ) “You may delay, but
time will not, and lost time is never found again.”
Patient Delay System Delay
FMC
door-to-balloon time
door-to-needle time

11. STEMI diagnosis
Primary PCI capable
center
Primary - PCI
Non primary-PCI
capable center
PCI possible <120 min? Yes
Primary - PCI
Transfer
to PCI
center
DIDO time

12. STEMI diagnosis
Non primary-PCI capable
center
PCI possible <120 min? No
Thrombolytic
Therapy
Failed or Reocclusion Successful
Rescue PCI
Coronary angiography

14. Initial risk stratification

16. Initial risk stratification

17. Selection of NSTE-ACS treatment strategy and
timing according to initial risk stratification.

18. A few words about
antiplatelet therapy

19. Pathophysiology of ACS: The Role of Platelets

20. Rivaroxaban

22. Antiplatelet Agents—Oral P2Y12 Inhibitors
++++++Bleeding Risk

24. Ischemic RiskBleeding Risk
Balanced Benefit/Risk Ratio
Tailoring antiplatelet therapy :
a step toward individualized therapy to improve clinical outcome?
Thus, the thousand dollar question is :
Where is the sweet spot between
ischaemia and bleeding?

25. A call for individualised medicine
One Size Does Not Fit All
Precision medicine
( Personalized medicine )

26. Factors for physicians to consider in determining the optimal
duration of DAPT after DES implantation for individual patients
Eisen, A. & Bhatt, D. L. (2015) Defining the optimal duration of DAPT
after PCI with DES Nat. Rev. Cardiol. doi:10.1038/nrcardio.2015.87