The initial assessment of patients presenting with chest pain involves considering the presentation, ECG, and troponin levels to determine the likelihood of acute coronary syndrome. A higher likelihood is present with factors like cardiorespiratory arrest, syncope, dyspnea, arrhythmias, age over 40, previous cardiovascular disease or risk factors. A lower likelihood is suggested by factors like age under 40, no prior disease or risk factors, and chest pain that is variable, short-lived or position-dependent. The assessment guides whether the diagnosis is likely to be cardiac ischemia, noncardiac chest pain, or another cause.

1. CLINICAL DECISION
MAKING TOOLKIT
Instant guidance
for diagnosis, risk management
and treatment
2018 edition

2. The
Clinical Decision Making
Toolkit is produced by the Acute Cardiovascular
Care Association (ACCA), developed and distributed
through an educational grant from AstraZeneca.
AstraZeneca was not involved in the development
of this publication and in no way influenced its content.

3. ISBN: 978-2-9537898-7-4
The Acute Cardiovascular Care Association
Clinical Decision-Making
TOOLKIT
Héctor Bueno, M.D., PhD., FESC
Editor in Chief
Pascal Vranckx, M.D., PhD
Associate Editor

4. The ACCA Toolkit is available
through different platforms:
•
Printed booklet, available at congresses
where ESC-ACCA is represented
•
Web-based pdf file downloadable at:
www.escardio.org/ACCA
•
Mobile application for smartphones/tablets
available in both Apple Googleplay stores
Héctor Bueno
M.D., PhD., FESC
Editor in Chief
The best care of patients with acute cardiovascular syndromes
relies not only on specialists but also on systems of care that
involve many non-cardiologists. Several of these syndromes
require immediate diagnosis and decisions on treatment,
some of them life-saving. Critical decisions must often be
made quickly by professionals with different backgrounds
and levels of expertise with limited resources. This poses a
significant clinical challenge.
Against this background, the ACCA Clinical Decision-
Making Toolkit was created as a comprehensive resource
encompassing all aspects of acute cardiovascular care but
structured as an easy-to-use instrument in environments
where initial acute cardiovascular care is typically initiated.
Comprehensive tables, clear diagrams and algorithms, based
on the ESC clinical practice guidelines as well as in clinical
experience should provide diagnostic and therapeutic
guidance at a glance.
This 2018 Edition of the Clinical Decision Making Toolkit
has been updated with the 2016 and 2017 ESC Guidelines,
a chapter on secondary prevention was added and the chapter
on acute heart failure benefited a major update. However, it
does not replace textbooks and other sources of information
that need to be consulted to reach an optimal management
of these patients.
II
Preface

5. 7 DAYS F R O M C A R D I A C E V E N T
U N T I L P A T I E N T S T A B I L I S A T I O N
ICCU
INTENSIVE
CARDIAC
CARE UNIT
CCU
CORONARY
CARE UNIT
PRE-HOSPITAL CARE
GENERAL
HOSPITAL
EMERGENCY ROOM
CARDIAC ARREST, STEMI, ACS, AHF,
CARDIOGENIC SHOCK, ARRHYTHMIAS,
VASCULAR SYNDROMES

6. List of Authors �������������������������������������������������������������������������������������������������������������������������� VI
CHAPTER 1: KEY SYMPTOMS
Chest Pain - M. Lettino, F. Schiele �������������������������������������������������������������������������������������������������� P. 2
Dyspnea - C. Müller ��������������������������������������������������������������������������������������������������������������������� P. 9
Syncope - R. Sutton ������������������������������������������������������������������������������������������������������������������� P. 16
CHAPTER 2: ACUTE CORONARY SYNDROMES
General concepts - H. Bueno ������������������������������������������������������������������������������������������������������ P. 24
Non ST-segment elevation ACS - H. Bueno ���������������������������������������������������������������������������������� P. 29
STEMI - P. Vranckx, B. Ibañez ������������������������������������������������������������������������������������������������������ P. 34
CHAPTER 3: SECONDARY PREVENTION AFTER ACS
General secondary prevention strategies and lipid lowering - H. Bueno, S. Halvorsen ����������������������� P. 38
Antithrombotic treatment - F. Costa, S. Halvorsen ������������������������������������������������������������������������ P. 41
CHAPTER 4: ACUTE HEART FAILURE
Wet-and-warm heart failure patient - V.P. Harjola, O. Miró ������������������������������������������������������������� P. 52
Cardiogenic shock (wet-and-cold) - P. Vranckx, U. Zeymer ������������������������������������������������������������� P. 61
IV
Contents

7. CHAPTER 5: CARDIAC ARREST AND CPR - N. Nikolaou, L. Bossaert ������������������������������������ P. 71
CHAPTER 6: RHYTHM DISTURBANCES
Supraventricular tachycardias and atrial fibrillation - J. Brugada �������������������������������������������������� P. 80
Ventricular tachycardias - M. Santini, C. Lavalle, S. Lanzara ���������������������������������������������������������� P. 84
Bradyarrhythmias - B. Gorenek �������������������������������������������������������������������������������������������������� P. 87
CHAPTER 7: ACUTE VASCULAR SYNDROMES
Acute aortic syndromes - A. Evangelista �������������������������������������������������������������������������������������� P. 92
Acute pulmonary embolism - A. Torbicki ������������������������������������������������������������������������������������� P. 102
CHAPTER 8: ACUTE MYOCARDIAL/PERICARDIAL SYNDROMES
Acute myocarditis - A. Keren, A. Caforio �������������������������������������������������������������������������������������� P. 112
Acute pericarditis and cardiac tamponade - C. Vrints, S. Price ������������������������������������������������������� P. 117
CHAPTER 9: DRUGS IN ACUTE CARDIOVASCULAR CARE - A. de Lorenzo ���������������������� P. 121
Abbreviations ���������������������������������������������������������������������������������������������������������������������� P. 191
References and copyright acknowledgments ����������������������������������������������������������������� P. 199
V
Contents (Cont.)

8. Leo Bossaert
Department of Medicine, University and University Hospital Antwerp, Antwerp,
Belgium
Josep Brugada
Department of Cardiology, Hospital Clinic Universitat de Barcelona, Barcelona, Spain
Héctor Bueno
Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC),
and Department of Cardiology, Hospital Universitario 12 de Octubre, Madrid, Spain
Alida Caforio
Department of Cardiology, Padua University Medical School, Padua, Italy
Francesco Costa
Cardiovascular institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
Artur Evangelista
Department of Cardiology, Hospital Universitario Vall d’Hebrón, Barcelona, Spain
Bulent Gorenek
Department of Cardiology, Eskisehir Osmangazy University, Eskisehir, Turkey
Sigrun Halvorsen
Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
Veli-Pekka Harjola
Division of Emergency Medicine, Department of Emergency Care and Services, Helsinki
University Hospital, Finland
Borja Ibañez
Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC),
and Department of Cardiology, University Hospital Fundación Jiménez Díaz, Madrid, Spain
Andre Keren
Heart Failure and Heart Muscle Disease Centre, Hadassah University Hospital,
Jerusalem, Israel
VI
List of Authors

9. Stefania Lanzara
Department of Emergency, Ospedale Madre Giuseppina Vannini, Rome, Italy
Carlo Lavalle
Department of Cardiology, Ospedale San Filippo Neri, Rome Italy
Maddalena Lettino
Clinical Cardiology Unit, IRCCS Istituto Clinico Humanitas, Milano, Italy
Ana de Lorenzo
Pharmacy Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
Òscar Miró
Emergency Department, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
Christian Müller
Department of Cardiology, University Hospital Basel, Basel,Switzerland
Nikolaos Nikolaou
Departement of Cardiology, Konstantopouleio General Hospital, Athens, Greece
Susanna Price
Consultant Cardiologist Intensivist, Royal Brompton Hospital, London, United Kingdom
Massimo Santini
Department of Cardiology, Ospedale San Filippo Neri, Rome, Italy
François Schiele
Department of Cardiology, University Hospital Jean-Minjoz, Besancon, France
Richard Sutton
Department of Cardiology, National Heart and Lung Institute Imperial College,
London, United Kingdom
Adam Torbicki
Department of Pulmonary Circulation and Thromboembolic Diseases, Centre of
Postgraduate Medical Education, ECZ Otwock, Poland
Pascal Vranckx
Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Hasselt, Belgium
Christiaan Vrints
Department of Cardiology, Antwerp University Hospital, Edegem, Belgium
Uwe Zeymer
Department of Cardiology, Herzzentrum Klinikum Ludwigshafen, Ludwigshafen, Germany
VII
List of Authors (Cont.)

11. CHAPTER 1
KEY SYMPTOMS
1.1 CHEST PAIN ����������������������������������������������������������������� p.2
M. Lettino, F. Schiele
1.2 DYSPNEA �������������������������������������������������������������������� p.9
C. Müller
1.3 SYNCOPE ������������������������������������������������������������������� p.16
R. Sutton
P.1
1

12. 1. Presentation
2. ECG
3. Troponin
4. Diagnosis
Reference: Roffi et al. Eur Heart J 2015; eurheartj.ehv320.
Low likelihood
of Acute Coronary Syndrome
High likelihood
of Acute Coronary Syndrome
Noncardiac
Other
Cardiac
UA STEMI
NSTEMI
P.2
1.1
Initial assessment of patients with CHEST PAIN

13. First call for
chest pain Higher death risk / probability for ACS Lower death risk / probability for ACS
Arguments
for vital risk
•
Cardiorespiratory arrest, syncope/
loss of consciousness, neurological defect
• Dyspnea (see chapter 1.2 page 9)
•
Arrhythmias – tachycardia
• Normal consciousness
• Normal breathing
•
Normal heart rhythm
Context, CV risk Age 40 years, previous CV disease
(MI, stroke, PE), modifiable CV risk factors
(smoker, HTN, hypercholesterolemia, diabetes),
chronic CV treatment
•
Age 40 years,
•
No previous CV disease
•
No CV risk factors
• No chronic treatment
Chest Pain Medial/lateral thoracic pain, intense,
with dyspnea
•
Depends on position/palpation/
movements
•
Variable intensity, short duration (1 min)
• Hyperthermia
Cardiac
Ischemic
Pain
Retro-sternal, constriction, jaw/cervical/arm/back
irradiation, spontaneous, prolonged 20 min +
dyspnea, sweating, lightheadedness, nausea
•
Lateral, abdominal irradiation
•
No neuro-vegetative symptoms
P.3
1.1
Factors to be considered in the evaluation
after the first call for CHEST PAIN

14. No
Yes
Likelihood of ACS
High probability for ACS Low probability for ACS
Emergency transport
with trained medical team
Emergency care:
Resuscitation, hemodynamic or
rhythm restoration (see chapter 5)
APPROACH AFTER FIRST CALL FOR OUT-OF-HOSPITAL CHEST PAIN
VITAL RISK? (see chapter 1.1 page 3)
P.4
1.1
Approach after first call for out-of-hospital CHEST PAIN

15. ECG, decision for reperfusion,
antithrombotics, immediate
transport to ED/CPU/ICCU/Cathlab
(see chapter 2)
Emergency transport
Emergency transport
with trained medical team
Hospital admission
to the ED/CPU
Cardiology
ward
Non-cardiology
ward
Discharge after
prolonged observation
P.5
1.1

16. First medical contact Higher death risk / probability for ACS Lower death risk / probability for ACS
Hemodynamic,
respiratory, neurological
distress
•
Cardiopulmonary arrest, hypotension, tachycardia,
shock
•
Dyspnea, hypoxemia, lung rales (Killip class 2)
•
ECG: ST-segment deviation
•
Normal consciousness, no motion defects
•
Normal HR and BP
•
Normal breathing and SpO2,
no loss of pulse
Probability for ACS •
Context, typical symptoms consistent
with myocardial ischemia
• ECG changes
• Hs cTn
•
No CV risk, atypical symptoms,
normal ECG
•
Negative hs cTn only if onset of pain
3 hours (see chapter 2.1 page 24)
STEMI NSTE-ACS
Uncertain diagnosis
(see chapter 2.1 page 24)
ECG criteria for STEMI
ST depression or normal ECG
Normal ECG (repeat 12-lead ECG
recording if symptoms persist/recur)
Other ST-segment abnormalities
Type of reperfusion
Time assessment
•
Primary PCI or thrombolysis? Primary PCI if delay
120 min (preferably 90 min)
or 60 min if onset of pain 120 min
Consider age, anterior wall location
•
Relevant times: Symptom onset, first medical
contact (FMC). FMC → ECG/diagnosis; FMC → PCI;
FMC → thrombolysis
•
Primary PCI between 12-48 hours
in patients with ongoing ischemia,
symptoms or clinical/haemodynamic
or electrical instability
•
No reperfusion if delay 12 hours
and stable, asymptomatic, without
ST-segment elevation
P.6
1.1
Factors to be considered in the evaluation
during the first medical contact for CHEST PAIN

17. Yes
Resuscitation, hemodynamic
or respiratory support
(see chapters 4 5)
Type of reperfusion (primary PCI or fibrinolysis)
Record times (symptom onset, FMC)
High probability Low probability
No
FIRST MEDICAL CONTACT IN PATIENTS WITH CHEST PAIN (HOME-AMBULANCE)
Hemodynamic, respiratory or neurological distress?
ST-segment elevation
ECG 10 min → ACS ?
No ST-segment elevation but
other ECG changes or persistent pain
Suspect ACS
Uncertain diagnosis
No antithrombotic treatment
Transfer to a proximity centre
(with or without cath-lab)
Start recommended medical therapy
(including antithrombotic drugs)
Transfer to a centre with cath-lab
Non cardiovascular disease?
• Sepsis
• Acute respiratory distress
• GI disease, bleeding, others
Acute cardiovascular disease other than ACS?
• Acute aortic syndrome (see chapter 7)
• Pulmonary embolism (see chapter 7)
• Acute pericarditis (see chapter 8)
• Acute heart failure (see chapter 4)
P.7
1.1
First medical contact in patients with CHEST PAIN (home-ambulance)

18. • Diagnosis of NSTE-ACS (see chapter 2)
• Acute aortic syndrome (see chapter 7)
• Acute pulmonary embolism (see chapter 7)
• Acute pericarditis (see chapter 8)
• Acute heart failure (see chapter 4)
• Aortic stenosis, hyperthrophic cardiomyopathy
• Acute gastro-oesophageal disease
• Acute pleuro-pulmonary disease
• Acute psychogenic disorders
Repeat clinical and ECG examination
Laboratory: cTn, renal function, Hb,
D-dimers
Imaging: TTE, CT scan
Diagnostic coronary angiography
Yes No
Yes No
MANAGEMENT OF PATIENTS WITH CHEST PAIN (EMERGENCY ROOM)
STEMI,
NSTE-ACS with persistent pain,
Hemodynamic distress
No direct transfer to cath-lab
→ ED, Chest Pain Unit,
cardiology ward, other wards
Other CVD
or No ACS
Resuscitation, hemodynamic
or respiratory support
(see chapters 4 5)
Direct transfer to cath-lab
Complicated NSTEMI
STEMI (see chapter 2)
Hemodynamic, respiratory or neurological distress?
P.8
1.1
Management of patients with CHEST PAIN (emergency room)

19. DYSPNEA: DIFERENTIAL DIAGNOSIS
50% have ≥2 diagnoses, which may result in acute respiratory failure*!
• ECG • Chest X-ray • Blood count • cTn
• BNP • Venous BG • D-dimers if suspicion of PE
Basic measures
• BP, HR, respiratory rate, SpO2 temperature
• Start oxygen to target SpO2 94-98%
• Start i.v. line monitor patient
Criteria for transfer to ICU
(despite treatment for 30 minutes)
• Respiratory rate 35/min
• SpO2 85%
• SBP 90 mmHg
• HR 120 bpm
Investigations:
Acute heart
failure
Acute coronary
syndrome
Exacerbated COPD
or other chronic
lung disease
Other causes, including
• Asthma
• Severe sepsis
• Tumor
• Pneumothorax
• Pleural effusion/ascites
• Anxiety disorder
• Anemia
• Bronchitis
• Metabolic acidosis
• Neurologic disease
Pneumonia Pulmonary
embolism
* Defined as ≥1 criterion:
• Respiratory rate ≥25/min
• PaO2 ≤75 mmHg
• SpO2 ≤92% in ambient air
• PaCO2 ≥45 mmHg with arterial pH ≤7.35
Reference: Ray P et al. Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Critical Care (2006); 10 (3):R82.
P.9
1.2
DYSPNEA: Diferential diagnosis

20. BASIC WORK-UP
• Positioning Keep head of bed elevated above level of legs
• Oxygen Up to 12 l/min via rebreather mask, titrate oxygen saturation to 94%
• Nitroglycerin 1-2 SL tablets or 2-3 patches 10 mg (1st
choice). In pulmonary edema with severe shortness
of breath: NTG drip 0.05% (100 mg in 200 ml)
- Start with 25 µg/min = 3 ml/h, check BP after 5 and 10 min
- Increase dose by 25 µg/min at a time as long as SBP 90 mmHg
- Additional BP check 5 and 10 min after each increase in dosing
- Check BP every 20 min once a steady drip rate is reached
• Furosemide 40-120 mg i.v. (adjust based on kidney function and clinical findings; monitor creatinine)
• Morphine 2 mg i.v. (preceeded by 10 mg i.v. metoclopramide PRN) if patient is in severe dyspnoea
• Consider digoxin 0.5 (-1.0) mg i.v. in patients with atrial fibrillation
• Anticoagulation Therapeutic dosing in ACS and atrial fibrillation: Enoxaparin 1 mg/kg body weight as 1st
dose
• Chest X-ray (lung ultrasound)
• Echocardiogram
During admission (earlier if decompensated
aortic stenosis or endocarditis are suspected)
• Coronary angiography
Emergent in patients with ACS; delayed in
patients with suspected coronary artery disease
• Immediate 12-lead ECG, cardiac monitor, BP, respiratory rate,
pulse oximetry
• Clinical findings
Most commonly: lower extremity edema, jugular venous
distension,rales,workupforunderlyingcardiacdiseaseandtriggers
• Laboratory findings
Complete blood count, chemistries, cardiac enzymes, BNP,
TSH, ABG as needed
P.10
1.2
DYSPNEA: Acute heart failure (see chapter 4.1)

21. Reference: Ware L B and Matthay M A. Acute Pulmonary Edema. New Engl J Med (2005); 353:2788-2796.
Unstable after 30 minutes
CCU/ICU transfer Ward transfer
Stable after 30 minutes
P.11
1.2

22. Priorities: 1. Vital signs 2. Diagnostic screening dependent upon clinical stratification
Hemodynamically unstable Hemodynamically stable
Initiate transfer to ICU
Immediate TTE (if available)
Result
inconclusive
→ CT-angio
Right
ventricular
dysfunction
Wells criteria for PE:
Score
• Clinical signs and symptoms of
deep vein thrombosis (DVT) + 3.0
• No alternative diagnosis (or alternative
diagnosis less likely than PE) + 3.0
• Heart rate 100/min + 1.5
• Immobilization or operation within
the last 4 weeks + 1.5
• Previous DVT or PE + 1.5
• Hemoptysis + 1.0
• Malignant tumor with treatment within the
last 6 months or palliative care + 1.0
ABG, ECG, chest X-ray plus clinical assessment of PE probability (risk factors) plus monitoring
P.12
1.2
DYSPNEA: Acute pulmonary embolism (see chapter 7.2)

23. Copyright: Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.
Am J Med (2006); 119:1048–55. - Goldhaber SZ. Pulmonary embolism. Lancet (2004); 363 (9417) 1295-1305. - Agnelli G and Becattini C. Acute Pulmonary
Embolism. New Engl J Med (2010); 363:266-274.
Intermediate
probability
Total score 2-6
High
probability
Total score 6
Low
probability
Total score 2
Outpatient management possible?
→ Risk stratification
PE confirmed: Treatment
(see chapter 7.2)
(see chapter 7.2)
P.13
1.2

24. DYSPNEA: COPD EXACERBATION
• Verify diagnosis (DD: PE, acute heart failure, pneumothorax)
• Oxygen administration → SpO2 target 88-92% (Beware of carbonarcosis: ABC after 1 h)
Definition:
Known COPD and/or • Progressive dyspnea and/or
• Change in quantitiy and color of sputum and/or
• Heavy coughing
• COPD classification
(GOLD)
• Etiology
• Hospitalisation indicated?
• Follow-up
• Evaluate ICU criteria
• NIV indicated?
• Laboratory findings: Blood count, coagulation, ProCT, perhaps BNP, D-Dimers
• Chest X-ray; ECG (exclusion of differential diagnoses)
• Sputum cultures (always in case of hospitalisation or previous
outpatient antibiotic treatment)
• Oxygen therapy 2-(4) l; target saturation 90%
• Salbutamol/ipratropium inhalations ≥4-6 x/d, if needed long-term inhalation
• Systemic steroids prednisone 0.5 mg/kg of body weight for 5 days
• Antibiotic treatment should be considered; always indicated in stage Gold IV
• Physiotherapy
• History, clinical examination (blood pressure, pulse, oxygen saturation, vigilance)
Copyright: Leuppi JD et al. JAMA. 2013 Jun 5; 309(21):2223-31.
P.14
1.2
DYSPNEA: COPD exacerbation

25. DYSPNEA: COMMUNITY-ACQUIRED PNEUMONIA
Objective: diagnostics, risk stratification empirical immediate treatment 2(-4) hours
Definition
Complications
• Chest X-ray if dyspnea cough
• Laboratory workup clinical chemistry; BGA; procalcitonin
• Sputum if patient admitted
• Blood cultures (2x2) if patient admitted
• Legionella antigen (urine) if Legionellosis suspected
• Pneumococcus antigen (urine) if no other pathogen isolated
Risk stratification → manageable on an outpatient basis?
- Pneumonia Severity Index
- CURB-65
• Treatment; procalcitonin guided treatment
• Consider outpatient treatment where PSI I-III or CURB65 0 or 1
• Minimum 5-day course of treatment and afebrile for 48-72h, 7-10 days,
14 days where intracellular organisms (e.g. Legionella) are present
Copyrights:MandellLAetal.InfectiousDiseasesSocietyofAmerica/AmericanThoracicSocietyconsensusguidelinesonthemanagementofcommunity-acquired
pneumonia in adults. Clin Infect Dis. (2007); 44 Suppl 2:S27-72. - Halm EA and Teirstein AS. Management of Community-Acquired Pneumonia New Engl J Med
(2002);347:2039-2045.-WoodheadMetal.GuidelinesforthemanagementofadultlowerrespiratorytractinfectionsERJDecember1,(2005);26(6)1138-1180.
P.15
1.2
DYSPNEA: Community-acquired pneumonia

26. Syncope is a transient loss of consciousness due to global cerebral hypoperfusion (usually, itself due to
period of low blood pressure) characterised by rapid onset, short duration, spontaneous and complete recovery.
The differentiation between syncope and non-syncopal conditions with real or apparent LOC can be achieved
in most cases with a detailed clinical history but sometimes can be extremely difficult. The following
questions should be answered:
•
Was LOC complete?
•
Was LOC transient with rapid onset and short duration?
•
Did the patient recover spontaneously, completely and without sequelae?
•
Did the patient lose postural tone?
If the answers to these questions are positive, the episode has a high likelihood of being syncope. If the answer to
one or more of these questions is negative, exclude other forms of LOC before proceeding with syncope evaluation.
Loss of Consciousness?
TLOC
Trauma Not Trauma
• Accidental • Fall
• Other abnormal mental state
No
No
Yes
Yes
• Coma
• Intoxication
• Metabolic disturbance
• Aborted sudden death
Transient, rapid onset,
short time, self-terminating
Syncope Epilepsy Psychogenic
Reference: Sutton R. Clinical classification of syncope. - Prog Cardiovasc Dis. (2013); 55(4):339-44.
P.16
1.3
SYNCOPE: Assessment of patients
with transient loss of conscioussness (TLOC)

27. Vasovagal syncope is diagnosed if syncope is precipitated by emotional distress or orthostatic stress
and is associated with typical prodrome.
Situational syncope is diagnosed if syncope occurs during or immediately after specific triggers.
Orthostatic syncope is diagnosed when it occurs after standing up and there is documentation
of orthostatic hypotension.
Arrhythmia related syncope is diagnosed by ECG when there is:
•
Persistent sinus bradycardia 40 bpm in awake or repetitive sinoatrial block or sinus pauses 3 s
•
Mobitz II 2nd
or 3rd
degree AV block
•
Alternating left and right BBB
•
VT or rapid paroxysmal SVT
•
Non-sustained episodes of polymorphic VT and long or short QT interval
•
Pacemaker or ICD malfunction with cardiac pauses
Cardiac ischemia related syncope is diagnosed when syncope presents with ECG evidence of acute ischemia
with or without myocardial infarction.
Cardiovascular syncope is diagnosed when syncope presents in patients with prolapsing atrial myxoma, severe
aortic stenosis, pulmonary hypertension, pulmonary embolus or acute aortic dissection.
Reference: Moya A et al. Eur Heart J(2009) 30, 2631–2671 (1).
P.17
1.3
SYNCOPE: Diagnostic criteria (1)
Diagnostic criteria with initial evaluation

28. Patients with suspected syncope presenting to ED or clinic
“Uncertain” or unexplained syncope Certain diagnosis of syncope
Risk stratification
High risk Intermediate risk Low risk
Observation Unit
Home if stable,
Admit to hospital
if evidence of high risk
Home
Outpatient SMU
referral
Outpatient SMU for diagnosis, treatment
and follow-up as appropriate
Hospital admission
Inpatient SMU
Initiate therapy
Inpatient SMU, outpatient SMU or
personal physician as appropriate
Copyright: Sutton R, Brignole M, Benditt DG. Key challenges in the current management of syncope. Nat Rev Cardiol. (2012 ); (10):590-8.
Once syncope is considered to be the likely diagnosis, risk stratification is required to determine further management. P.18
1.3
SYNCOPE: Evaluation and risk stratification of patients
with suspected syncope

29. Carotid sinus massage Orthostatic Hypotension
Indications
•
CSM is indicated in patients 40 years with syncope
of unknown aetiology after initial evaluation;
•
CSM should be avoided in patients with previous MI,
TIA or stroke within the past 3 months and in
patients with carotid bruits (except if carotid Doppler
studies excluded significant stenosis)
Recommendations: Active standing Indications
•
Manual intermittent determination with
sphygmomanometer of BP supine and, when OH
is suspected, during active standing for 3 min is
indicated as initial evaluation;
•
Continuous beat-to-beat non-invasive pressure
measurement may be helpful in cases of doubt
Diagnostic criteria
•
CSM is diagnostic if syncope is reproduced in presence
of asystole longer than 3 s and/or a fall in systolic
BP 50 mmHg
Diagnostic criteria
•
The test is diagnostic when there is a symptomatic
fall in systolic BP from baseline value ≥20 mmHg
or diastolic BP ≥10 mmHg or a decrease in systolic BP
to 90 mmHg;
•
The test should be considered diagnostic when there
is an asymptomatic fall in systolic BP from baseline
value ≥20 mmHg or diastolic BP 10 mmHg
or a decrease in systolic BP to 90 mmHg
Reference: Moya A et al. Eur Heart J(2009) 30; 2631–2671 (2).
P.19
1.3
SYNCOPE: Diagnostic criteria (2)
Diagnostic criteria with provocation maneuvers

30. Treatment of reflex syncope Treatment of orthostatic hypotension
•
Explanation of the diagnosis, provision of reassurance and explanation
of risk of recurrence are in all patients
•
Isometric PCM are indicated in patients with prodrome
•
Cardiac pacing should be considered in patients with dominant
cardioinhibitory CSS
•
Cardiac pacing should be considered in patients with frequent recurrent reflex
syncope, age 40 years and documented spontaneous cardioinhibitory response
during monitoring
•
Midodrine may be indicated in patients with VVS refractory to lifestyle measures
•
Tilt training may be useful for education of patients but long-term benefit depends
on compliance
•
Cardiac pacing may be indicated in patients with tilt-induced cardioinhibitory
response with recurrent frequent unpredictable syncope and age 40 after
alternative therapy has failed
•
Triggers or situations inducing syncope must be avoided as much as possible
•
Hypotensive drugs must be modified or discontinued
•
Cardiac pacing is not indicated in the absence of a documented cardioinhibitory
reflex
•
Beta-adrenergic blocking drugs are not indicated
•
Fluid consumption and salt in the diet should be increased
•
Adequate hydration and salt
intake must be maintained
•
Midodrine should be administered
as adjunctive therapy if needed
•
Fludrocortisone should be
administered as adjunctive
therapy if needed
•
PCM may be indicated
•
Abdominal binders and/or support
stockings to reduce venous
pooling may be indicated
•
Head-up tilt sleeping (10°)
to increase fluid volume
may be indicated
•
Triggers or situations inducing
syncope must be avoided
as much as possible
•
Hypotensive drugs administered
for concomitant conditions must
be discontinued or reduced
Copyright: Moya A et al. Eur Heart J(2009) 30; 2631–2671 (3).
P.20
1.3
Treatment according to type of SYNCOPE (1)

31. Treatment of arrhythmic syncope
Cardiac Pacing
•
Pacing is indicated in patients with sinus node disease in
whom syncope is demonstrated to be due to sinus arrest
(symptom-ECG correlation) without a correctable cause
•
Pacing is indicated in sinus node disease patients with
syncope and abnormal CSNRT
•
Pacing is indicated in sinus node disease patients with
syncope and asymptomatic pauses 3 sec. (with possible
exceptions of young trained persons, during sleep and in
medicated patients)
•
Pacing is indicated in patients with syncope and 2nd
degree
Mobitz II, advanced or complete AV block
•
Pacing is indicated in patients with syncope,
BBB and positive EPS
•
Pacing should be considered in patients with unexplained
syncope and BBB
•
Pacing may be indicated in patients with unexplained
syncope and sinus node disease with persistent sinus
bradycardia itself asymptomatic
•
Pacing is not indicated in patients with unexplained syncope
without evidence of any conduction disturbance
Catheter ablation
•
Catheter ablation is indicated in patients with symptom/
arrhythmia ECG correlation in both SVT and VT in the
absence of structural heart disease
(with exception of atrial fibrillation)
•
Catheter ablation may be indicated in patients with syncope
due to the onset of rapid atrial fibrillation
Antiarrhythmic drug therapy
•
Antiarrhythmic drug therapy, including rate control drugs,
is indicated in patients with syncope due to onset of rapid
atrial fibrillation
•
Drug therapy should be considered in patients with
symptom/ arrhythmia ECG correlation in both SVT and VT
when catheter ablation cannot be undertaken or has failed
Implantable Cardioverter Defibrillator (ICD)
•
ICD is indicated in patients with documented VT
and structural heart disease
•
ICD is indicated when sustained monomorphic VT is induced
at EPS in patients with previous myocardial infarction
•
ICD should be considered in patients with documented VT
and inherited cardiomyopathies or channelopathies
Copyright: Moya A et al. Eur Heart J(2009) 30; 2631–2671 (4).
P.21
1.3
Treatment according to type of SYNCOPE (2)

33. CHAPTER 2
ACUTE CORONARY SYNDROMES
2.1 GENERAL CONCEPTS ������������������������������������������������������ p.24
H. Bueno
2.2
NON ST-SEGMENT ELEVATION ACS ��������������������������������������� p.29
H. Bueno
2.3 ST-SEGMENT ELEVATION MI (STEMI) �������������������������������������� p.35
P. Vranckx, B. Ibañez
2

34. hs-cTnULN
hs-cTnULN
ACUTE CORONARY SYNDROMES: DIAGNOSIS
CHEST PAIN
or symptoms sugestive of myocardial ischemia
ECG
ST elevation
(persistent)
Repolarization not interpretable
(i.e. LBBB, pacemaker...)
ST/T abnormalities Normal ECG
STEMI
Pain resolves with
nitroglycerin 1st hsTn
NSTEMI Unstable Angina
Work-up
differential diagnoses
Pain onset 6 h
Pain onset 6 h
Re-test hs-cTn (3h later)
See next page for 1 h rule-in rule-out algorithm
hs-cTn
no change
∆ hs-cTn
(1 value ULN)
hs-cTn x5 ULN
or
clinical
diagnosis
clear
Potential
noncardiac
causes for
abnormal Tn
Consider
STEMI
Yes
No
References: Roffi M. Eur Heart J 2016; 37:267-315.
Ibañez B. Eur Heart J 2018; 39:119-177.
P.24
2.1
ACUTE CORONARY SYNDROMES: Diagnosis (1)

35. Suspected NSTEMI
Other
0h≥D ng/l
or
≥
Observe
Rule-out Rule-in
hs-cTnT (Elecsys)*
hs-cTnl (Architect)*
hs-cTnl (DimensionVista)*
0-1h E ng/l
0hA ng/l
0hB ng/l
and
0-1hCng/l
A
5
2
0,5
B
12
5
5
C
3
2
2
D
52
52
107
E
5
6
19
or
or
•
NSTEMI can be ruled-out at presentation, if hs-cTn concentration is very low
•
NSTEMI can be ruled out by the combination of low baseline levels and the lack of a relevant increase within 1 h
•
NSTEMI is highly likely if initial hs-cTn concentration is at least moderately elevated or hs-cTn concentrations
show a clear rise within the first hour
Reference: Roffi M. Eur Heart J 2016; 37:267-315.
*Cut-off levels are assay-specific.
P.25
2.1
ACUTE CORONARY SYNDROMES: Diagnosis (2)
0-1 H Rule-in rule out test for NSTEMI

36. Causes of chest pain
Not related to ACS
Causes of troponin elevation
Not related to ACS
Primary cardiovascular
•
Acute pericarditis, pericardial effusion
• Acute myocarditis
•
Severe hypertensive crisis
•
Stress cardiomyopathy (Tako-Tsubo syndrome)
•
Hypertrophic cardiomyopathy, aortic stenosis
•
Severe acute heart failure
•
Acute aortic syndrome (dissection, hematoma)
•
Pulmonary embolism, pulmonary infarction
• Cardiac contusion
Primary cardiovascular
• Acute myo(peri)carditis
•
Severe hypertensive crisis
•
Pulmonary edema or severe congestive heart failure
•
Stress cardiomyopathy (Tako-Tsubo syndrome)
•
Post- tachy- or bradyarrhythmias
•
Cardiac contusion or cardiac procedures
(ablation, cardioversion, or endomyocardial biopsy)
•
Aortic dissection, aortic valve disease or hypertrophic cardiomyopathy
•
Pulmonary embolism, severe pulmonary hypertension
Primary non-cardiovascular
•
Oesophageal spasm, oesophagitis, Gastro
Esophageal Reflux (GER)
•
Peptic ulcer disease, cholecystitis, pancreatitis
•
Pneumonia, bronchitis, asthma attack
•
Pleuritis, pleural effusion, pneumothorax
•
Pulmonary embolism, severe pulmonary
hypertension
• Thoracic trauma
•
Costochondritis, rib fracture
•
Cervical / thoracic vertebral or discal damage
• Herpes Zoster
Primary non-cardiovascular
•
Renal dysfunction (acute or chronic)
•
Critical illness (sepsis, repiratory failure…)
•
Acute neurological damage (i.e. stroke, subarachnoid hemorrhage)
•
Severe burns (affecting 30% of body surface area)
• Rhabdomyolysis
•
Drug toxicity (chemotherapy with adriamycin, 5-fluorouracil,
herceptin, snake venoms…)
•
Inflammatory or degenerative muscle diseases
• Hypothyroidism
•
Infiltrative diseases (amyloidosis, hemochromatosis, sarcoidosis)
• Scleroderma
P.26
2.1
ACUTE CORONARY SYNDROMES: Differential diagnosis (1)

37. ST-segment elevation Negative T waves
Fixed
• LV aneurysm
•
LBBB, WPW, hypertrophic cardiomyopathy, LVH
• Pacemaker stimulation
•
Early repolarisation (elevated J-point)
Dynamic
•
Acute (myo)pericarditis
•
Pulmonary embolism
•
Electrolyte disturbances (hyperkalemia)
•
Acute brain damage (stroke, subarachnoid haemorrhage)
•
Tako Tsubo syndrome
•
Normal variants, i.e. women
(right precordial leads),
children, teenagers
•
Evolutive changes post
myocardial infarction
•
Chronic ischemic heart disease
• Acute (myo)pericarditis,
cardiomyopathies
•
BBB, LVH, WPW
• Post-tachycardia or
pacemaker stimulation
•
Metabolic or ionic disturbances
ST-segment depression Prominent T waves
Fixed
•
Abnormal QRS (LBBB, WPW, pacemaker stimulation…)
•
LVH, hypertrophic cardiomyopathy
•
Chronic ischemic heart disease
•
Normal variants, i.e.
early repolarisation
•
Metabolic or ionic disturbances
(i.e. hyperkalemia)
•
Acute neurological damage
(stroke, subarachnoid haemorrhage)
Dynamic
•
Acute (myo)pericarditis
•
Acute pulmonary hypertension
•
Electrolyte disturbances (hyperkalemia)
•
Intermitent LBBB, WPW, pacing
•
Post-tachycardia / cardioversion
•
Severe hypertensive crisis
• Drug effects (digoxin)
• Shock, pancreatitis
• Hyperventilation
• Tako Tsubo syndrome
P.27
2.1
ACUTE CORONARY SYNDROMES: Differential diagnosis (2)
Causes of repolarisation abnormalities in the ECG not related to ACS

38. 2
ECG
(10 min)
3
Diagnosis /
Risk assessment
4
Medical
Treatment
5
Invasive
Strategy
STEMI (see chapter 2.3)
Thrombolysis
for STEMI if
primary PCI not
timely available
Primary
PCI
1
Clinical
Evaluation
NSTE ACS
(see chapter 2.2)
ACS unclear
(Rule out ACS) (see chapter 1.1)
No ACS
Chest Pain Unit
• Clinical presentation
(BP, HR)
• ECG presentation
• Past history
• Ischemic risk
(i.e. GRACE, TIMI scores)
• Bleeding risk
(i.e. CRUSADE score)
• Additional information
(labs, imaging...) optional
Anti-ischemic
therapy
Antiplatelet
therapy
Anticoagulation
Emergent
2 hours
Urgent
2-24 hours
Early
24-72 hours
No /
Elective
Quality of
chest pain
Clinical
context
Probability
of CAD
Physical
examination
GENERAL APPROACH TO THE PATIENT WITH CHEST PAIN / SUSPECTED ACS
ECG
Rule out noncardiac causes
P.28
2.1
GENERAL APPROACH
to the patient with chest pain/suspected ACS

39. Ischemic risk
GRACE risk score TIMI risk score
Predictive Factors
• Age
• HR*
• SBP*
• Creatinine (mg/dl)*
• Killip class*
• Cardiac arrest*
• ST-segment deviation
•
Elevated cardiac markers
Outcomes
In-hospital, 6-month,
1-year and 3-year mortality
1-year death/MI
Predictive Factors
•
Age 65 years
•
At least 3 risk factors for CAD
•
Significant (50%) coronary stenosis
•
ST deviation
•
Severe anginal symptoms (2 events in last 24h)
•
Use of aspirin in last 7 days
•
Elevated serum cardiac markers
Outcome
All-cause mortality/new
or recurrent MI/severe
recurrent ischemia requiring
urgent revascularisation at
14 days
* At admission.
50
40
30
20
10
0
70 90 110 130 150 170 190 210
GRACE Risk Score
Probability of all-cause mortality from
hopital discharge to 6 months (%)
50
40
30
20
10
0
0-1 2 3 4 5 =6
TIMI Risk Score
Risk of 14 days events (%)
Risk calculation
http://www.gracescore.org/WebSite/WebVersion.aspx
Risk calculation
http://www.timi.org/index.php?page=calculators
P.29
2.2
NON ST-SEGMENT ELEVATION ACS: Risk stratification (1)

40. Bleeding risk
CRUSADE risk score
Predictive Factors
• Sex
• HR*
• SBP*
• Creatinine (mg/dl)*
• Baseline hematocrit*
• GFR: Cockcroft-Gault*
• Diabetes
•
Prior vascular disease
•
Signs of congestive heart failure*
Outcome
In-hospital major bleeding
Copyrights: Eagle KA et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death
in an international registry. JAMA. (2004); 291(22):2727-33. - Antman EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method
for prognostication and therapeutic decision making. JAMA. (2000); 284(7):835-42. - Subherwal S, et al Baseline risk of major bleeding in non-ST-segment-
elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation
of the ACC/AHA Guidelines) Bleeding Score. Circulation (2009); 119(14):1873-82.
* At admission.
50
40
30
20
10
0
0 20 40 60 80 100
CRUSADE Bleeding Score
Probability of in-hospital major bleeding(%)
Risk calculation
www.crusadebleedingscore.org
P.30
2.2
NON ST-SEGMENT ELEVATION ACS: Risk stratification (2)

41. Initial treatment*
• Nitrates
• Morphine
• Oxygen (if SpO2 90%)
One of the following:
• Fondaparinux
• Enoxaparin
• UFH
• Bivalirudin
Aspirin + one of:
• Ticagrelor
• Prasugrel
• Clopidogrel
Optionally:
• GP IIb/IIIa inhibitors
• Cangrelor
• Nitrates
• Beta-blockers
• Calcium antagonists
• Statins
• ACE inh. (or ARB)
• Aldosterone inhibitors
Pharmacological
treatment*
Anti ischemic
treatment
Antithrombotic
therapy
Anticoagulation Antiplatelets
PCI
CABG
Other preventive
therapies
Myocardial
revascularisation
*
For more information on individual drug doses and indications,
SEE CHAPTER3 SECONDARY PREVENTION AFTER ACS CHAPTER9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.31
2.2
NON ST-SEGMENT ELEVATION ACS: Treatment (1)
General overview

42. Very-high-risk
criteria
• Haemodynamic instability or cardiogenic shock
• Recurrent or ongoing chest pain refractory to medical treatment
• Life-threatening arrhythmias or cardiac arrest
• Mechanical complications of MI
• Acute heart failure
• Recurrent dynamic ST-T wave changes, particularly with intermittent ST-elevation
High-risk criteria • Rise or fall in cardiac troponin compatible with MI
• Dynamic ST- or T-wave changes (symptomatic or silent)
• GRACE score 140
Intermediate-risk
criteria
• Diabetes mellitus
• Renal insufficienty (eGFR 60 ml/min/1.73 m2
)
• LVEF 40% or congestive heart failure
• Early post-infarction angina
• Prior PCI
• Prior CABG
• GRACE risk score 109 and 140
Low-risk criteria • Any characteristics not mentioned above
Reference: Roffi M. Eur Heart J 2016; 37:267-315.
P.32
2.2
NON ST-SEGMENT ELEVATION ACS: Treatment (2)
Risk criteria mandating invasive strategy in NSTE-ACS

43. Symptoms Onset
PCI centre
Very high
Immediate
Invasive (2 hr)
Early invasive
(24 hr)
Invasive
(72 hr)
High
Intermediate
Immediate transfer to PCI centre
Same-day transfer
Transfer
Transfer optional
Risk
stratification
Therapeutic
strategy
Low
EMS or Non–PCI centre
First medical contact NSTE-ACS diagnosis
Very high
High
Intermediate
Low
Non-invasive
testing if appropriate
Reference: Roffi M. Eur Heart J 2016; 37:267-315.
P.33
2.2
NON ST-SEGMENT ELEVATION ACS: Treatment (3)
Timing and strategy for invasive management

44. 0
24 hours
10 min
90 min
2 hours
Strategy
clock ECG STEMI diagnosis
Time to PCI?
≤120min
Primary PCI
strategy
Fibrinolysis
strategya
Bolus of
fibrinolyticb
Transfer
to PCI centre
Meet reperfusion
criteria?
No Yes
Routine PCI strategy
Rescue
PCI
120min
Alert transfer
to PCI centre
Wire crossing
(reperfusion)
≥120min
60-90min
Reference: Ibañez B. Eur Heart J 2018; 39:119-177.
STEMI Treatment (1):
Reperfusion strategy
a
If fibrinolysis is contra-indicated, direct for primary PCI strategy regardless of time to PCI.
b
10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however, it should be given as soon as
possible after STEMI diagnosis (after ruling out contra-indications).
P.34
2.3

45. Aspirin
Loading
Prasugrel or ticagrelor loading
(clopidogrel as alternative)
Aspirin
maintenance
Prasugrel or ticagrelor maintenance
(clopidogrel as alternative)
Oxygen when SpO2 90%
High dose statin
(e.g. atorvastatin 80 mg or rosuvastatin 40 mg)
Oral β-blocker
ACE inhibitor
Mineralocorticoid receptor antagonist
(if LVEF 40% and heart failure)
i.v. Beta-blocker
i.v. Opioids/tranquilizer
DURING PCI: radial access, UFH (enoxaparin/bivalirudin as alternatives)
STEMI
diagnosis
Wire crossing
(reperfusion)
Hospital
Admission
Hospital
Discharge
Reference: Ibañez B. Eur Heart J 2018; 39:119-177.
P.35
2.3
STEMI Treatment (2):
Medical management of patients treated with primary PCI

46. Aspirin
loading
Clopidogrel
loading
Fibrinolysis bolus Enoxaparin
Aspirin
maintenance
Clopidogrel
maintenance
Oxygen when SpO2 90%
i.v. Opioids/tranquilizer
High dose statin
(e.g. atorvastatin 80 mg or rosuvastatin 40 mg)
Oral β-blocker
ACE inhibitor
Mineralocorticoid receptor antagonist
(if LVEF 40% and heart failure)
STEMI
diagnosis
Hospital
Admission
Hospital
Discharge
10min
Coronary angiography ± PCI
(2-24h)
Reference: Ibañez B. Eur Heart J 2018; 39:119-177.
P.36
2.3
STEMI Treatment (3):
Medical management of patients treated with fibrinolysis

47. CHAPTER 3
SECONDARY PREVENTION
AFTER ACS
3.1 GENERAL SECONDARY PREVENTION STRATEGIES
AND LIPID LOWERING ����������������������������������������������������� p.38
H. Bueno, S. Halvorsen
3.2 ANTITHROMBOTIC TREATMENT ������������������������������������������� p.41
F. Costa, S. Halvorsen
P.37
3

48. Acute Coronary Syndrome
Antithrombotic
therapy
Aspirin + P2Y12
inhibitor
(12 months)
Lipid
lowering
High intensity
statin therapy
BP/LVD/
HF control
ACEI / ARB*,
Beta-blockers*,
MRA*
Glucose
control
Metformin
Insulin*
Hospitalization
• Risk factor control (e.g.
weight control, smoking cessation,
blood pressure and lipid control)
• Diet/nutritional counseling
• Physical activity counseling/
excercise training
• Psychosocial management,
sex advice
• Vocational advice
Plan and schedule
Cardiac Rehabilitation
Education
and counselling
Cardioprotective drugs
in secondary prevention
1- Acute care
• Drug therapy
• Coronary revascularisation
2- Cardiovascular risk assessment (e.g. concealed and uncontrolled risk factors)
3- Initiate secondary prevention and set treatment goals
Cardiac
Rehabilitation
programme
P.38
3.1
SECONDARY PREVENTION STRATEGIES after ACS

49. Re-evaluate lifestyle, control of risk factors, psychosocial factors and adherance to therapy
Adjustment of secondary prevention therapies. Consider polypill, if needed
Consider adding
Ezetimibe*
PCSK9 inhibitor*
Consider
dose adjustment
Consider ARNI*
Consider
SGLT2 inhibitor*
GLP-1 agonists*
Reinforce education
Psychosocial support
After Discharge
After 12 months
consider*:
Ticagrelor
60 mg bid
Anticoagulation?**
Reference modified from Cortés-Beringola A. Eur J Prev Cardiol 2017; 24(3 suppl): 22-28.
* When individually indicated and without specific contraindications. - ** Rivaroxaban 2.5 mg bid pending approval for indication in chronic CAD.
P.39
3.1

50. Potential strategies to optimize secondary prevention therapy after ACS
•
Participation in a comprehensive, multi-disciplinary cardiac
rehabilitation programme after hospital discharge
•
Coordination with primary care provider
(and other specilaists) in therapeutic plan and objectives
•
Re-check and reinforce advise on all lifestyle changes
(diet, physical activity, smoking cessation…) during follow-up visits
•
Check and optimise doses of all indicated secondary prevention drugs
•
Use of specialist support, nicotine replacement therapies, varenicline,
and/or bupropion individually or in combination
for patients who do not quit or restart smoking
•
Use of ezetimibe and/or a PCSK9 inhibitor in patients
who remain at high risk with LDL-cholesterol 70 mg/dl despite
apropriate diet and maximally tolerated doses of statins
•
Use of a polypill or combination therapy in patients
with suboptimal adherence to drug therapy
P.40
3.1
After ACS: POTENTIAL STRATEGIES
TO OPTIMIZE SECONDARY PREVENTION THERAPY

51. PCI
Stable CAD
DES/BMS or DCB BRS DES/BMS or DCB
High Bleeding Risk
6mo DAPT
Class I A1
1mo DAPT Class IIb C
3mo DAPT Class IIa B
≥12mo DAPT
Class IIa C
12mo DAPT
Class I A
6mo DAPT
Class IIa B
12mo DAPT
Class IIb B
DAPT 6mo
Class IIb A
High Bleeding Risk
ACS
No
1mo
3mo
6mo
12mo
30mo
Yes No
or
Yes
A C
A C
A C
A C
2
A P A T
or
A C
3
A C
A P A T
or A C
4
A P
A T
A T
Treatment
indication
Device used
Time
A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260.
P.41
3.2
ANTITHROMBOTIC TREATMENT:
Dual antiplatelet therapy duration in patients with ACS (1)

52. Medical Treatment Alone
Stable CAD ACS
No indication
for DAPT unless
concomitant or
prior indication
overrides
Stable CAD
No indication
for DAPT unless
concomitant or
prior indication
overrides
12mo DAPT
Class I C
6mo DAPT
Class IIa C
12moDAPT
Class IIb C
High Bleeding Risk
CABG
No
1mo
3mo
6mo
12mo
30mo
Yes
ACS
High Bleeding Risk
No Yes
Time
or
A C
3
A C
A P A T
or
A C
A P
A T
A T
12mo DAPT
Class I C
1mo DAPT
Class IIa C
12moDAPT
Class IIb C
or
A C
3
A C
A T
or A C
A T
Treatment
indication
Device used
A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260.
P.42
3.2
ANTITHROMBOTIC TREATMENT:
Dual antiplatelet therapy duration in patients with ACS (2)

53. CLOPIDOGREL
Ticagrelor LD (180 mg)
24h after last prasugrel dose
Prasugrel LD (60 mg)
24h after last ticagrelor dose
P
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s
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g
a
n
d
d
o
s
i
n
g
C
l
o
p
i
d
o
g
r
e
l
L
D
(
6
0
0
m
g
)
2
4
h
a
f
t
e
r
l
a
s
t
t
i
c
a
g
r
e
l
o
r
d
o
s
e
ACCUTE SETTING
ALWAYS RELOAD
PRASUGREL TICAGRELOR
Reference: Valgimigli M, et al. Eur Heart J. 2018;39:213-260.
P.43
3.2
ANTITHROMBOTIC TREATMENT:
Switching between P2Y12 inhibitors for DAPT after ACS (1)

54. Ticagrelor LD (90 mg b.i.d.)
24h after last prasugrel dose
Prasugrel LD (60 mg)
24h after last ticagrelor dose
P
r
a
s
u
g
r
e
l
M
D
(
1
0
m
g
q
.
d
.
)
2
4
h
a
f
t
e
r
l
a
s
t
c
l
o
p
i
d
o
g
r
e
l
d
o
s
e
C
l
o
p
i
d
o
g
r
e
l
M
D
(
7
5
m
g
q
.
d
.
)
2
4
h
a
f
t
e
r
l
a
s
t
p
r
a
s
u
g
r
e
l
d
o
s
e
T
r
i
c
a
g
r
e
l
o
r
M
D
(
9
0
m
g
b
.
i
.
d
.
)
2
4
h
a
f
t
e
r
l
a
s
t
c
l
o
p
i
d
o
g
r
e
l
d
o
s
e
C
l
o
p
i
d
o
g
r
e
l
L
D
(
6
0
0
m
g
)
2
4
h
a
f
t
e
r
l
a
s
t
t
i
c
a
g
r
e
l
o
r
d
o
s
e
CLOPIDOGREL
CHRONIC
SETTING
PRASUGREL TICAGRELOR
Reference: Valgimigli M, et al. Eur Heart J. 2018;39:213-260.
P.44
3.2
ANTITHROMBOTIC TREATMENT:
Switching between P2Y12 inhibitors for DAPT after ACS (2)

55. P.45
3.2
ANTITHROMBOTIC TREATMENT:
Risk scores validated for DAPT duration decision-making
PRECISE-DAPT score DAPT score
Time of use At the time of coronary stenting After 12 months of uneventful DAPT
DAPT duration
strategies assessed
Short DAPT (3-6 months)
vs. Standard/long DAPT (12-24 monts)
Standard DAPT (12 months)
vs. Long DAPT (30 months)
Score calculation
HB
Age
≥75
65 to 75
65
Cigarette smoking
Diabetes mellitus
MI at presentation
Prior PCI or prior MI
Paclitaxel-eluting stent
Stent diameter 3 mm
CHF or LVEF 30%
Vein graft stent
— 2 pt
— 1 pt
0 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 1 pt
+ 2 pt
+ 2 pt
WBC
Age
CrCl
Prior
Bleeding
Score
Points
Score range 0 to 100 points — 2 to 10 points
Decision making
cut-off
Score ≥25 → Short DAPT
Score 25 → Standard/long DAPT
Score ≥2 → Long DAPT
Score 2 → Standard DAPT
Electronic calculator www.precisedaptscore.com www.daptstudy.org

56. DUAL THERAPY strategy:
TRIPLE THERAPY strategy:
STEP
2:
Treatment
type
STEP
3:
Treatment
duration
STEP
1:
Patient
risk
assessment
BRIR
DUAL (12 mo.) OAC alone
OAC alone
OAC alone
TRIPLE (for 1 mo.)
TRIPLE (up to 6 mo.)
DUAL
(up to 12 mo.)
DUAL (up to 12 mo.)
BRIR
• NOAC* (preferable)
- Apixaban 5 mg b.i.d. (reduce to 2.5 mg b.i.d.(1)
- Dabigatran 110 mg b.i.d. (preferable while on DAPT)
or 150 mg b.i.d.
- Edoxaban 60 mg q.d. (reduce to 30 mg q.d.(2)
- Rivaroxaban 20 mg q.d. (reduce to 15 mg q.d.(3)
or 15 mg
(may be considered DAPT/SAPT)
or
• VKA dose ajusted: consider maintaining INR in the lower
part of the recommended target range (e.g. 2.0-2.5 for AF
and MV in aortic position, 2.5-3.0 for MV in mitral position)
OAC:
• Clopidogrel 75 mg q.d.
(preferable)*
or
• Aspirin 75-100 mg q.d.
SAPT:
• Clopidogrel 75 mg q.d.
and
• Aspirin 75-100 mg q.d.
DAPT:
• HIGH RISK OF BLEEDING?
High HAS-BLED: Hypertension, abnormal liver/renal function, prior stroke, bleeding diathesis, labile INR if on VKA, age 65, drugs
(e.g. NSAIDs or antiplatelets), alcohol abuse, ABC score: Age, Biomarkers (GDF-15, hs cTnT, Hb) and Clinical history of prior bleeding
• HIGH RISK OF RECURRENT CORONARY ISCHEMIC EVENTS?
ACS at presentation, prior ST, stenting of last remaining vessel, CrCL 60 ml/min, ≥3 stents implanted or lesions treated,
bifurcation with 2 stents, overall stentlengh 60 mm, treatment of CTO
TRIPLE
THERAPY
(If High BR Low IR)
(If High BR High IR)
or
(If Low BR High IR)
DUAL
THERAPY
Reference adapted from Valgimigli M et al. Eur Heart J. 2018;39:213-260.
*
In case of
selecting
dual therapy
immediately after
stent implantation
clopidogrel should
be selected as
single antiplatelet
agent. Aspirin
should however
be administered
at the time of the
intervention.
(1)
Age ≥80 years,
body weight ≤60 kg
or serum creatinine
level ≥1.5 mg/dL.
(2)
CrCl of
30–50 ml/min,
body weight
≤60 kg,
concomitant use
of verapamil,
quinidine or
dronedarone.
(3)
CrCl30-49 ml/min.
P.46
3.2
ANTITHROMBOTIC TREATMENT in patients with concomitant
indication for DAPT and chronic oral anticoagulation (1)

57. SURGERY
Minimal delay for P2Y12 interruption Days after surgery
CLOPIDOGREL
PRASUGREL
TICAGRELOR
CLOPIDOGREL
PRASUGREL(2)
TICAGRELOR(2)
ASPIRIN(1)
//••••••9••••••8••••••7••••••6••••••5••••••4••••••3••••••2••••••1•••••• 0••••••••••••••••••1-4
STOP
STOP
STOP
= Expected average platelet function recovery
(1)
Decision to stop aspirin throughout surgery should be made on a single case basis taking into account the surgical bleeding risk
(2)
In patients not requiring OAC
Reference: Valgimigli et al. Eur Heart J.2018; 39:213-260.
P.47
3.2
ANTITHROMBOTIC TREATMENT:
Management of DAPT after ACS in patients
with indication for surgery

58. LIFE-THREATENING BLEEDING
e.g. massive overt genitourinary,
respiratory or upper/lower
gastrointestinal bleeding,
active intracranial, spinal
or intraocular haemorrhage,
or any bleeding
STOP ALL ANTITHROMBOTIC MEDICATIONS
and reverse OAC. Once bleeding has ceased, re-evaluate the need
for DAPT or SAPT, preferably with the P2Y12 inhibitor
especially in case of upper GI bleeding
CONTINUE DAPT a
, CONTINUE OAC c
CONTINUE DAPT, CONTINUE OAC Consider skipping one single next pill
CONSIDER STOPPING DAPT
and continue with SAPT, preferably with the P2Y12 inhibitor
especially in case of upper GI bleeding. Once bleeding has ceased,
re-evaluate the need for DAPT or SAPTa
CONSIDER STOPPING OAC
or even reversal until bleeding is controlled, unless prohibitive thrombotic risk
(i.e. mechanical heart valve in mitral position, cardiac assist device )b-c-d
Reinitiate treatment within one week if clinically indicated.
If Bleeding persist despite treatment, or treatment is not possible
CONSIDER STOPPING ALL ANTITHROMBOTIC MEDICATIONS
CONSIDER STOPPING DAPT
and continue with SAPT, preferably with the P2Y12 inhibitorespecially in case
of upper GI bleeding Reinitiate DAPT as soon as deemed safea
CONSIDER STOPPING OAC
or even reversal until bleeding is controlled, unless very high thrombotic risk
(i.e. mechanical heart valves, cardiac assist device, CHA2DS2-VASc ≥4 ).b-c-d
Reinitiate treatment within one week if clinically indicated.
SEVERE BLEEDING
e.g. severe genitourinary,
respiratory or upper/lower
gastrointestinal bleeding
MODERATE BLEEDING
e.g. genitourinary, respiratory
or upper/lower gastrointestinal
bleeding with significant blood
loss or requiring transfusion
MILD BLEEDING
e.g. not self resolving epistaxis,
moderate conjunctival bleeding,
genitourinary or upper/lower
gastrointestinal bleeding
without significant blood loss,
mild haemoptysis
TRIVIAL BLEEDING e.g. skin bruising or ecchimosis,
self-resolving epistaxis, minimal conjunctival bleeding
ANTITHROMBOTIC TREATMENT
MANAGEMENT DURING BLEEDING
Active bleeding and unstable hemodynamic
putting patient’s life immediately at risk?
Hospitalization required? Hb loss 5 g/dl
Hb loss 5 g/dl
Significant blood loss (3 g/dl) ?
Requires medical intervention
or further evaluation?
Yes
Yes
Yes
Yes
No
No
No
No
Reference: Valgimigli et al. Eur Heart J.2018; 39:213-260.
a
Consider shortening DAPT duration or switching to less potent P2Y12 inhibitor (i.e. from ticagrelor/prasugrel to clopidogrel), especially if recurrent bleeding occurs
b
Reinitiate treatment within one week if clinically indicated. For Vitamin-K antagonist consider a target INR of 2.0-2.5 unless overriding indication (i.e. mechanical
heart valves or cardiac assist device) for NOAC consider the lowest effective dose. - c
In case of triple therapy consider downgrading to dual therapy, preferably with
clopidogrel and OAC. - d
If patients on dual therapy, consider stopping antiplatelet therapy if deemed safe.
P.48
3.2
ANTITHROMBOTIC TREATMENT:
Management of acute bleeding after ACS

59. Acute upper GI haemorrhage in patient using antiplatelet agent(s) (APT)
Upper GI endoscopy demonstrates a nonvariceal source of bleeding (e.g. peptic ucler bleed)
High risk endoscopic stigmata identified
(Forrest classification* Ia, Ib, IIa, IIb)
APT used for secondary prophylaxis
(known cardiovascular disease)
Patients on low dose ASA alone
•Resumelow-loseASAbyday3followingindexendoscopy
• Second-look endoscopy at the discretion
of the endoscopist may be considered
Paptients on dual antiplatelet therapy (DAPT)
• Continue low dose ASA without interruption
• Early cardiology consultation for recommendation
of second resumption/ continuation of second APT
• Second-look endoscopy at the discretion of the
endoscopoist may be considered
APT used for secondary prophylaxis
(known cardiovascular disease)
Patients on low dose ASA alone
•Continue low-dose ASA without interruption
Paptients on dual antiplatelet therapy (DAPT)
• Continue DAPT without interruption
Low risk endoscopic stigmata identified
(Forrest classification* IIc, III)
*The Forrest classification in defined as follows: Ia spuring
hemorrhage, Ib oozing hemorrhage, IIa nonbleeding visible
vessel, IIb an adherent clot, IIc flat pigmented spot, and III clean
base ucler.
Reference: Halvorsen et al. Eur Heart J 2017; 38: 1455-62.
P.49
3.2
ANTITHROMBOTIC TREATMENT:
Management of antiplatelet therapy after acute GI bleeding

61. CHAPTER 4
ACUTE HEART FAILURE
4.1 WET-AND-WARM HEART FAILURE PATIENT ������������������������������ p.52
V.P. Harjola, O. Miró
4.2 CARDIOGENIC SHOCK (WET-AND-COLD) ����������������������������������� p.61
P. Vranckx, U. Zeymer
4

62. Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8):891-975. DOI: 10.1002/ejhf.592.
WARM-DRY WARM-WET
COLD-DRY COLD-WET
HYPOPERFUSION (+)
Cold sweaty extremities, Oliguria,
Mental confusion, Dizziness,
Narrow pulse pressure
HYPOPERFUSION (-)
CONGESTION (-) CONGESTION (+)
Pulmonary congestion, orthopnoea/paroxismal,
nocturnal dyspnoea, peripheral (bilateral) oedema,
jugular venous dilatation, congested hepatomegaly,
gut congestion, ascites, hepatojugular reflux
Clinical profiles of patients with acute heart failure
based on the presence/absence of congestion and/or hypoperfusion
Hypoperfusion is not synonymous with hypotension, but often hypoperfusion is accompanied by hypotension.
P.52
4.1
Clinical profiles of patients with acute heart failure

63. Reference: McMurray JJ et al. Eur Heart J (2012); 33:1787-847.
Ponikowski P et al. Eur J Heart Fail. 2016; 18:891-975.
1 Symptoms: Dyspnea (on effort or at rest)/
breathlessness, fatigue, orthopnea, cough,
weight gain/ankle swelling.
2 Signs: Tachypnea, tachycardia, low or normal blood
pressure, raised jugular venous pressure,
3rd
/4th
heart sound, rales, oedema, intolerance
of the supine position.
3
Cardiovascular risk profile: Older age, HTN, diabetes,
smoking, dyslipidemia, family history, history of CVD.
4
Precipitants/causes that need urgent management
(CHAMP): Acute coronary syndrome. Hypertensive
emergency. Rapid arrhythmias or severe
bradyarrhythmia/conduction disturbance. Mechanical
causes. Pulmonary embolism.
5 Differential diagnosis: Exacerbated pulmonary disease,
pneumonia, pulmonary embolism, pneumothorax,
acute respiratory distress syndrome, (severe) anaemia,
hyperventilation (metabolic acidosis), sepsis/septic
shock, redistributive/hypovolemic shock.
FACTORS TRIGGERING ACUTE HEART FAILURE
•
Acute coronary syndrome
•
Tachyarrhythmia (e.g. atrial fibrillation, ventricular tachycardia)
•
Excessive rise in blood pressure
•
Infection (e.g. pneumonia, infective endocarditis, sepsis).
•
Non-adherence with salt/fluid intake or medications
•
Toxic substances (alcohol, recreational drugs)
•
Drugs (e.g. NSAIDs, corticosteroids, negative inotropic
substances, cardiotoxic chemotherapeutics)
•
Exacerbation of chronic obstructive pulmonary disease
• Pulmonary embolism
•
Surgery and perioperative complications
•
Increased sympathetic drive, stress-related cardiomyopathy
•
Metabolic/hormonal derangements (e.g. thyroid dysfunction,
diabetic ketosis, adrenal dysfunction, pregnancy and
peripartum related abnormalities)
• Cerebrovascular insult
•
Acute mechanical cause : myocardial rupture complicating
ACS (free wall rupture, ventricular septal defect, acute
mitral regurgitation), chest trauma or cardiac intervention,
acute native or prosthetic valve incompetence secondary
to endocarditis, aortic dissection or thrombosis
P.53
4.1
ACUTE HEART FAILURE: Diagnosis and causes (2)

64. Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8): 891-975. DOI: 10.1002/ejhf.592.
Patient with suspected AHF
1. Cardiogenic shock ?
Urgent phase after
first medical contact
Immediate stabilization
and transfer to ICU/CCU
Immediate initiation
of specific treatement
Indentification of acute aeticology :
C = Acute Coronary syndrome
H = Hypertension emergency
A = Arrhythmia
M = Acute Mechanical cause
P = Pulmonary embolism
Diagnostic work-up to confirm AHF
Clinical evaluation to select optimal management
Immediate phase
(initial 60-120 minutes)
Circulatory support
• pharmacological
• mechanical
Ventilatory support
• oxygen
• non-invasive positive
pressure ventilation (CPAP, BiPAP)
• mechanical ventilation
2. Respiratory failure ?
Yes
No
No
No
Yes
Yes
P.54
4.1
Initial management of a patient with ACUTE HEART FAILURE

65. After
60-90 min
In hospital
Pre-hospital or
emergency room
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17:544-58.
Conventional oxygen therapy
Conventional
oxygen therapy
Intolerance
Weaning
CPAP
CPAP
FAILURE
PS-PEEP
SUCCESS
SIGNIFICANT HYPERCAPNIA
AND ACIDOSIS
NORMAL pH
AND pCO2
Intubation
Intubation
RESPIRATORY DISTRESS?
SpO2 90%, RR25,
Work of breathing, orthopnea
PERSISTENT RESPIRATORY DISTRESS?
Upright position
No Yes
Yes
Venous/Arterial blood gases
No
Room air
P.55
4.1
ACUTE HEART FAILURE: Airway (A) and breathing (B)
Oxygen therapy and ventilatory support in acute heart failure

66. INSTRUMENTATION INVESTIGATIONS:
Intravenous line (peripheral/central) and BP monitoring (arterial line in shock
and severe ventilatory/gas-exchange disturbances)
Laboratory measures
• Cardiac markers (troponin, BNP/NT-proBNP/MR-proANP)
•
Complete blood count, electrolytes, creatinine, urea, glucose,
inflammation, TSH
•
Consider arterial or venous blood gases, lactate, D-dimer
(suspicion of acute pulmonary embolism)
Standard 12-lead ECG
• Rhythm, rate, conduction times?
• Signs of ischemia/myocardial infarction? Hypertrophy?
Echocardiography
a) Immediately in haemodynamically unstable patients
b)
Within 48 hours when cardiac structure and function are either not known or
may have changed since previous studies
Ventricular function (systolic and diastolic)? Estimated left-and right-side filling
pressures? Lung ultrasound? Presence of valve dysfunction (severe stenosis/
insufficiency)? Pericardial tamponade?
ACTIONS:
Rule in/out
acute heart failure
as cause of symptoms
and signs
Determine
clinical profile
Start as soon as
possible treatment of
both heart failure and
the factors identified
as triggers
Establish cause
C - CIRCULATION*
HR (bradycardia [60/min], normal [60-100/min], tachycardia [100/min]), rhythm (regular, irregular), SBP (very low
[90 mmHg], low, normal [110-140 mmHg], high [140 mmHg]), and elevated jugular pressure should be checked.
P.56
4.1
ACUTE HEART FAILURE: Initial diagnosis (CDE)

67. References: Mebazaa A et al. Intensive Care Med. (2016); 42(2):147-63; Mueller C et al. Eur Heart J Acute Cardiovasc Care. (2017); 6(1):81-6.
D – DISABILITY DUE TO NEUROLOGICAL DETERIORATION
•
Normal consiousness/altered mental status?
Measurement of mental state with AVPU (alert, visual, pain or unresponsive)
or Glasgow
•
Coma Scale: EMV score 8 Consider endotracheal intubation and mechanical ventilation
•
Anxiety, severe dyspnea? Consider cautious administration of morphine 2 mg i.v. bolus,
preceded by antiemetic as needed
E – EXPOSURE EXAMINATION
• Temperature/fever: central and peripheral
• Weight
• Skin/extremities: circulation (e.g. capilary refill), color
•
Urinary output (0.5 ml/kg/hr) Consider inserting indwelling catheter;
the benefits should outweigh the risks of infection and long-term complications
P.57
4.1

68. Patient with AHF
Bedside assessment to identify haemodynamic profiles
DRY patient
WET patient
No
(5% of all AHF patients)
Yes
(95% of all AHF patients)
Yes No
Yes
No
PRESENCE OF CONGESTIONa
?
ADEQUATE PERIPHERAL PERFUSION?
DRY and COLD
Hypoperfused, hypovolemic
DRY and WARM
Adequately perfused
≈ Compensated
Consider fluid challenge
Consider inotropic agent if still hypoperfused
Adjust oral therapy
WET and WARM
patient (typically elevated
or normal systolic blood
pressure)
P.58
4.1
ACUTE HEART FAILURE: Management of patients with acute heart
failure based on clinical profile during an early phase

69. WET and COLD patient
Systolic blood pressure 90 mmHg
Yes No
• Inotropic agent
• Consider vasopressor
in refractory cases
• Diuretic
(when perfusion corrected)
• Consider machanical circulatory
support if no response to drugs
• Vasodilators
• Diuretics
• Consider inotropic agent
In refractory cases
• Vasodilator
• Diuretic
• Diuretic
• Vasodilator
• Ultrafiltration
(consider if diuretic resistance)
Vascular type-fluid
redistribution
Hypertension predominates
Cardiac type-fluid
accumulation
Congestion predominates
a
Symptoms/signs of congestion: orthopnoea, paroxysmal nocturnal dyspnoea, breathlessness, bi-basilar rales, abnormal blood pressure response to the
Valsalva maneuver (left-sided); symptoms of gut congestion, jugular venous distension, hepatojugular reflux, hepatomegaly, ascites, and peripheral
oedema (right-sided).
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8):891-975. DOI: 10.1002/ejhf.592.
P.59
4.1

70. No acute heart failure
MONITORING
Dyspnea (VAS, RR), BP, SpO2, HR and
rhythm, urine output, peripheral perfusion
REASSESSMENT
Clinical, biological and psychosocial parameters by trained nurses
Observation unit (24h)
Discharge home
Ward (cardiology, internal
medicine, geriatrics)
Rehabilitation
program
Visit to cardiologist
1-2 weeks
Palliative care
hospitals
ICU/CCU
Confirmed acute heart failure
DIAGNOSTIC TESTS
OBSERVATION
UP
TO
120
min
ADMISSION/DISCHARGE
Risk stratification: ensure patient
is at low risk before direct discharge
Risk stratification: ensure patient
is at low risk before direct discharge
TREATMENT OBJECTIVES to prevent organ dysfunction:
Improve symptoms, maintain SBP 90 mmHg and peripheral
perfusion, mantain SpO2 90% (see table in pages 63-64)
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17: 544-58 and Miró Ò et al. Ann Intern Med (2017); 167:698-705.
P.60
4.1
ACUTE HEART FAILURE: Management of acute heart failure

71. Normotension/
Hypertension
Hypotension Low heart rate Potassium Renal impairment
100 90
mmHg
90
mmHg
60
≥50 bpm
50 bpm ≤3.5
mmol/L
5.5
mmol/L
Cr 2.5,
eGFR 30
Cr 2.5,
eGFR 30
ACE-I/ARB Review/
increase
Reduce/
stop
Stop No
change
No
change
Review/
increase
Stop Review Stop
Beta-blocker No change Reduce/
stop
Stop Reduce Stop No
change
No
change
No
change
No
change
MRA No change No
change
Stop No
change
No
change
Review/
increase
Stop Reduce Stop
Diuretics Increase Reduce Stop No
change
No
change
Review/
No
change
Review/
increase
No
change
Review
Sacubitril/
Valsartan
Review/
increase
Stop Stop No
change
No
change
Review/
increase
Stop Review Stop
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17(6):544-58.
Management of oral therapy in AHF in the first 48 hours P.61
ACUTE HEART FAILURE: Treatment (C) and preventive measures 4.0
4.1

72. Normotension/
Hypertension
Hypotension Low heart rate Potassium Renal impairment
100 90
mmHg
90
mmHg
60
≥50 bpm
50 bpm ≤3.5
mmol/L
5.5
mmol/L
Cr 2.5,
eGFR 30
Cr 2.5,
eGFR 30
Other
vasodilators
(nitrates)
Increase Reduce/
stop
Stop No
change
No
change
No
change
No
change
No
change
No
change
Other heart rate
slowing drugs
(amiodarone,
non-dihydropyridine
CCB, ivabradine)
Review Reduce/
stop
Stop Reduce/
stop
Stop Review/
stop(*)
No
change
No
change
No
change
Thrombosis prophylaxis should be started in patients not anticoagulated.
(*) Amiodarone.
Management of oral therapy in AHF in the first 48 hours
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17(6):544-58.
P.62
ACUTEHEARTFAILURE:Treatment(C)andpreventivemeasures(Cont.) 4.1

73. Hemodynamic criteria to define cardiogenic shock
•
Systolic blood pressure 80 to 90 mmHg
or mean arterial pressure 30 mmHg lower than baseline
•
Severe reduction in cardiac index:
1.8 l/min/m2
without support
or 2.0 to 2.2 l/min/m2
with support
•
Adequate or elevated filling pressure:
Left ventricular end-diastolic pressure 18 mmHg
or Right atrial pressure 10 to 15 mmHg
Clinical condition defined as the inability of the heart to deliver an adequate amount of blood
to the tissues to meet resting metabolic demands as a result of impairment of its pumping function.
Cardiogenic shock is equal to wet-cold phenotype. The clinical signs of hypoperfusion are listed in page 65.
In addition, blood lactate is typically elevated above 2 mmol/L.
P.63
4.2
CARDIOGENIC SHOCK: Definition

74. LV pump failure is the primary insult in most forms of CS, but other parts of the circulatory system
contribute to shock with inadequate compensation or additional defects P.64
4.2
CARDIOGENIC SHOCK: Causes

75. This protocol should be initiated as soon as cardiogenic shock/end organ hypoperfusion is recognised
and should not be delayed pending intensive care admission.
EARLY TRIAGE MONITORING
Start high flow O2
Establish i.v. access
• Age: 65–74, ≥75
• Heart rate 100 beats per minute
• Systolic blood pressure 100 mmHg
• Proportional pulse pressure ≤25 % (CI 2.2 l/min/m2
)
• Orthopnea (PCWP 22 mmHg)
• Tachypnea (20/min), 30/min (!)
• Killip class IV
•
Clinical symptoms of tissue hypoperfusion/hypoxia:
- cool extremities - decreasedurineoutput(urineoutput40
ml/h)
- decreased capillary refill or mottling - alteration in mental status
INITIAL RESUSCITATION
•
Arterial and a central venous
catheterization with a catheter
capable of measuring central venous
oxygen saturation
•
Standard transthoracic
echocardiogram to assess left (and
right) ventricular function and for
the detection of potential mechanical
complications following MI
•
Early coronary angiography in
specialized myocardial intervention
centre when signs and/or symptoms
of ongoing myocardial ischemia
(e.g. ST-segment elevation myocardial
infarction).
• CORRECT: hypoglycemia hypocalcemia,
• TREAT: sustaned arrhythmias: brady- or tachycardia
•
Isotonic saline-fluid challenge - 200-300 ml
over 30 min period to achieve a central venous pressure of 8 to 12 mmHg
or until perfusion improves (with a maximum of 500 ml)
•
CONSIDER NIMV for comfort (fatigue, distress) or as needed:
- To correct acidosis - To correct hypoxemia
• INOTROPIC SUPPORT (dobutamine, levosimendan and/or vasopressor support)
TREATMENT GOALS
• a mean arterial pressure of 60 mmHg or above,
• a mean pulmonary artery wedge pressure of 18 mmHg or below,
• a central venous pressure of 8 to 12 mmHg,
• a urinary output of 0,5 ml or more per hour per kilogram of body weight
• an arterial pH of 7.3 to 7.5
•
a central venous saturation (ScvO2) ≥70% (provided SpO2 ≥93%
and Hb level ≥9 g/dl)
In persistent drug-resistant cardiogenic shock,
consider mechanical circulatory support
0 min
5 min
15 min
60 min
EMERGENCY
DEPARTMENT
CARDIAC
INTENSIVE
CARE
UNIT
P.65
4.2
CARDIOGENIC SHOCK: Initial triage and management

76. Ventilator mode
Tidal Volume goal
Plateau Pressure goal
Anticipated PEEP levels
Ventilator rate and pH goal
Inspiration: Expiration time
Oxygenation goal:
• PaO2
• SpO2
Pressure assist/control
Reduce tidal volume to 6-8 ml/kg lean body weight
≤30 cm H2O
5-10 cm H2O
12-20, adjusted to achieve a pH ≥7.30 if possible
1:1 to 1:2
50-80 mmHg
90%
Predicted body weight calculation:
• Male: 50 + 0.91 (height in cm - 152.4)
• Female: 45.5 + 0.91 (height in cm - 152.4)
Some patients with CS will require increased PEEP to attain functional residual capacity and maintain oxygenation,
and peak pressures above 30 cm H2O to attain effective tidal volumes of 6-8 ml/kg with adequate CO2 removal.
For more informations on individual drug doses and indications:
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.66
4.2
CARDIOGENIC SHOCK: Treatment and ventilator procedures

77. CARDIOGENIC SHOCK: MANAGEMENT FOLLOWING STEMI
Assess volume status
Treat sustained arrhythmias: brady - or tachy -
Consider mechanical ventilation for comfort (during PCI) and/or as needed:
• to correct acidosis
• to correct hypoxemia
Inotropic support (dobutamine and/or vasopressor support)
Signs (ST-segment elevation or new LBBB)
and/or clinical symptoms of ongoing
myocardial ischemia
Early coronary angiography
± Pulmonary artery catheter
± IABP in selected patients
in a specialised Myocardial
Intervention Centre
PCI ± stenting
of the culprit lesion
CABG
+ correct mechanical complications
Pump failure
RV, LV, both
Short-term
mechanical
circulatory
support
Aortic
dissection
Pericardial
tamponade
• Acute severe mitral valve regurgitation
• Ventricular septum rupture
• Severe aortic/mitral valve stenosis
Operating theater ± coronary angiography
Emergency echocardiography
± Tissue doppler imaging
± Color flow imaging
No
NSTEACS,
Delayed CS
Yes
P.67
4.2
CARDIOGENIC SHOCK: management following STEMI

78. 72-hrs
2-weeks
1-month ...
Left ventricular support BiVentricular support
Partial support
IABP Impella 2.5 Tandem-
heart
Impella 5.0 Implantable
ECMO
Levitronix
Full support
Level of support
Pulmonary support
P.68
4.2
CARDIOGENIC SHOCK:
Mechanical circulatory support, basic characteristics

79. Different systems for mechanical circulatory support are available to the medical community.
The available devices differ in terms of the insertion procedure, mechanical properties, and
mode of action. A minimal flow rate of 70 ml/kg/min, representing a cardiac index of at least
2.5 L/m2
, is generally required to provide adequate organ perfusion. This flow is the sum
of the mechanical circulatory support output and the remaining function of the heart.
The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory
cardiogenic shock
Type Support Access
Intra-aortic balloon
pump
Balloon
counterpulsation
Pulsatile flow 0.5 L Arterial: 7.5 French
Impella Recover
LP 2.5
CP
LP 5.0
Axial flow Continuous flow
2.5 L
4.0 L
5.0 L
Arterial: 12 French
Arterial: 14 French
Arterial: 21 French
Tandemheart
Centrifugal flow
5.0 L
Continuous flow
5.0 L
Venous: 21 French
Arterial: 15-17 French
Venous: 15-29 French
Arterial: 15-29 French
Cardiohelp
(www.save-score.com).
P.69
4.2

81. Monsieurs KG, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 1
Executive Summary. Resuscitation 2015; 95C:1-80, DOI:10.1016/j.resuscitation.2015.07.038
CHAPTER 5
CARDIAC ARREST AND
CARDIOPULMONARY RESUSCITATION
N. Nikolaou, L. Bossaert
5
THE CHAIN OF SURVIVAL
P.71

82. OUT OF HOSPITAL CARDIAC ARREST:
ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
VICTIM COLLAPSES
Victim responds
Victim unresponsive
Leave victim as found
Find out what is wrong
Reassess victim regularly
Shout for help
Open airway
Assess breathing
Not breathing normally
Call for an ambulance
Start CPR 30:2
Send or go for an AED
As soon as AED arrives
Start AED,
listen to and follow voice prompts
AED Assesses rhythm
AED not available
30 chest compressions:
2 rescue breaths
Breathing normally
Put victim in recovery position
and call for an ambulance
Approach safely
Check response
P.72
5
OUT OF HOSPITAL CARDIAC ARREST:
Assessment of a collapsed victim and initial treatment

83. Continue until victim starts to wake up: to move, open eyes, and breathe normally
No shock advised
Immediately resume
CPR 30:2 for 2 min
Shock advised
1 shock
Immediately resume
CPR 30:2 for 2 min
P.73
5

84. IN-HOSPITAL CARDIAC ARREST:
ASSESSMENT OF A COLLAPSED VICTIM AND INITIAL TREATMENT
Collapsed/sick patient
Shout for HELP assess patient
Yes
No
Assess ABCDE
Recognise treat
oxygen; monitoring, i.v. access
Call resuscitation
team
CPR 30:2
with oxygen and airway adjuncts
Signs of life?
P.74
5
IN-HOSPITAL CARDIAC ARREST:
Assessment of a collapsed victim and initial treatment

85. Call resuscitation team
if appropriate
Apply pads/monitor
Attempt defibrillation
if appropriate
Handover to resuscitation team
Advanced Life Support
when resuscitation team arrives
P.75
5

86. IN-HOSPITAL CARDIAC ARREST: ADVANCED LIFE SUPPORT
Unresponsive
and not breathing
normally ?
Assess
rhythm
CPR 30:2
Attach defibrillator/monitor
Minimise interruptions
Call resuscitation
team
Shockable
(VF/Pulseless VT)
Non-shockable
(PEA/Asystole)
P.76
5
IN-HOSPITAL CARDIAC ARREST: Advanced life support

87. DURING CPR
• Ensure high-quality
chest compressions
• Minimise interruptions
to compressions
• Give Oxygen
• Use waveform capnography
• Continuous chest compressions
when advanced airway in place
• Vascular access (intravenous,
intraosseous)
• Give adrenaline every 3-5 min
• Give amiodarone after 3 shocks
• Correct reversible causes
REVERSIBLE CAUSES
• Hypoxia
• Hypovolaemia
• Hypo-/hyperkalaemia/metabolic
• Hypothermia
• Thrombosis
• Tamponade - cardiac
• Toxins
• Tension pneumothorax
1 Shock
Return of
spontaneous circulation
IMMEDIATE POST
CARDIAC
ARREST TREATMENT
Immediately resume:
CPR for 2 min
Minimise interruptions
Immediately resume:
CPR for 2 min
Minimise interruptions • Use ABCDE approach
• Aim for SaO2 94-98%
• Aim for normal PaCO2
• 12-lead ECG
• Treat precipitating cause
• Temperature control /
Therapeutic hypothermia
CONSIDER
• Ultrasound imaging
• Mechanical chest
compressions to facilitate
transfer/treatment
• Coronary angiography
and PCI
• Extracorporeal CPR
P.77
5

88. Give adrenaline and amiodarone
after 3rd
shock
Adrenaline: 1 mg i.v.
(10 ml 1:10,000 or 1 ml 1:1000)
repeated every 3-5 min
(alternate loops)
given without interrupting
chest compressions
Amiodarone
300 mg bolus i.v.
Second bolus dose of 150 mg i.v.
if VF/VT persists
followed by infusion of
900 mg over 24 h
Adrenaline: 1mg i.v. (10 ml 1:10,000 or 1 ml 1:1000)
given as soon as circulatory access is obtained
Repeat every 3-5 min (alternate loops)
Give without interrupting chest compressions
IN-HOSPITAL CARDIAC ARREST: DRUG THERAPY DURING ADVANCED LIFE SUPPORT
Cardiac Arrest
Non-shockable
rhythm
Shockable rhythm
(VF, pulseless VT)
P.78
5
IN-HOSPITAL CARDIAC ARREST:
Drug therapy during advanced life support

89. CHAPTER 6
RHYTHM DISTURBANCES
6.1 SUPRAVENTRICULAR TACHYCARDIAS AND ATRIAL FIBRILLATION ���� p.80
J. Brugada
6.2 VENTRICULAR TACHYCARDIAS ������������������������������������������ p.84
M. Santini, C. Lavalle, S. Lanzara
6.3 BRADYARRHYTHMIAS ���������������������������������������������������� p.87
B. Gorenek
6

90. QRS morphology similar to QRS morphology
in sinus rhythm?
QRS morphology similar to QRS morphology
in sinus rhythm?
YES
QRS complex
120 msec
Supraventr.
Tachycardia
QRS complex
120 msec
Supraventr.
Tachycardia
+ BBB
QRS complex
120 msec
QRS complex
120 msec
Fascicular
Tachycardia
or SVT with
aberrant
conduction
Ventricular
Tachycardia
or SVT with
aberrant
conduction
QRS complex
120 msec
QRS complex
120 msec
AF
conducting
over AVN
AF + BBB
or
AF + WPW
AF
+
WPW
Irregular
Ventricular
Tachycardia
Variable QRS
morphology
NO YES NO
TACHYARRHYTHMIAS: DIAGNOSTIC CRITERIA
Tachycardia
100 beats/min
Irregular
Regular
P.80
6.1
TACHYARRHYTHMIAS: Diagnostic criteria

91. • Concordant precordial pattern
(all leads + or all leads –)
• No RS pattern in precordial leads
• RS pattern with beginning
of R wave to nadir
of S wave 100 msec
Consider
SVT using
the AV node
(AVNRT, AVNT)
Atrial flutter
or atrial
tachycardia
Ventricular
Tachycardia
Ventricular
Tachycardia
Ventricular
Tachycardia
Consider
Sinus tachycardia
or non proper
administration
of adenosine
(too slow, insufficient
dose, etc)
Typical
morphology
in V1 V6
More As
than Vs
More Vs
than As
Wide
QRS complex
Narrow
QRS complex
Regular tachycardia
Vagal maneuvers
or
i.v. adenosine
No change
Tachycardia
terminates
AV relation
changes
P.81
6.1
TACHYARRHYTHMIAS: Diagnostic maneuvers

92. Hemodynamically
non-stable
Immediate electrical
cardioversion
No termination
Hemodynamically
stable
Vagal maneuvers
and/or i.v. Adenosine
Less than 48 hours
since initiation
AND
hemodynamically stable
Cardioversion
Electrical or pharmacological
using oral or i.v. flecainide
(only in normal heart)
or i.v. vernakalant
Anticoagulation
is initiated using i.v. heparine
Hemodynamically non-stable
Immediate electrical
Cardioversion
If no cardioversion
is considered: rate control
using betablockers or
calcium antagonists,
together with proper
anticoagulation, if required
Narrow QRS
complex tachycardia
Reconsider diagnosis:
sinus tachycardia,
atrial tachycardia
If no evidence:
Intravenous verapamil
Wide QRS
complex tachycardia
Reconsider the diagnosis of
Ventricular Tachycardia even
if hemodynamically stable
Do not administer
verapimil
More than 48 hours OR
unknown time of initiation,
AND
Patient chronically anticoagulated
OR
a TEE showing no thrombus
Electrical or pharmacological Cardioversion
Termination
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (1)
Regular Supraventricular Tachycardias
with or without bundle branch block
Irregular and narrow QRS complex
Tachycardia
Hemodynamically
non-stable
Immediate electrical
cardioversion
No termination
Hemodynamically
stable
Vagal maneuvers
and/or i.v. Adenosine
Less than 48 hours
since initiation
AND
hemodynamically stable
Cardioversion
Electrical or pharmacological
using oral or i.v. flecainide
(only in normal heart)
or i.v. vernakalant
Anticoagulation
is initiated using i.v. heparine
Hemodynamically non-stable
Immediate electrical
Cardioversion
If no cardioversion
is considered: rate control
using betablockers or
calcium antagonists,
together with proper
anticoagulation, if required
Narrow QRS
complex tachycardia
Reconsider diagnosis:
sinus tachycardia,
atrial tachycardia
If no evidence:
Intravenous verapamil
Wide QRS
complex tachycardia
Reconsider the diagnosis of
Ventricular Tachycardia even
if hemodynamically stable
Do not administer
verapimil
More than 48 hours OR
unknown time of initiation,
AND
Patient chronically anticoagulated
OR
a TEE showing no thrombus
Electrical or pharmacological Cardioversion
Termination
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (1)
Regular Supraventricular Tachycardias
with or without bundle branch block
Irregular and narrow QRS complex
Tachycardia
P.82
6.1
TACHYARRHYTHMIAS: Therapeutic algorithms (1)

93. Hemodynamically
non-stable
Immediate electrical
Cardioversion
If no cardioversion is considered:
rate control using betablockers or
calcium antagonists (only if VT and
AF+WPW is excluded), together
with proper anticoagulation
if required
Less than 48 hours since initiation
AND
hemodynamically stable
Cardioversion
electrical or pharmacological
using oral or i.v. flecainide
(only in normal heart)
or i.v. amiodarone
Anticoagulation
is initiated using i.v. heparin
More than 48 hours
or unknown initiation,
AND
patient chronically anticoagulated
or a TEE showing no thrombus
Electrical or pharmacological
Cardioversion
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (2)
Irregular and wide QRS complex Tachycardia
P.83
6.1
TACHYARRHYTHMIAS: Therapeutic algorithms (2)

94. VENTRICULAR TACHYCARDIAS: DIFERENTIAL DIAGNOSIS OF WIDE QRS TACHYCARDIA
EKG signs of atrio-ventricular dissociation
Random P waves unrelated to QRS complexes
Capture beats / fusion beats / second degree V-A block
1st
Step
2nd
Step
3rd
Step
Concordant pattern in precordial leads
No RS morphology in any of the precordial leads
An interval 100 ms from the beginning of the
QRS complex to the nadir of S in a precordial lead
Morphology in precordial leads Morphology
in aVR lead
Yes
Yes
Yes
No
No
No
VT
P.84
6.2
VENTRICULAR TACHYSCARDIAS:
Diferential diagnosis of wide QRS tachyscardias

95. RBBB morphology LBBB morphology Initial R wave
Initial R wave
or q 40 msec
V1: qR, R, R’
V6: rS,QS
V1: rsR’, RSR’
V6: qRs
Aberrant conduction
V6: R V1: rS; R 30 ms,
S nadir 60 ms,
notching of the
S wave
V6: qR, QS
Yes
No
No
No
No
Yes
Yes
Yes
Notch in the
descending
Q wave limb
Vi/Vt ≤1
VT
Aberrant conduction
VT
P.85
6.2

96. MANAGEMENT OF WIDE QRS TACHYCARDIAS
Hemodynamic Tolerance
Stable
Regular rhythm
Irregular rhythm
Vagal maneuver
and/or
i.v. adenosine (push)
Differential Diagnosis
Interruption or
slow down HR
Yes
Yes
No
No
Differential
Diagnosis
(see chapter 6.1
page 81)
SVT
AF with aberrant
ventricular conduction
• β-blockers
• i.v.
• Verapamil or diltazem
Pre excited AF
• Class 1 AADs
Polymorphic VT
• Amiodarone
Amiodarone 150 mg i.v.
(can be repeated up to
a maximum dose of 2.2 g in 24 h)
Synchronised cardioversion
With pulse
Pulseless
Non-stable
• Sedation
or analgesia
• Synchronised
cardioversion
100 to 200 J
(monophasic)
or 50-100 J
(biphasic)
ACLS Resuscitation algorithm
• Immediate high- energy
defibrillation (200 J biphasic
or 360 monophasic)
• Resume CPR and continue
according to the ACLS algorithm
Drugs used in the ACLS algorithm
• Epinephrine 1 mg i.v./i.o.
(repeat every 3-5 min)
• Vasopressin 40 i.v./i.o.
• Amiodarone 300 mg i.v./i.o.
once then consider an additional
150 mg i.v./i.o. dose
• Lidocaine 1-1.5 mg/kg first dose
then 0.5-0-75 mg/kg i.v./i.o.
for max 3 doses or 3 mg/kg
• Magnesium loading dose 1-2 gr
i.v./i.o. for torsade des pointes
P.86
6.2
Management of wide QRS TACHYSCARDIAS

97. Sinus node dysfunction Atrioventricular (AV) blocks
• Sinus bradycardia: It is a rhythm that originates
from the sinus node and has a rate of under 60 beats
per minute
•
Sinoatrial exit block: The depolarisations that occur in
the sinus node cannot leave the node towards the atria
• Sinus arrest: Sinus pause or arrest is defined as the
transient absence of sinus P waves
on the ECG
•
First degree AV block: Atrioventricular impulse
transmission is delayed, resulting in a PR interval
longer than 200 msec
•
Second degree AV block: Mobitz type I (Wenckebach
block): Progressive PR interval prolongation, which
precedes a nonconducted P wave
•
Second degree AV block: Mobitz type II: PR interval
remains unchanged prior to a P wave that suddenly fails
to conduct to the ventricles
•
Third degree (complete) AV block:
No atrial impulses reach the ventricle
P.87
6.3
BRADYARRHYTHMIAS: Definitions and diagnosis

98. •
Rule out and treat any underlying causes of bradyarrhythmia
•
Treat symptomatic patients only
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
Temporary transvenous pacing
Be Careful!
•
Complications are common!
•
Shall not be used routinely
•
Use only as a last resource when chronotropic drugs are insufficient
•
Every effort should be made to implant a permanent pacemaker
as soon as possible, if the indications are established.
Indications limited to:
•
High-degree AV block without escape rhythm
•
Life threatening bradyarrhythmias, such as those that occur during interventional
procedures, in acute settings such as acute myocardial infarction, drug toxicity.
P.88
6.3
BRADYARRHYTHMIAS: Treatment (1)

99. Permanent pacemaker is indicated in the following settings:
•
Documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms
•
Symptomatic chronotropic incompetence
•
Symptomatic sinus bradycardia that results from required drug therapy for medical conditions
Permanent pacemaker is not recommended in the following settings:
•
Asymptomatic patients
•
Patients for whom the symptoms suggestive of bradycardia
have been clearly documented to occur in the absence of bradycardia
•
Symptomatic bradycardia due to nonessential drug therapy
P.89
6.3
BRADYARRHYTHMIAS: Treatment (2)
Pacemaker therapies in sinus node dysfunction

100. Permanent pacemaker therapy is indicated in the following settings regardless of associated symptoms:
•
Third-degree AV block
•
Advanced second-degree AV block
•
Symptomatic Mobitz I or Mobitz II second-degree AV block
•
Mobitz II second-degree AV block with a wide QRS or chronic bifascicular block
•
Exercise-induced second- or third-degree AV block
•
Neuromuscular diseases with third- or second-degree AV block
•
Third- or second-degree (Mobitz I or II) AV block after catheter ablation or valve surgery
when block is not expected to resolve
Permanent pacemaker is not recommended in the following settings:
•
Asymptomatic patients
•
Patients for whom the symptoms suggestive of bradycardia have been clearly documented
to occur in the absence of bradycardia
•
Symptomatic bradycardia due to nonessential drug therapy
P.90
6.3
BRADYARRHYTHMIAS: Treatment (3)
Pacemaker therapies in atrioventricular blocks

101. CHAPTER 7
ACUTE VASCULAR SYNDROMES
7.1 ACUTE AORTIC SYNDROMES ���������������������������������������������� p.92
A. Evangelista
7.2 ACUTE PULMONARY EMBOLISM ������������������������������������������ p.102
A. Torbicki
7

102. Classic aortic dissection
Separation of the aorta media with presence
of extraluminal blood within the layers of the aortic wall.
The intimal flap divides the aorta into two lumina, the true and the false
Penetrating aortic ulcer (PAU)
Atherosclerotic lesion penetrates
the internal elastic lamina of the aorta wall
Aortic aneurysm rupture
(contained or not contained)
Intramural hematoma (IMH)
Aortic wall hematoma with no entry tear
and no two-lumen flow
P.92
7.1
ACUTE AORTIC SYNDROMES: Concept and classification (1)
Types of presentation

103. DeBakey’s Classification
•
Type I and Type II dissections both originate in the ascending aorta
In type I, the dissection extends distally to the descending aorta
In type II, it is confined to the ascending aorta
•
Type III dissections originate in the descending aorta
Stanford Classification
•
Type A includes all dissections involving the ascending
aorta regardless of entry site location
•
Type B dissections include all those distal to the
brachiocephalic trunk, sparing the ascending aorta
Time course
•
Acute: 14 days
•
Subacute: 15-90 days
•
Chronic: 90 days
Copyright: Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up.
Circulation (2003); 108(6),772-778.
Adapted with permission from Nienaber CA, Eagle KA,
Circulation 2003;108(6):772-778. All rights reserved.
De Bakey
Stanford
Type I
Type A
Type II
Type A
Type III
Type B
P.93
7.1
ACUTE AORTIC SYNDROMES: Concept and classification (2)
Anatomic classification and time course

104. SYMPTOMS AND SIGNS
SUGGESTIVE OF AAS
•
Abrupt and severe chest/back pain with
maximum intensity at onset
• Pulse/pressure deficit
- Peripheral or visceral ischemia
- Neurological deficit
•
Widened mediastinum on chest X -ray
•
Risk factors for dissection
• Other
- Acute aortic regurgitation
- Pericardial effusion
- Hemomediastinum/hemothorax
DIFFERENTIAL DIAGNOSIS
•
Acute coronary syndrome
(with/without ST-segment elevation)
•
Aortic regurgitation without dissection
•
Aortic aneurysms without dissection
• Musculoskeletal pain
• Pericarditis
• Pleuritis
• Mediastinal tumours
• Pulmonary embolism
• Cholecystitis
•
Atherosclerosis or cholesterol embolism
P.94
7.1
ACUTE AORTIC SYNDROME:
Clinical suspicion and differential diagnosis

105. Copyright: Hiratzka et al. 2010 Guidelines on Thoracic Aortic Disease. Circulation. (2010) ; 121: page-310 (fig 25 step 2).
Consider acute aortic dissection in all patients presenting with:
• Chest, back or abdominal pain
• Syncope
• Symptoms consistent with perfusion deficit
(central nervous system, visceral myocardial or limb ischemia)
Pre-test risk assessment for acute aortic dissection
• Marfan’s syndrome
• Connective tissue disease
• Family history of aortic disease
• Aortic valve disease
• Thoracic aortic aneurysm
• Perfusion deficit:
- Pulse deficit
- SBP differential
- Focal neurological deficit
• Aortic regurgitation murmur
• Hypotension or shock
Chest, back or abdominal pain
described as:
Abrupt at onset, severe in intensity,
and ripping/sharp or stabbing quality
High-risk conditions High-risk pain features High-risk exam features
P.95
7.1
General approach to the patient
with suspected ACUTE AORTIC SYNDROME

106. Laboratory tests To detect signs of:
Red blood cell count Blood loss, bleeding, anaemia
White blood cell count Infection, inflammation (SIRS)
C-reactive protein Inflammatory response
ProCalcitonin Differential diagnosis between SIRS and sepsis
Creatine kinase Reperfusion injury, rhabdomyolysis
TroponinIorT Myocardial ischaemia, myocardial infarction
D-dimer Aortic dissection, pulmonary embolism, thrombosis
Creatinine Renal failure (existing or developing)
Aspartate transaminase / alanine aminotransferase Liver ischaemia, liver disease
Lactate Bowel ischaemia, metabolic disorder
Glucose Diabetes mellitus
Blood gases Metabolic disorder, oxygenation
Reference: Eur Heart J 2014; eurheartj.ehu281.
P.96
7.1
Laboratory tests required for patients
with ACUTE AORTIC dissection

107. a
STEMI can be associated with AAS in rare cases.
b
Pending local availability, patient
characteristics, and physician experience.
c
Proof of type-A AD by the presence of flap, aortic
regurgitation, and/or pericardial effusion.
d
Preferably point-of-care, otherwise classical.
e
Also troponin to detect non–ST-segment
elevation myocardial infarction.
Flowchart for decision-making based on pre-test sensitivity of acute aortic syndrome. Reference: Eur Heart J 2014; eurheartj.ehu281.
ACUTE CHEST PAIN
High probability (score 2-3)
or typical chest pain
Medical history + clinical examination + ECG STEMIa: see ESC guidelines169
HAEMODYNAMIC STATE
UNSTABLE
Low probability (score 0-1)
TTE + TOE/CT°
STABLE
AAS
confirmed
AAS
excluded
Consider
alternate
diagnosis
D-dimersd,e + TTE + Chest X-ray TTE
Consider
alternate
diagnosis
No argument
for AD
Signs
of AD
Widened
media-
stinum
Definite
Type A -ADc
Inconclusive
Refer on emergency
to surgical team and
pre-operative TOE
CT (or TOE)
AAS
confirmed
Consider
alternate
diagnosis
repeat CT
if necessary
AAS
confirmed
Consider
alternate
diagnosis
CT (MRI or TOE)b
P.97
7.1
ACUTE CHEST PAIN

108. Aortic dissection •
Visualization of intimal flap
•
Extent of the disease according to the aortic anatomic segmentation
•
Identification of the false and true lumens (if present)
•
Localization of entry and re-entry tears (if present)
•
Identification of antegrade and/or retrograde aortic dissection
•
Identification grading, and mechanism of aortic valve regurgitation
•
Involvement of side branches
•
Detection of malperfusion (low flow or no flow)
•
Detection of organ ischaemia (brain, myocardium, bowels, kidneys, etc.)
•
Detection of pericardial effusion and its severity
•
Detection and extent of pleural effusion
•
Detection of peri-aortic bleeding
•
Signs of mediastinal bleeding
Intramural
haematoma
•
Localization and extent of aortic wall thickening
•
Co-existence of atheromatous disease (calcium shift)
•
Presence of small intimal tears
Penetrating aortic
ulcer
•
Localization of the lesion (length and depth)
•
Co-existence of intramural haematoma
•
Involvement of the peri-aortic tissue and bleeding
•
Thickness of the residual wall
In all cases •
Co-existence of other aortic lesions: aneurysms, plaques, signs of inflammatory disease, etc.
P.98
7.1
Details required from imaging in ACUTE AORTIC dissection

109. ACUTE AORTIC SYNDROMES MANAGEMENT: GENERAL APPROACH
ACUTE AORTIC DISSECTION
Type A
(Ascending aorta
involvement)
Type B
(No ascending
aorta involvement)
Uncomplicated
Medical
treatment
Open Surgery
with/without
Endovascular
Therapy
Endovascular
Therapy or
Open Surgery
(TEVAR)
Complicated
(malperfusion,
rupture)
P.99
7.1
ACUTE AORTIC SYNDROMES MANAGEMENT: General approach

110. 1 • Detailed medical history and complete physical examination (when possible)
2 •
Standard 12-lead ECG: Rule-out ACS, documentation of myocardial ischemia
3 •
Intravenous line, blood sample (CK, cTn, myoglobin, white blood count, D-dimer, hematocrit, LDH)
4 •
Monitoring: HR and BP
5 •
Pain relief (morphine sulphate) (see chapter 4)
6 •
Noninvasive imaging (see previous page)
7 •
Transfer to ICU
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.100
7.1
ACUTE AORTIC SYNDROMES: Initial management

111. URGENT SURGERY (24h)
Emergency Surgery
Graft replacement of ascending aorta +/- arch
with/without aortic valve or aortic root
replacement/repair (depending on aortic regurgitation
and aortic root involvement)
ACUTE AORTIC SYNDROMES: SURGICAL MANAGEMENT
TYPE A ACUTE AORTIC DISSECTION TYPE B ACUTE AORTIC DISSECTION
• Haemodynamic instability
(hypotension/shock)
• Tamponade
• Severe acute aortic
regurgitation
• Impending rupture
• Flap in aortic root
• Malperfusion syndrome
Elective/individualised
Surgery
• Non-complicated
intramural hematoma
• Comorbidities
• Age 80 years
Definitive diagnosis
COMPLICATED
defined as:
by clinical presentation and imaging
• Impending rupture
• Malperfusion
• Refractory HTN
• SBP (90 mmHg)
• Shock
UNCOMPLICATED
defined as:
No features
of complicated
dissection
MEDICAL
MANAGEMENT
and imaging
surveillance protocol
• On admission
• At 7 days
• At discharge
• Every 6 months
thereafter
MEDICAL
MANAGEMENT
and
TEVAR
MEDICAL
MANAGEMENT
and
OPEN SURGERY
REPAIR
if TEVAR
contraindicated
Yes No
P.101
7.1
ACUTE AORTIC SYNDROMES: Surgical management

112. Diagnostic
algorithm
as for suspected
high-risk PE
Diagnostic algorithm as for suspected not high-risk PE
Assess clinical risk (PESI or SPESI)
RV function (echo or CT) a
Laboratory testing b
Intermediate risk
PE confirmed
Consider further
risk stratificaiton
PESI Class III-IV
or sPESI ≥ I
PESI Class I-II
or sPESI = 0
PE confirmed
Both positive One positive
or both negative
Clinical suspicion
Shock / hypotension?
No
Yes
P.102
7.2
Risk-adjusted management strategies
in ACUTE PULMONARY EMBOLISM

113. Reference: Eur Heart J 2014; 35:3033-3073.
a
If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction,
or if the CT already performed for diagnostic work–up has shown RV enlargement (RV/LV (left ventricular)
ratio ≥0.9, a cardiac troponin test should be performed except for cases in which primary reperfusion is
not a therapeutic option (e.g. due to severe comorbidity or limited life expectancy of the patient).
b
Markers of myocardial injury (e.g. elevated cardiac troponin I or T concentrations in plasma), or of heart failure as a
result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for
a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was
positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.
c
Patients in the PESI Class I-II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests, are
also to be classified into the intermediate-low risk category. This might apply to situations in which imaging or biomarker results
become available before calculation of the clinical severity index. These patients are probably no candidates for home treatment.
d
Thrombolysis, if (and as soon as) clinical signs of haemodynamic decompensation appear; surgical
pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as
alternative options to systemic thrombolysis, particularly if the bleeding risk is high.
e
Monitoring should be considered for patients with confirmed PE and a positive troponin test,
even if there is no evidence of RV dysfunction on echocardiography or CT.
f
The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion
criteria other than the PESI were used in two single-armed (non-randomized) management studies.
Intermediate-high risk Intermediate-low risk
A/C; monitoring
consider rescue
reperfusiond
Hospitalization A/C e
Consider early
discharge and home
treatment if feasible f
Primary
reperfusion
High-risk Low riskc
P.103
7.2

114. CARDIOVASCULAR
Symptoms/Signs
including but not limited to:
Shock? or
SBP 90 mmHg?
or
SBP fall by 40 mmHg?
persisting 15 min, otherwise unexplained
RESPIRATORY
Symptoms/Signs
including but not limited to:
ACUTE PULMONARY EMBOLISM: DIAGNOSIS
YES NO
Dyspnea
• Chest pain (angina)
• Syncope
• Tachycardia
• ECG changes
• NT-proBNP ↑
• Troponin ↑
• Chest pain (pleural)
• Pleural effusion
• Tachypnea
• Hemoptysis
• Hypoxemia
• Atelectasis
Suspect
acute
PE
Management algorithm
for UNSTABLE patients
Management algorithm
for initially STABLE patients
Reference: IACC Textbook (2015) chapter 66 Pulmonary embolism - page 638 - figure 66.1.
P.104
7.2
ACUTE PULMONARY EMBOLISM: Diagnosis

115. MANAGEMENT ALGORITHM FOR UNSTABLE PATIENTS WITH
SUSPECTED ACUTE PULMONARY EMBOLISM
CT angiography immediately available
and patient stabilised
Primary PA reperfusion
Primary PA reperfusion not justified
patient stabilised
No further diagnostic
tests feasible
Right heart,
pulmonary artery or
venous thrombi?
Echocardiography
(bedside)
CT*
Angio
RV pressure overload
CUS
No Yes
Yes
Yes positive
negative
No
TEE
Search for other causes
* Consider also pulmonary angiography if unstable patient in hemodynamic lab.
Reference: IACC Textbook (2015) chapter 66 Pulmonary embolism - page 639 - figure 66.2.
P.105
7.2
Management algorithm for unstable patients
with suspected ACUTE PULMONARY EMBOLISM

116. Shock or hypotension YES
Contraindications
for thrombolysis
No Relative Absolute
Primary PA
reperfusion
strategy
Thrombolysis
Low-­dose
transcatheter
thrombolysis /
clot fragmetation
Surgical or
Percutaneous catheter
embolectomy
(availability/experience)
Supportive treatment i.v. UFH, STABILISE SYSTEMIC BLOOD PRESSURE, CORRECT HYPOXEMIA
P.106
7.2
ACUTE PE: Management strategy for initially unstable patients
with confirmed high risk pulmonary embolism

117. MANAGEMENT ALGORITHM FOR INITIALLY STABLE PATIENTS WITH
SUSPECTED ACUTE PULMONARY EMBOLISM
Low or intermediate
“PE unlikely“
positive
negative D-dimer
CT angiography
negative positive
negative
Confirm by CUS
V/Q scan or angiography
positive
CT angiography
CUS
CUS
positive
High or
“PE likely“
Anticoagulation
not justified
Anticoagulation
required
Anticoagulation
not justified
Anticoagulation
required
Asses clinical (pre-test) probalility
Reference: IACC Textbook (2015) chapter 66 Pulmonary embolism - page 640 - figure 66.3.
P.107
7.2
Management algorithm for initially stable patients
with suspected ACUTE PULMONARY EMBOLISM

118. Markers for myocardial injury Positive Positive Negative
Markers for RV overload Positive Positive Negative
Clinical risk assessment
score (PESI)
Positive (class III-V) Positive (class III-V) Negative (class I-II)
Suggested initial
anticoagulation
UFH i.v./LMWH s.c.
LMWH/Fonda/apixaban/
rivaroxaban
apixaban/rivaroxaban
STRATEGY
Monitoring (ICU)*
rescue thrombolysis
Hospitalisation**
(telemonitoring)
Early
discharge***
* When all markers are positive. - ** When at least one marker is positive. - *** When all markers are negative.
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.108
7.2
Suggested management strategy for initially stable patients
with (non-high risk) confirmed PE

119. Key drugs for initial treatment of patients with confirmed PE
Unstable
Alteplase (rtPA) (intravenous) 100 mp/2h
or 0.6 mp/kg/15 min (max 50 mp)
Urokinase (intravenous) 3 million IU over 2h
Streptokinase (intravenous) 1.5 million IU over 2h
Unfractionated heparin (intravenous) 80 IU/kg bolus + 18 IU/kg/h
Stable
Enoxaparine (subcutaneous) 1 mp/kg BID or 1.5 mp/kg QD
Tinzaparin (subcutaneous) 175 U/kg QD
Fondaparinux (subcutaneous) 7.5 mp (50-100 kg of body weight)
5 mp for patients 50 kg,
10 mp for patients 100 kg
Rivaroxaban (oral) 15 mp BID
(for 3 weeks, then 20 mp QD)
Apixaban (oral) 10 mg bid (for 7 days, than 5 mg bid)
For more information on individual drug doses and indications,
SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.109
7.2
PULMONARY EMBOLISM: Pharmacological treatment

121. CHAPTER 8
ACUTE MYOCARDIAL/
PERICARDIAL SYNDROMES
8.1 ACUTE MYOCARDITIS ����������������������������������������������������� p.112
A. Keren, A. Caforio
8.2 ACUTE PERICARDITIS AND CARDIAC TAMPONADE ���������������������� p.117
C. Vrints, S. Price
8

122. CAUSES OF MYOCARDITIS
MYOCARDITIS (WHO /ISFC): Inflammatory disease of the myocardium diagnosed
by established histological, immunological and immunohistochemical criteria.
INFECTIOUS TOXIC
IMMUNE-MEDIATED
• Viral
• Bacterial
• Spirochaetal
• Fungal
• Protozoal
• Parasitic
• Rickettsial
• Drugs
• Heavy Metals
• Hormones, e.g.
catecholamines
(Pheochromocytoma)
• Physical agents
• Allergens: Tetanus toxoid, vaccines,
serum sickness, Drugs
• Alloantigens: Heart transplant rejection
• Autoantigens: Infection-negative lymphocytic,
infection-negative giant cell,
associated with autoimmune or
immune oriented disorders
P.112
8.1
ACUTE MYOCARDITIS: Definition and causes

123. Reference: Caforio ALP et al. Eur Heart J. (2013) Jul 3 (15).
Clinical presentations
with or without ancillary findings
Diagnostic criteria
•
Acute chest pain (pericarditic or pseudo-ischemic)
•
New-onset (days up to 3 months) or worsening
dyspnea or fatigue, with or without left/right heart
failure signs
•
Palpitation, unexplained arrhythmia symptoms,
syncope, aborted sudden cardiac death
•
Unexplained cardiogenic shock
and/or pulmonary oedema
I. ECG/Holter/stress test features: Newly abnormal ECG and/or Holter
and/or stress testing, any of the following:
•
I to III degree atrioventricular block, or bundle branch block,
ST/T wave changes (ST elevation or non ST elevation, T wave inversion),
•
Sinus arrest, ventricular tachycardia or fibrillation and asystole,
atrial fibrillation, frequent premature beats, supraventricular tachycardia
•
Reduced R wave height, intraventricular conduction delay
(widened QRS complex), abnormal Q waves, low voltage
II. Myocardiocytolysis markers: Elevated cTnT/cTnI
III. Functional/structural abnormalities on echocardiography
•
New, otherwise unexplained LV and/or RV structure and function
abnormality (including incidental finding in apparently asymptomatic
subjects): regional wall motion or global systolic or diastolic function
abnormality, with or without ventricular dilatation, with or without
increased wall thickness, with or without pericardial effusion, with
or without endocavitary thrombi
IV. Tissue characterisation by CMR:
Edema and/or LGE of classical myocarditic pattern
Ancillary findings which support
the clinical suspicion of myocarditis
• Fever ≥38.1°C within the preceding 30 days
•
A respiratory or gastrointestinal infection
•
Previous clinically suspected or biopsy proven
myocarditis
• Peri-partum period
•
Personal and/or family history of allergic asthma
•
Other types of allergy
•
Extra-cardiac autoimmune disease
• Toxic agents
•
Family history of dilated cardiomyopathy, myocarditis
P.113
8.1
ACUTE MYOCARDITIS: Diagnostic criteria (1)
Diagnostic criteria for clinically suspected myocarditis

124. One or more of the clinical presentations shown in the Diagnostic Criteria*
with or without Ancillary Features*
AND
One or more Diagnostic Criteria from different categories (I to IV)*
OR
when the patient is asymptomatic, two or more diagnostic criteria from different categories (I to IV)*
in the absence of:
1) angiographically detectable coronary artery disease
2) known pre-existing cardiovascular disease or extra-cardiac causes that could explain the syndrome
(e.g. valve disease, congenital heart disease, hyperthyroidism, etc.)
Suspicion is higher with higher number of fulfilled criteria*
Endomyocardial biopsy is necessary to:
1) confirm the diagnosis of clinically suspected myocarditis,
2) identify the type and aetiology of inflammation,
and 3) provide the basis for safe immunosuppression
(in virus negative cases).
Reference: Caforio ALP et al. Eur Heart J. (2013) Jul 3 (16).
*SEE CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
P.114
8.1
ACUTE MYOCARDITIS: Diagnostic criteria (2)
Acute myocarditis should be clinically suspected in the presence of:

125. Hemodynamically stable
Preserved LV function
No eosinophilia
No significant rhythm or
conduction disturbances
Not associated with
systemic immune disease*
General supportive therapy
General supportive therapy
Immunosuppression if
unresponsive and virus negative EMB
Hemodynamically unstable,
decreased LV function, cardiogenic shock
Pharmacological and, if needed,
mechanical circulatory support (ECMO, LVAD/Bi-VAD,
bridge to heart transplant or to recovery)
Lymphocytic Giant cell, eosinophilic,
sarcoidosis (acute decompensation)
Immunosuppression
if infection-negative EMB
History, Physycal examination; ECG; Echocardiogram; Laboratory tests
(Troponin, CRP, ESR, blood cell count, BNP); CMR; If available, serum cardiac autoantibodies
Clinically suspected myocarditis
Consider coronary angiography and EMB
No coronary artery disease
*If myocarditis is associated with systemic immune disease exacerbation, therapy overlaps with treatment of the background disease (usually immunosuppression).
P.115
8.1
ACUTE MYOCARDITIS: Diagnostic and management protocol

126. •
Patients with a life-threatening presentation should be sent to specialised units with capability for
hemodynamic monitoring, cardiac catheterisation and expertise in endomyocardial biopsy.
•
In patients with hemodynamic instability a mechanical cardio-pulmonary assist device
may be needed as a bridge to recovery or to heart transplantation.
•
Heart transplant should be deferred in the acute phase, because recovery may occur, but can be considered
for hemodynamically unstable myocarditis patients, including those with giant cell myocarditis, if optimal
pharmacological support and mechanical assistance cannot stabilise the patient
• ICD implantation for complex arrhythmias should be deferred until resolution of the acute episode, with
possible use of a lifevest during the recovery period.
Reference: Caforio ALP et al. Eur Heart J. 2013 Jul 3 (18).
P.116
8.1
Management of patients
with life-threatening ACUTE MYOCARDITIS

127. DIAGNOSIS (≥ 2 of the following):
• Chest pain (pleuritic) varying with position
• Pericardial friction rub
• Typical ECG changes (PR depression and/or diffuse concave ST-segment elevation)
• Echocardiography: new pericardial effusion
Yes
Myopericarditis if:
↑ Troponin
Echocardiography: ↓ LV-function
Acute
pericarditis
Equivocal or no
Consider
cardiac
MRI
Delayed
enhancement
pericardium
Consider
alternative
diagnoses
P.117
8.2
ACUTE PERICARDITIS: Diagnosis

128. ACUTE PERICARDITIS: MANAGEMENT
Acute pericarditis
High-risk features?
• Fever 38°C
• Subacute onset
• Anticoagulated
• Trauma
• Immunocompromised
• Hypotension
• Jugular venous distension
• Large effusion
Other causes
• Post cardiac injury syndrome
• Post cardiac surgery
• Post MI: Dressler syndrome
• Uremic
• Neoplastic
• Collagen vascular diseases (e.g. SLE)
• Bacterial
• Tuberculous
Yes
Hospital admission
Stable
Ibuprofen + colchicine
Further testing for underlying etiology
Tamponade?
Pericardiocentesis
No
Most frequent cause:
Viral pericarditis
Outpatient treatment
Aspirin 800 mg
or Ibuprofen 600 mg BID - 2 weeks
If persisting or recurrent chest pain :
Add colchicine 0.5 mg once (70 kg)
or 0.5 mg BID (≥70 kg) for 3 months
Avoid corticosteroids!
P.118
8.2
ACUTE PERICARDITIS: Management

129. CARDIAC TAMPONADE: DIAGNOSIS AND MANAGEMENT
Tamponade ?
Tamponade
Echocardiography
with respirometer
• Presence of a moderate to large
pericardial effusion
• Diastolic collapses of right atrium and
right ventricle
• Ventricular interdependence
• Increased tricuspid and pulmonary flow
velocities (50%) with decreased mitral
and aortic flow velocities (25%) during
inspiration (predictive value 90%)
Physical examination
• Distended neck veins
• Shock
• Pulsus paradoxus
• Muffled heart sounds
ECG
• Sinus tachycardia
• Microvoltage QRS
• Electrical alternans
Cardiac catheterization
Early
• Right atrial pressure ↑
• Loss of X-descent
Late
• Aortic pressure ↓
• Pulsus paradoxus
• Intracardiac diastolic
pressure equilibration
Percutaneous
pericardiocentesis drainage
Consider surgical drainage
Avoid PEEP ventilation
Not performed in routine
P.119
8.2
CARDIAC TAMPONADE: Diagnosis and management

131. CHAPTER 9
DRUGS IN
ACUTE CARDIOVASCULAR
CARE
Ana de Lorenzo
P.121
9

132. Drug Indications Dose
Dose
adjustments
Comments
Aspirin
Primary (not universally approved)
and secondary cardiovascular
disease prevention
LD (if ACS):
150-300 mg oral
MD: 75-100 mg
oral QD
-
Major contraindications:
GI bleeding-active peptic ulcer
Ticagrelor
ACS (all patients at moderate-to-high
risk of ischaemic events, e.g. elevated
cardiac troponins)
LD: 180 mg oral
MD: 90 mg oral BID -
Major contraindications: previous intracerebral
hemorrhage, severe hepatic impairment,
strong CYP3A4 inhibitors
Secondary prevention
1-3 years post-MI
MD: 60 mg oral BID
-
Prasugrel
ACS with planned PCI LD: 60 mg oral
MD: 10 mg oral QD
MD: 5 mg QD
weight 60kg
Contraindication:
previous stroke/TIA
Prasugrel is generally not recommended in
elderly, and if positive benefit/risk 5 mg is
recommended
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.122
Oral antiplatelets 9

133. Drug Indications Dose
Dose
adjustments
Comments
Clopidogrel
ACS + PCI or medical management
(patients who cannot receive
ticagrelor or prasugrel) and in
ACS patients at high bleeding risk
(e.g. patients who require oral
anticoagulation)
LD: 300-600 mg
oral
MD: 75 mg oral QD
-
Prasugrel and ticagrelor have not been studied
as adjuncts to fibrinolysis and oral anticoagulants
STEMI
+ fibrinolysis 75 years
LD: 300 mg oral
MD: 75 mg oral QD
-
Prasugrel and ticagrelor have not been studied
as adjuncts to fibrinolysis and oral anticoagulants
STEMI
+ fibrinolysis ≥75 years
LD: 75 mg oral
MD: 75 mg oral QD
-
Secondary prevention 12 months
post coronary stenting
MD: 75 mg oral QD
-
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.123
Oral antiplatelets (Cont.) 9

134. Drug Indications Dose
Dose
adjustments
Comments
Abciximab
Adjunct to PCI for bailout
situations or thrombotic
complications
LD: 0.25 mg/Kg i.v.
MD: 0.125 μg/Kg/
min i.v. (max: 10 μg/
min) for 12h
-
Contraindications:
Active internal bleeding - History of CVA within 2 years
- Bleeding diathesis - Preexisting thrombocytopenia
- Recent (within 2 months) intracranial or intraspinal
surgery or trauma - Recent (within 2 months) major
surgery - Intracranial neoplasm, arteriovenous
malformation, or aneurysm - Severe uncontrolled
hypertension - Presumed or documented history of
vasculitis - Severe hepatic failure or severe renal failure
requiring haemodialysis - Hypertensive retinopathy
Eptifibatide
ACS treated medically
or with PCI
LD: 180 μg/Kg i.v.
(at a 10 min
interval)
If STEMI and PCI:
add a second
180 mcg/kg i.v.
bolus
at 10 min
MD: 2 μg/Kg/min i.v.
infusion
Reduce infusion
dose to 1 μg/kg/
min if CrCl
30-50 ml/min
Contraindications:
Bleeding diathesis or bleeding within the previous
30 days - Severe uncontrolled hypertension - Major
surgery within the preceding 6 weeks - Stroke within
30 days or any history of hemorrhagic stroke -
Coadministration of another parenteral GP II b/III a
inhibitor - Severe renal impairment or dependency on
renal dialysis - History of intracranial disease - Clinically
significant hepatic impairment - Thrombocytopenia -
Prothrombine time 1.2 times control or INR ≥2
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.124
Intravenous antiplatelets 9

135. Drug Indications Dose
Dose
adjustments
Comments
Tirofiban
ACS treated medically
or with PCI
LD: 25 μg/Kg i.v.
over 5 min
MD: 0.15 μg/Kg/
min i.v. Infusion to
18 hours
CrCl 30 ml/min:
decrease 50%
bolus and infusion
dose
Contraindications:
A history of thrombocytopenia following prior exposure
Active internal bleeding or a history of bleeding
diathesis, major surgical procedure or severe physical
trauma within the previous month
Cangrelor
All patients undergoing PCI
(elective + ACS)
immediate onset + rapid
offset
(platelet recovery in 60min)
IV Bolus
of 30 μg/Kg
+
IV infusion
of 4 μg/kg/min
for at least 2 hours
from start of PCI
-
Major contraindications:
Significant active bleeding or stroke
Transition to oral P2Y12 inhibitors variable
according to type of agent
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.125
Intravenous antiplatelets (Cont.) 9

136. Drug Indications Dose Dose adjustments Comments
Warfarin
Acenocoumarol
Treatment and
prophylaxis
of thrombosis
INR goal of 2-3
(INR: 2.5-3.5 for mechanical
mitral valve prostheses or
double valve replacement)
Assessing individual risks for
thromboembolism and bleeding
-
Apixaban
Prevention of stroke
and systemic embolism
in NVAF
5 mg oral BID 2.5 mg oral BID
1) when at least 2 of the following
characteristics: age ≥80,
Cr 1.5 mg/dl or weight 60Kg
2) when CrCl 15-29 ml/min
Contraindicated if CrCl 15 ml/min
or severe hepatic impairment
Treatment of DVT and PE 10 mg oral BID for the first
7 days
followed by 5 mg oral BID
-
Prevention of recurrent
DVT and PE
2.5 mg oral BID
-
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.126
Oral anticoagulants and antagonists 9

137. Drug Indications Dose Dose adjustments Comments
Dabigatran
Prevention of stroke
and systemic embolism
in NVAF
150 mg oral BID 110 mg BID
(if age ≥80, increased bleeding
risk or concomitant use of
verapamil)
Contraindicated if CrCl 30 ml/min
or severe hepatic impairment
Active clinically significant bleeding
Concomitant treatment
with systemic ketoconazole,
cyclosporine, itraconazole and
dronedarone
Treatment of DVT and PE
in patients who have been
treated with a parenteral
anticoagulant for 5-10
days and prevention of
recurrent DVT and PE in
patients who have been
previously treated
Edoxaban
Prevention of stroke and
systemic embolism in
NVAF
60 mg oral QD 30 mg oral QD
1) when CrCl 15-50 ml/min
2) weight 60Kg
3) concomitant use of the
following P-glycoprotein inhibitors:
ciclosporin, dronedarone,
erythromycin, or ketoconazole.
Edoxaban can be initiated
in patients who may require
cardioversion. Treatment should
be started at least 2 hours before
cardioversion
Treatment of DVT and
PE and prevention of
recurrent DVT and PE
60 mg oral QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.127
Oral anticoagulants and antagonists (Cont.) 9

138. Drug Indications Dose Dose adjustments Comments
Rivaroxaban
Prevention of stroke and
systemic embolism in
NVAF
20 mg oral QD CrCl 50 ml/min: 15 mg QD Contraindicated if CrCl 15 ml/min
or hepatic disease associated with
coagulopathy and clinically relevant
bleeding risk
Rivaroxaban can be initiated
in patients who may require
cardioversion
Treatment should be started at
least 4 hours before cardioversion
Treatment of DVT and
PE and prevention of
recurrent DVT and PE
15 mg oral BID for the first
3 weeks
followed by 20 mg QD
Reduce the maintenance dose to
15 mg QD if bleeding risk outweighs
the risk for recurrent DVT and PE
(not formally approved)
Prevention of
atherothrombotic events
2.5 mg oral BID
-
Anticoagulant antagonists
Idarucizumab
Specific reversal agent
for dabigatran
5g i.v. over 5 to 10 min
Another 5g dose if prolonged
clotting times and:
-
recurrence of clinically
relevant bleeding
-
if potential re-bleeding
would be life-threatening
-
second emergency
surgery/urgent procedure
-
Dabigatran treatment can be re-
initiated 24h after administration of
idarucizumab, other antithrombotic
therapy at any time
Relevant coagulation parameters
are aPTT, dTT or ECT
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.128
Oral anticoagulants and antagonists (Cont.) 9

139. Drug Indications Dose Dose adjustments Comments
Anticoagulant antagonists
Phytomenadione
(Vitamin
K)
Reversal for vitamin K
antagonists
Patients with asymptomatic high INR with or without mild haemorrhage
Anticoagulant INR Oral Vitamin K i.v. Vitamin K
Warfarin
5-9 1-2.5 mg or 2-5 mg for a rapid reversal
(additional dose of 1-2 mg if INR
remains high after 24h)
0.5-1 mg
9 2.5-5 mg (up to 10 mg) 1 mg
Acenocoumarol
5-8 1-2 mg 1-2 mg
8 3-5 mg 1-2 mg
Severe or life-threatening haemorrhage
Anticoagulant Situation i.v. Vitamin K Concomitant treatment
Warfarin
Severe
haemorrhage
5-10 mg CCP or FFP
Life-threatening 10 mg CCP, FFP or rFVIIa
Acenocoumarol
Severe
haemorrhage
5 mg CCP, FFP or rFVIIa
P.129
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral anticoagulants and antagonists (Cont.) 9

140. Drug Indications Dose Dose adjustments Comments
UFH
NSTE-ACS LD: 4,000 IU i.v. MD: 1,000 IU/h i.v. Target aPTT: 50-70s or 1.5 to
2.0 times that of control to be
monitored at 3, 6, 12 and 24h
Monitoring for heparin-induced
thrombocytopenia (HIT)
Dose-independent reaction
STEMI Primary PCI: 70-100 IU/Kg i.v. when no
GP-IIb/IIIa inhibitor is planned. 50-60 IU/Kg i.v.
bolus with GP-IIb/IIIa inhibitors - Fibrinolysis/
No reperfusion: 60 IU/kg i.v. bolus (max:
4,000 IU) followed by an i.v. infusion of 12 IU/kg
(max: 1,000 IU/h) for 24-48h
Target aPTT: 50-70s or 1.5 to
2.0 times that of control to be
monitored at 3, 6, 12 and 24h
Treatment of DVT
and PE
80 IU/Kg i.v. bolus
followed by 18 IU/Kg/h
According to aPTT,
thromboembolic and bleeding risk
Fondaparinux
NSTE-ACS 2.5 mg QD s.c. up to 8 days or hospital discharge - Acute bacterial endocarditis
Severe hepatic impairment:
caution advised
Contraindicated
if CrCl 20 ml/min
Contraindicated for DVT/PE
treatment if CrCl 30 ml/min
STEMI Fibrinolysis/No reperfusion: 2.5 mg i.v. bolus
followed by 2.5 mg QD s.c. up to 8 days
or hospital discharge
-
Treatment of
DVT and PE
5 mg QD s.c. (50kg); 7.5 mg QD s.c.
(50-100kg); 10 mg QD s.c. (100kg)
If 100Kg and CrCl 30-50 ml/min:
10 mg followed by 7.5 mg/24h s.c.
Prevention of VTE 2.5 mg QD s.c. CrCl 20-50 ml/min: 1.5 mg QD s.c.
P.130
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Parenteral anticoagulants 9

141. Drug Indications Dose Dose adjustments Comments
Bivalirudin
PCI for NSTE-ACS 0.75 mg/kg i.v. bolus followed immediatelly
by 1.75 mg/kg/h infusion which may be
continued for up to 4h post PCI as clinically
warranted and further continued at a reduced
infusion dose of 0.25 mg/kg/h for 4-12h as
clinically necessary
Patients undergoing PCI
with CrCl 30-50 ml/min should
receive a lower infusion rate of
1.4 mg/kg/h
No change for the bolus dose
Contraindicated
if CrCl 30 ml/min
Active bleeding or increased
risk of bleeding, severe
uncontrolled hypertension,
subacute bacterial endocarditis
PCI for STEMI 0.75 mg/kg i.v. bolus followed immediatelly
by 1.75 mg/kg/h infusion which should be
continued for up to 4h after the procedure
After cessation of the 1.75 mg/kg/h infusion,
a reduced infusion dose of 0.25 mg/kg/h may
be continued for 4-12h
PCI for elective
cases
0.75 mg/kg i.v. bolus followed immediatelly
by 1.75 mg/kg/h infusion which may be
continued for up to 4h post PCI
as clinically waranted
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.131
Parenteral anticoagulants (Cont.) 9

142. Drug Indications Dose Dose adjustments Comments
Enoxaparin
NSTE-ACS 30 mg i.v. + 1 mg/kg s.c. BID If 75 years: no LD and MD
0.75 mg/Kg BID s.c.
CrCl 30 ml/min: no LD and MD
1 mg/Kg QD s.c.
If 75 years and CrCl 30 ml/min:
no LD and 0.75 mg/Kg QD s.c.
Monitoring for HIT
Anti Xa monitoring during
treatment with LMWH might
be helpful in pregnancy,
extreme body weights and renal
impairment
STE-ACS Primary PCI: 0.5 mg/Kg i.v. bolus
Fibrinolysis/No reperfusion:
a) Age 75 years: 30 mg i.v. bolus followed by
1 mg/Kg BID s.c. until hospital discharge for a
max of 8 days
The first two doses should not exceed 100 mg
b) Age 75 years: no bolus; 0.75 mg/Kg
BID s.c. - The first two doses should not
exceed 75 mg
In patients with CrCl 30 ml/min:
regardless of age, the s.c. doses
are given once daily
Treatment of DVT
and PE
1 mg/Kg s.c. BID or 1.5 mg/Kg s.c. QD CrCl 30 ml/min: 1 mg/Kg/24h
s.c.
Prevention of VTE 40 mg s.c. QD CrCl 30 ml/min: 20 mg s.c. QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.132
Parenteral anticoagulants (Cont.) 9

143. Drug Indications Dose Dose adjustments Comments
Tinzaparin
Prevention of VTE 3,500 IU s.c. QD (moderate risk)
4,500 IU s.c. QD (high risk)
-
Monitoring for HIT
Anti Xa monitoring during
treatment with LMWH might
be helpful in pregnancy,
extreme body weights and renal
impairment
Dalteparin:
In cancer patients, dose of
200 IU/kg (max: 18,000 IU)/24h
for 1 month, followed by 150 IU/
kg/24h for 5 months
After this period, vitamin K antag
or a LMWH should be continued
indefinitely or until the cancer is
considered cured
Treatment of DVT
and PE
175 IU/Kg s.c. QD
-
Dalteparin
Prevention of VTE 2,500 IU s.c. QD (moderate risk)
5,000 IU s.c. QD (high risk)
-
Treatment of DVT
and PE
200 IU/Kg QD or 100 IU/Kg BID s.c. Anti Xa monitoring
if renal impairment
Argatroban
Anticoagulant in
patients with HIT
Initial i.v. infusion dose: 2 μg/kg/min
(not to exceed 10 μg/kg/min)
Patients undergoing PCI: 350 μg/kg i.v.
followed by 25 μg/kg/min i.v.
Renal and hepatic impairment:
caution advised
Monitored using aPTT goal:
1.5 to 3.0 times the initial
baseline value
PCI: ACT goal: 300-450s
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.133
Parenteral anticoagulants (Cont.) 9

144. Drug Indications Dose
Dose
adjustments
Comments
Streptokinase
(SK)
STEMI 12 hours 1.5 million units over 30-60 min
i.v. -
Absolute contraindications to
fibrinolytics:
Previous intracranial haemorrhage or
stroke of unknown origin at any time
Ischaemic stroke in the preceding 6
months
Central nervous system damage
or neoplasms or atrioventricular
malformation
Recent major trauma/surgery/head injury
(within the preceding 3 weeks)
Gastrointestinal bleeding
within the past month
Known bleeding disorder (excluding
menses)
Aortic dissection
Non-compressible punctures in the past
24h (e.g. liver biopsy, lumbar puncture)
Treatment of PE 250,000 IU as a LD over 30min,
followed by 100,000 IU/h over
12-24h
-
Alteplase
(tPA)
STEMI 12 hours 15 mg i.v. bolus:
0.75 mg/kg over 30 min
(up to 50 mg) then
0.5 mg/kg over 60 min i.v.
(up to 35 mg)
-
Treatment of PE Total dose of 100 mg: 10 mg
i.v. bolus followed by 90 mg i.v.
for 2h
If weight 65 Kg: max
dose 1.5 mg/kg
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.134
Fibrinolytics 9

145. Drug Indications Dose
Dose
adjustments
Comments
Reteplase
(rt-PA)
STEMI 12 hours 10 units + 10 units i.v. bolus given
30 min apart
Renal and hepatic
impairment:
caution advised
Absolute contraindications to
fibrinolytics:
Previous intracranial haemorrhage or
stroke of unknown origin at any time
Ischaemic stroke in the preceding 6
months
Central nervous system damage
or neoplasms or atrioventricular
malformation
Recent major trauma/surgery/head injury
(within the preceding 3 weeks)
Gastrointestinal bleeding
within the past month
Known bleeding disorder (excluding
menses)
Aortic dissection
Non-compressible punctures in the past
24h (e.g. liver biopsy, lumbar puncture)
Tenecteplase
(TNK-tPA)
STEMI 12 hours Single i.v. bolus over 10 seconds:
30 mg if 60kg
35 mg if 60 to 70kg
40 mg if 70 to 80kg
45 mg if 80 to 90kg
50 mg if ≥90kg -
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.135
Fibrinolytics (Cont.) 9

146. Drug Indications Dose Dose adjustments Comments
Beta-blockers: Preferred over calcium channel blockers - Contraindicated if coronary spasm, severe bradycardia, AV block, severe bronchospasm
Atenolol
NSTE-ACS LD: 25-100 mg oral
MD: 25-100 mg QD
Elderly: start at
a lower dose
CrCl 15-35 ml/min:
max dose 50 mg/day;
CrCl 15 ml/min:
max dose 25 mg/day
Only if normal LVEF
STEMI 25-100 mg QD,
titrate as tolerated up to 100 mg QD
only if no LVSD or CHF
Carvedilol
NSTE-ACS LD: 3.125-25 mg oral
MD: 3.125-25 mg BID
Caution in elderly and hepatic
impairment
Preferred if LVSD/HF
STEMI 3.125-6.25 mg BID,
titrated as tolerated up to 50 mg BID
Bisoprolol
NSTE-ACS LD: 1.25-10 mg oral
MD: 1.25-10 mg QD
Caution in renal or hepatic impairment Preferred if LVSD/HF
STEMI 1.25-5 mg QD,
titrate as tolerated up to 10 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.136
Antiischemic drugs 9

147. Drug Indications Dose Dose adjustments Comments
Beta-blockers:Preferredovercalciumchannelblockers-Contraindicatedifcoronaryspasm,severebradycardia,AVblock,severebronchospasm
Metoprolol
NSTE-ACS LD: 25-100 mg oral
MD: 25-100 mg BID
Caution in hepatic impairment Preferred if LVSD/HF
STEMI 5-25 mg BID,
titrate as tolerated up to 200 mg QD
Calcium antagonists: Consider if beta-blockers are contraindicated. First option in vasospastic angina
Verapamil
ACS LD: 80-120 mg oral
MD: 80-240 mg TID-QD
Caution in elderly, renal
or hepatic impairment
Contraindicated if
bradycardia,
HF, LVSD
Diltiazem
ACS LD: 60-120 mg oral
MD: 60-300 mg TID-QD
Caution in elderly and hepatic
impairment
Contraindicated if
bradycardia,
HF, LVSD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.137
Antiischemic drugs (Cont.) 9

148. Drug Indications Dose Dose adjustments Comments
Calcium antagonists: Consider if beta-blockers are contraindicated. First option in vasospastic angina
Amlodipine
ACS LD: 5-10 mg oral, MD: 5-10 mg QD Caution in hepatic impairment Contraindicated
if hypotension
Nitrates
Nitroglycerin
i.v.
ACS If intolerant or unresponsive to
nitroglycerin s.l. 5 μg/min - Increase by
5 mcg/min q 3-5 min up to 20 μg/min
If 20 mcg/min is inadequate, increase by
10 to 20 μg/min every 3 to 5 min
Max dose: 400 μg/min
-
Contraindicated
if severe
hypotension and co-
administration with
phosphodiesterase
inhibitors
The most common
adverse effects
are headache and
dizziness
i.v. nitroglycerin
requires NON-PVC
containers
spray
Angina 1-2 puff s.l. every 5 min as needed,
up to 3 puffs in 15 min -
sublingual
tablet
Angina 0.3 to 0.6 mg s.l. or in the buccal pouch
every 5 min as needed, up to 3 doses
in 15 min -
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.138
Antiischemic drugs (Cont.) 9

149. Drug Indications Dose Dose adjustments Comments
Isosorbide
mononitrate
Angina 5-10 mg BID with the two doses given
7h apart (8am and 3pm) to decrease
tolerance development - then titrate to
10 mg BID in first 2-3 days
Extended release tablet: Initial: 30-
60 mg given in the morning as a single
dose
Titrate upward as needed, giving at least
3 days between increases
Max daily single dose: 240 mg
-
Contraindicated
if severe
hypotension and co-
administration with
phosphodiesterase
inhibitors
The most common
adverse effects
are headache and
dizziness
Isosorbide
dinitrate
Angina Initial dose: 5 to 20 mg orally 2 or
3 times/day
MD: 10 to 40 mg orally 2 or 3 times a day
Extended release: 40 to 160 mg/day
orally
-
Nitroglycerin
transdermal
patch
Angina 0.2 to 0.4 mg/h patch applied topically
once a day for 12 to 14h per day;
titrate as needed and tolerated up
to 0.8 mg/h -
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.139
Antiischemic drugs (Cont.) 9

150. Drug Indications Dose Dose adjustments Comments
Other antiishemic drugs
Ivabradine
Stable angina 5-7.5 mg oral BID Caution in elderly and CrCl 15 ml/min Contraindicated
if severe hepatic
impairment
Ranolazine
Stable angina Initial dose: 375 mg oral BID
After 2-4 weeks, the dose should be
titrated to 500 mg BID and, according to
the patient’s response, further titrated to
a recommended max dose of 750 mg BID
Use with caution in renal and hepatic
impairment, CHF, elderly, low weight
Contraindicated
if CrCl 30 ml/
min, concomitant
administration of
potent CYP3A4
inhibitors, moderate
or severe hepatic
impairment
Trimetazidine
Stable angina Modified-release: 35 mg oral BID Caution in elderly
and 30 CrCl 60 ml/min
Contraindicated in
parkinson disease,
parkinsonian
symptoms, tremors,
restlessleg syndrome,
movement disorders,
severe renal
impairment
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.140
Antiischemic drugs (Cont.) 9

151. Drug Indications Dose Dose adjustments Comments
Statins: Primary or secondary prevention of cardiovascular disease
For secondary prevention, start with high doses initiated early after admission and downtitrate if side effects.
Target LDL-C levels 70 mg/dl
Atorvastatin
LDL-C reduction
30% 30-40% 40-50% 50%
Simva
10 mg
Simva
20-40 mg
Simva/ezet
20/10 mg
Simva/ezet
40/10 mg
Lova
20 mg
Ator
10 mg
Ator
20-40 mg
Ator
40-80 mg
Prava
10-40 mg
Rosu 5 mg Rosu 10 mg
Rosu
20-40 mg
Pita 1 mg Pita 2 mg Pita 4 mg
Fluva
20-40 mg
Fluva 80 mg
-
Contraindicated
in patients with
active liver disease
or with unexplained
elevation of liver
function enzyme
levels
Rosuvastatin
CrCl 30 ml/min: start 5 mg QD,
max: 10 mg QD
Pitavastatin
CrCl 30-59 ml/min: start 1 mg
QD, max 2 mg/day;
CrCl 10-29 ml/min: not defined
Simvastatin
Severe renal impairment:
start 5 mg QPM
Fluvastatin
Caution in severe renal
impairment
Pravastatin
Significant renal impairment:
start 10 mg QD
Lovastatin
CrCl 30 ml/min:
caution if dose 20 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.141
Lipid lowering drugs 9

152. Drug Indications Dose Dose adjustments Comments
Others
Ezetimibe
Hypercholesterolaemia 10 mg oral QD Avoid use if moderate-severe
hepatic impairment
-
Fenofibrate
Hyperlipidemia 48-160 mg oral QD
May adjust dose
q 4-8 weeks
CrCl 50-90 ml/min:
start 48-54 mg QD
Contraindicated
if CrCl 50 ml/min
or hepatic impairment
Gemfibrozil
Hyperlipidemia 900-1,200 mg/day oral
-
Contraindicated
if severe renal
impairment or hepatic
dysfunction
Statins may increase
muscle toxicity: avoid
concomitant use
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.142
Lipid lowering drugs (Cont.) 9

153. Drug Indications Dose Dose adjustments Comments
PCSK9 Inhibitors
Evolocumab
Hypercholesterolaemia
and mixed dyslipidaemia
Homozygous familial
hypercholesterolaemia
140 mg s.c.
every 2 weeks
or 420 mg every month
Homozygous familial
hypercholesterolaemia:
420 mg s.c every month
Up-titrate to 420 mg
every 2 weeks if a
response is not achieved
-
Most common side
effects:
Nasopharingitis, upper
respiratory tract
infection, headache and
back pain
Alirocumab
Hypercholesterolaemia
and mixed dyslipidaemia
Start dose:
75 mg s.c. every 2 weeks
If a larger LDL-C reduction (60%)
is required, the start dose could
be 150 mg every 2 weeks, or
300 mg every 4 weeks
The dose can be individualised
based on LDL-C level, goal of
therapy, and response. Max dose:
150 mg once every 2 weeks
Most common side
effects:
Upper respiratory tract
signs and symptoms,
pruritus and injection site
reactions
P.143
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Lipid lowering drugs (Cont.) 9

154. Drug Indications Dose Dose adjustments Comments
ACEI
Captopril
HF Start: 6.25 mg oral TID
Target dose: 50 mg TID
CrCl 50 ml/min: 75-100%
of the normal dose
CrCl 10-50 ml/min: 25-50%
CrCl 10 ml/min: 12.5%
Check renal function,
electrolytes,
drug interactions
Major contraindications:
History of angioedema,
known bilateral renal artery
stenosis, pregnancy (risk)
HTN Start: 12.5 mg oral BID
Target dose: 25-50 mg TID
Max 450 mg/day
Enalapril
HF, HTN Start: 2.5 mg oral BID
Target dose: 10-20 mg BID
CrCl 30-80 ml/min: start 5 mg/day
CrCl 10-30 ml/min: start 2.5 mg/day
Lisinopril
HF Start: 2.5-5.0 mg oral QD
Target dose: 20-35 mg QD
CrCl 31-80 ml/min: start 5-10 mg/day
CrCl 10-30 ml/min: start 2.5-5 mg/day
CrCl 10 ml/min: start 2.5 mg/day
HTN 10-20 mg oral QD
Max: 80 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.144
Heart failure hypertension 9

155. Drug Indications Dose Dose adjustments Comments
Perindopril
HF Start: 2 mg oral QD
Target dose: 8 mg QD
CrCl 60 ml/min: start 4 mg/day
CrCl 31-60 ml/min: start 2 mg/day
CrCl 15-30 ml/min:
start 2 mg every other day
CrCl 15ml/min:
2 mg on the day of dialysis
Check renal function,
electrolytes,
drug interactions
Major contraindications:
History of angioedema,
known bilateral renal artery
stenosis, pregnancy (risk)
HTN Start: 4 mg QD
Max dose: 8 mg QD
Ramipril
HF, HTN Start: 2.5 mg oral QD
Target dose: 5 mg BID
CrCl 40 ml/min: start 1.25 mg QD,
max 5 mg/day
Caution in elderly and hepatic impairment
Trandolapril
HF Start: 0.5 mg oral QD
Target dose: 4 mg QD
CrCl 30 ml/min or severe hepatic
impairment: start 0.5 mg
HTN 2-4 mg oral QD CrCl 30 ml/min or severe hepatic
impairment: start 0.5 mg
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.145
Heart failure hypertension (Cont.) 9

156. Drug Indications Dose Dose adjustments Comments
ARB
Candesartan
HF, HTN Start: 4-8 mg oral QD
Target dose: 32 mg QD
If renal or hepatic impairment:
start 4 mg/day
If ACEI is not tolerated
Check renal function,
electrolytes, drug
interactions
Major contraindications:
History of angioedema,
known bilateral renal artery
stenosis, pregnancy (risk)
Losartan
HF Start: 50 mg oral QD
Target dose: 150 mg QD
CrCl 20 ml/min: 25 mg QD
Caution if hepatic impairment
HTN 50-100 mg oral QD CrCl 20 ml/min: 25 mg QD
Caution if hepatic impairment
Valsartan
HF Start: 40 mg oral BID
Target dose: 160 mg BID
If mild-moderate hepatic impairment:
max dose 80 mg/day
HTN 80-160 mg QD If mild-moderate hepatic impairment:
max dose 80 mg/day
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.146
Heart failure hypertension (Cont.) 9

157. Drug Indications Dose Dose adjustments Comments
Neprilysin inhibitor/ARB
Sacubitril/Valsartan
Symptomatic
chronic HF
with reduced
ejection
fraction
Start: 49 mg/51 mg
oral BID
Target dose:
97 mg/103 mg BID
Do not initiate if K 5.4 mmol/l
or SBP 100 mmHg
Start dose of 24 mg/26 mg BID
if SBP 100-110 mmHg
or CrCl 30-60 ml/min
Do not co-administer with an ACEI or ARB. It must not
be started for at least 36 hours after discontinuing
an ACEI
Contraindicated if history of angioedema related
to ACEI or ARB
Hereditary or idiopathic angioedema
Concomitant use with aliskiren if diabetes mellitus
or renal impairment
Severe hepatic impairment, biliary cirrhosis and
cholestasis
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.147
Heart failure hypertension (Cont.) 9

158. Drug Indications Dose Dose adjustments Comments
Beta-blockers: Check 12 - lead ECG
Cardioselective
(1)
Atenolol
HTN Start: 25 mg oral QD
Usual dose: 50-100 mg QD
CrCl 10-50 ml/min:
decrease dose 50%
CrCl 10 ml/min:
decrease dose 75%
Major contraindications:
asthma, 2nd
or 3rd
degree
AV block
Bisoprolol
HF Start: 1.25 mg oral QD
Target dose: 10 mg QD
CrCl 20 ml/min:
max dose 10 mg QD
Hepatic impairment: avoid use
HTN Start: 2.5-5 mg oral QD
Usual dose: 5-10 mg QD
Max dose: 20 mg QD
Metoprolol
HF Start: 12.5-25 mg oral QD
Target dose: 200 mg QD
Hepatic impairment: start with low
doses and titrate gradually
HTN 100-400 mg QD
Max dose: 400 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.148
Heart failure hypertension (Cont.) 9

159. Drug Indications Dose Dose adjustments Comments
Beta-blockers: Check 12- lead ECG
Cardioselective
(2)
Nebivolol
HF Start: 1.25 mg oral QD
Target dose: 10 mg QD
Renal impairment or elderly: start
dose 2.5 mg QD, titrate to 5 mg QD
Hepatic impairment: contraindicated
Major contraindications:
asthma, 2nd
or 3rd
degree
AV block
HTN Start: 2.5 mg oral QD
Usual dose: 5 mg QD
Non-cardioselective
Carvedilol
HF Start: 3.125 mg oral BID
Target dose: 25-50 mg BID
Caution in elderly
Contraindicated if hepatic
impairment
HTN Start: 12.5 mg oral QD
Usual dose: 25 mg QD
and max dose: 25 mg BID
or 50 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.149
Heart failure hypertension (Cont.) 9

160. Drug Indications Dose Dose adjustments Comments
Other vasodilators
Amlodipine
HTN Start: 5 mg oral QD,
increase after 1-2 weeks
Max: 10 mg/day
Elderly or secondary agent:
start 2.5 mg QD
Hepatic impairment:
start 2.5 mg QD
Contraindicated if
cardiogenic shock, 2nd
or 3rd
degree AV block,
severe hypotension
Nifedipine
HTN Extended-release form:
Start 20 mg oral BID or TID
Max: 60 mg BID
Renal and hepatic impairment:
caution advised
Verapamil
HTN Immediate-release form:
Dose: 80-120 mg oral TID;
Start: 80 mg TID;
Max: 480 mg/day
Start 40 mg oral TID in elderly
or small stature patients
Contraindicated if
bradycardia, HF, LVSD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.150
Heart failure hypertension (Cont.) 9

161. Drug Indications Dose Dose adjustments Comments
Loop diuretics
Furosemide
HF 20-40 mg i.v. bolus, continuous
100 mg/6h (adjust based on kidney
function and clinical findings;
monitor creatinine)
Anuria: contraindicated
Cirrhosis/ascites: caution advised
-
HTN 10-40 mg oral BID
Torsemide
HF 10-20 mg oral or i.v. QD Hepatic impairment: initial dose
should be reduced by 50% and
dosage adjustments made cautiously -
HTN 5 mg oral or i.v. QD
Max 10 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.151
Heart failure hypertension (Cont.) 9

162. Drug Indications Dose Dose adjustments Comments
Thiazides
Chlorthalidone
HF 50-100 mg oral QD
MD: 25-50 mg QD
Elderly: max dose 25 mg/day
CrCl 25 ml/min: avoid use -
HTN Start 12.5-25 mg oral QD;
Max: 50 mg/day
Elderly: max dose 25 mg/day
CrCl 25 ml/min: avoid use
-
Hydrochlorothiazide
HF 25-200 mg oral/day CrCl 25 ml/min: avoid use
Hepatic impairment: caution advised -
HTN Start 12.5-25 mg oral QD
MD: may increase to 50 mg oral
as a single or 2 divided doses
CrCl 25 ml/min: avoid use
Hepatic impairment: caution advised
-
Indapamide
HTN Start 1.25 mg PO QAM x4weeks,
then increase dose if no response
Max: 5 mg/day
CrCl 25 ml/min: avoid use
Hepatic impairment: caution advised
-
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.152
Heart failure hypertension (Cont.) 9

163. Drug Indications Dose Dose adjustments Comments
Aldosterone-antagonists
Spironolactone
HF Start 25 mg oral QD
Target dose: 25-50 mg QD
CrCl 10 ml/min, anuria or acute
renal impairment: contraindicated
Severe hepatic impairment
and elderly: caution advised
Check renal function,
electrolytes, drug
interactions
Produces gynecomastia
HTN 50-100 mg/day oral
Eplerenone
HF Start 25 mg oral QD
Target dose: 50 mg QD
Elderly: caution advised
CrCl 50 ml/min: contraindicated
Check renal function,
electrolytes, drug
interactions
Major contraindications:
strong CYP3A4 inhibitors
HTN 50 mg oral QD-BID
Max: 100 mg/day
Others
Ivabradine
HF 5-7.5 mg oral BID Caution in elderly
and CrCl 15ml/min
Contraindicated if severe
hepatic impairment
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.153
Heart failure hypertension (Cont.) 9

164. Drug Indications Dose Dose adjustments Comments
Levosimendan
HF/cardiogenic
shock
LD: 6 to 12 μg/kg i.v.
over 10 min (given only
if immediate effect is
needed) followed by
0.05 to 0.2 μg/kg/min
as a continuous infusion
for 24h
Avoid use if CrCl 30 ml/min or
severe hepatic impairment
Calcium sensitizer and ATP-dependent
potassium channel opener
Milrinone
HF/cardiogenic
shock
50 μg/kg i.v. in 10-20 min,
continuous 0.375-
0.75 μg/kg/min
Renal: Same bolus. Adjust infusion:
CrCl 50 ml/min: start 0.43 μg/kg/min
CrCl 40 ml/min: start 0.38 μg/kg/min
CrCl 30 ml/min: start 0.33 μg/kg/min
CrCl 20 ml/min: start 0.28 μg/kg/min
CrCl 10 ml/min: start 0.23 μg/kg/min
CrCl 5 ml/min: start 0.20 μg/kg/min
Phosphodiesterase inhibitor
Caution if atrial flutter
Hypotensive drug
Isoprenaline/
Isoproterenol
Cardiogenic
shock
0.5-5 μg/min (0.25-2.5ml
of a 1:250,000 dilution)
i.v. infusion
-
ß1, ß2 agonist
Contraindicated in patients with
tachyarrhythmia, tachycardia or heart
block caused by digitalis intoxication,
ventricular arrhythmias which require
inotropic therapy, angina pectoris, recent
ACS, hyperthyroidism
Bradyarrhythmias Bolus: 20-40 μg i.v.
Infusion: 0.5 μg/min of
2 mg/100 ml normal saline
ß
effect
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.154
Inotropics vasopressors 9

165. Drug Indications Dose Dose adjustments Comments
Dobutamine
Cardiogenic
shock
2-20 μg/kg/min i.v.
-
ß1, a1/ß2 agonist
Increases contractility with little effect
on heart rate and blood pressure.
Reduces pulmonary and systemic VR,
PCP
Dopamine
Cardiogenic
shock
Dopaminergic effect:
2-5 μg/Kg/min i.v.
ß effect : 5-15 μg/Kg/min i.v.
a effect : 15-40 μg/Kg/min i.v.
-
ß, a, dopaminergic agonist
Increases BP, PAP, heart rate, cardiac
output and pulmonary and systemic VR
More arrhythmogenic than dobutamine
and noradrenaline
Noradrenaline
Cardiogenic
shock
0.05-0.2 μg/kg/min i.v.
titrate to effect
-
a 1, ß1 agonist
Increases BP and PAP
Little arrhythmogenic
a
effect
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.155
Inotropics vasopressors (Cont.) 9

166. Drug Indications Dose Dose adjustments Comments
Group I
Procainamide
i.v.
AF
(termination);
stable VT
(with a pulse)
15-18 mg/kg i.v. over 60min, followed by
infusion of 1-4 mg/min
Reduce LD to 12 mg/kg in severe renal
impairment
Reduce MD by one-third in moderate
renal impairment and by two-thirds in
severe renal impairment
Caution in elderly and asthma
Hypotension
(negative inotropic agent)
Lupus-like syndrome
Contraindicated if myasthenia
gravis, AV block, severe renal
impairment
Lidocaine
i.v.
Pulseless
VT/VF
1-1.5 mg/kg i.v./i.o. bolus (can give
additional 0.5-0.75 mg/kg i.v./i.o. push
every 5-10 min if persistent VT/VF, max
cumulative dose = 3 mg/kg), followed
by infusion of 1-4 mg/min
1-2 mg/min infusion if liver disease
or HF
Contraindicated if advanced
AV block, bradycardia,
hypersensitivity to local
anesthetics
Caution in HF, renal
impairment and elderly
May cause seizures, psychosis
Stop if QRS widens 50%
Stable VT
(with a pulse)
1-1.5 mg/kg i.v. bolus (can give additional
0.5-0.75 mg/kg i.v. push every 5-10 min
if persistent VT, max cumulative dose
= 3 mg/kg), followed by infusion
of 1-4 mg/min
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.156
Antiarrhythmics 9

167. Drug Indications Dose Dose adjustments Comments
Group I
Flecainide
i.v.
SVT,
ventricular
arrhythmias
2 mg/kg (max 150 mg) i.v. over 30 min
This may be followed by an infusion at
a rate of 1.5 mg/kg/h for 1 h, reduced to
0.1-0.25 mg/kg/h for up to 24h,
max cumulative dose = 600 mg
Severe renal impairment: caution
advised
Contraindicated if cardiogenic
shock, recent MI, 2nd
or 3rd
degree AV block
Propafenone
i.v.
PSVT,
ventricular
arrhythmias
LD: 0.5-2 mg/kg i.v. direct over
aminimum of 3-5min
MD: 0.5-2.5 mg/kg i.v. direct q8h
(max 560 mg/day)
or continuous infusion up to 23 mg/h
May need to reduce dose in renal
or hepatic failure
Contraindicated if unstable
HF, cardiogenic shock,
AV block, bradycardia,
myasthenia gravis
severe hypotension,
bronchospastic disorders,
Brugada syndrome
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.157
Antiarrhythmics (Cont.) 9

168. Drug Indications Dose
Dose
adjustments
Comments
Group II
Atenolol
i.v.
Arrhythmias 2.5 mg i.v. over 2.5 min every 5 min
(max 10 mg)
Caution in
elderly and/or
severe renal
impairment
Contraindicated if cardiogenic shock, bradycardia
and greater than first-degree block, unstable HF
Metoprolol
i.v.
Arrhythmias 2.5-5 mg i.v. over 5min,
may repeat every 5 min
(max 15 mg)
Caution if
severe hepatic
impairment
Contraindicated if cardiogenic shock, bradycardia
and greater than first-degree block, unstable HF
Propranolol
i.v.
Arrhythmias Initially given as slow i.v. boluses of
1 mg, repeated at 2 min intervals
(max: 10 mg in conscious patients
and 5 mg if under anesthesia)
-
Contraindicated if cardiogenic shock, bradycardia
and greater than first-degree block, asthma,
unstable HF
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.158
Antiarrhythmics (Cont.) 9

169. Drug Indications Dose
Dose
adjustments
Comments
Group III
Amiodarone
i.v.
AF (termination) 5 mg/Kg i.v. over 30min, followed
by infusion of 1 mg/min for 6h,
then 0.5 mg/min
-
Reduce infusion rate if bradycardia, AV block,
hypotension
Bolus should be avoided if hypotension or severe
LV dysfunction
Highly vesicant agent
Stable VT
(with a pulse)
150 mg i.v. over 10 min followed by
infusion of 1 mg/min for 6h, then
0.5 mg/min
-
Pulseless VT/VF 300 mg bolus i.v. (can give additional
150 mg i.v. bolus if VF/VT persists)
followed by infusion of 900 mg
over 24h
-
Dronedarone
Paroxysmal
or persistent AF
prevention
400 mg oral BID
-
Contraindicated if severe renal or liver
dysfunction, LVSD, symptomatic HF, permanent AF,
bradycardia… (multiple contraindications)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.159
Antiarrhythmics (Cont.) 9

170. Drug Indications Dose
Dose
adjustments
Comments
Group IV
Diltiazem
i.v.
PSVT; AF (rate control) 0.25 mg/kg i.v. over 2 min
(may repeat with 0.35 mg/kg i.v.
over 2 min), followed by infusion of
5-15 mg/h
Hepatic
impairment:
caution advised -
Verapamil
i.v.
PSVT; AF (rate control) 2.5-5 mg i.v. over 2 min
(may repeat up to max cumulative
dose of 20 mg); can follow with
infusion of 2.5-10 mg/h -
Contraindicated if AF+WPW, tachycardias QRS
(except RVOT-VT), fascicular VT, bronchospasm,
age 70 years
Antidote:
- LVD: Calcium gluconate, dobutamine
- Bradycardia/AV block: Atropine, Isoproterenol
Adenosine
i.v.
Rapid conversion to a
normal sinus rhythm
of PSVT including
those associated
with accessory by-
pass tracts
(WPW syndrome)
Rapid i.v. boluses separated by
2 min: 6 mg → 6 mg → 12 mg
-
Contraindicated if sick sinus syndrome, second or
third degree Atrio-Ventricular (AV) block (except in
patients with a functioning artificial pacemaker),
chronic obstructive lung disease with evidence of
bronchospasm (e.g. asthma bronchiale), long QT
syndrome, severe hypotension; decompensated
states of heart failure - Adenosine can cause AF
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.160
Antiarrhythmics (Cont.) 9

171. Drug Indications Dose
Dose
adjustments
Comments
Others
Magnesium
sulfate
VT-Torsades
de Pointes
Bolus: 1-2g i.v./i.o. over 5 min
Perfusion: 5-20 mg/min i.v.
Caution if
severe renal
failure
Contraindicated if myasthenia gravis
Vernakalant
Conversion
of recent onset AF
3 mg/kg i.v. over 10 min
If AF persists, a second 10min-
infusion of 2 mg/kg, 15 min later
may be administered
-
Contraindicated if ACS within the last 30 days,
severe aortic stenosis, SBP 100 mmHg,
HF class NYHA III/IV, severe bradycardia, sinus
node dysfunction or 2nd
or 3rd
degree heart
block, prolonged QT at baseline, use of i.v.
antiarrhythmics (class I and class III) within 4h
prior to, as well as in the first 4h after, vernakalant
administration
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.161
Antiarrhythmics (Cont.) 9

172. Drug Indications Dose Dose adjustments Comments
Benzodiazepines: Use of benzodiazepines may lead to the development of physical and psychic dependence
upon these products. The risk of dependence increases with dose and duration of treatment. Benzodiazepines
may induce anterograde amnesia. Discontinuation: dosage should be reduced slowly
Short-acting benzodiazepines
Alprazolam
Moderate or
severe anxiety
or anxiety
associated with
depression
250-500mcg oral TID as short as
possible, increasing if required to a
total of 3 mg daily
Elderly or debilitating
disease: 250mcg BID or TID
and gradually increased
if needed and tolerated
Renal impairment
or mild-moderate hepatic
impairment: caution
Contraindicated if myasthenia gravis,
severe respiratory insufficiency, sleep
apnoea syndrome, severe hepatic
insufficiency
Loprazolam
Insomnia 1 mg oral at bedtime. This may
be increased to 1.5 mg or 2 mg if
necessary
Frail, debilitated or elderly:
start with half a tablet. Max
dose: 1 mg
Chronic pulmonary,
insufficiency, cerebrovascular
disease and chronic renal or
hepatic impairment: caution
Contraindicated if acute pulmonary
insufficiency, severe respiratory
insufficiency, myasthenia gravis, phobic
or obsessional states and sleep apnoea
syndrome, monotherapy in depression
or anxiety associated with depression
and chronic psychosis and alcohol
intake
P.162
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs 9

173. Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Lorazepam
oral
Severe anxiety
Premedication
before surgery
Anxiety: 1-4 mg oral in divided doses
Insomnia: 1-2 mg oral before retiring
Premedication before surgery: 2-3 mg
oral the night before operation 2-4 mg
oral 1-2h before the procedure
Elderly: may respond
to lower doses
Renal or hepatic
impairment: lower doses
may be sufficient
Contraindicated if acute pulmonary
insufficiency, respiratory depression,
sleep apnoea, obsessional states,
severe hepatic insufficiency,
myasthenia gravis
Lorazepam
injection
Pre-operative
medication, acute
anxiety states,
acute excitement
or acute
mania, status
epilepticus
Premedication: 0.05 mg/Kg
By the i.v. route the injection should
be given 30-45 min before surgery
By the i.m. route the injection should
be given 1-1.5h before surgery
Acute anxiety: 0.025-0.03 mg/kg
i.v./i.m. Repeat 6 hourly
Status epilepticus: 4 mg i.v.
P.163
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs 9

174. Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Lormetazepam
oral
Short-term
treatment of
insomnia
0.5-1.5 mg oral before retiring. The
initial dosage may be increased to
2 mg in individual cases if this proves
necessary
Elderly: may respond to
lower doses
Chronic respiratory
insufficiency: a lower dose
is recommended
Severe renal impairment:
caution
Contraindicated if myasthenia gravis,
severe respiratory insufficiency, sleep
apnoea syndrome, acute intoxication
with alcohol, hypnotics, analgesics
or psychotropic drugs, severe liver
insufficiency
Midazolam
oral
Insomnia DOSE / DOSE ADJUSTMENTS: 7.5-15 mg oral at bedtime
COMMENTS: Caution in adults 60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
P.164
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

175. Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Midazolam
injection
(1)
Short-acting
sleep-inducing
drug
DOSE / DOSE ADJUSTMENTS:
Indications Adults 60 y Adults ≥60 y/debilitated or chronically ill
Conscious sedation i.v.
Initial dose: 2-2.5 mg
Titration doses: 1 mg
Total dose: 3.5-7.5 mg
i.v
Initial dose: 0.5-1 mg
Titration doses: 0.5-1 mg
Total dose: 3.5 mg
Anaesthesia
premedication
i.v.
1-2 mg repeated
i.m. 0.07-0.1 mg/kg
i.v.
Initial dose: 0.5 mg
Slow uptitration as needed
i.m. 0.025-0.05 mg/kg
COMMENTS: Caution in adults 60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
P.165
Sedatives and neuropsychiatric drugs (Cont.) 9

176. Drug Indications Dose Dose adjustments Comments
Midazolam
injection
(2)
Short-acting
sleep-inducing
drug
DOSE / DOSE ADJUSTMENTS:
Indications Adults 60 y Adults ≥60 y/debilitated or chronically ill
Anaesthesia induction i.v. 0.15-0.2 mg/kg
(0.3-0.35 without premedication)
i.v. 0.05-0.15 mg/kg
(0.15-0.3 without premedication)
Sedative component in
combined anaesthesia
i.v.
Intermittent doses of 0.03-0.1 mg/kg
or continuous infusion of
0.03-0.1 mg/kg/h
i.v.
Lower doses than recommended
for adults 60 years
Sedation in ICU i.v.
LD: 0.03-0.3 mg/kg in increments of 1-2.5 mg
MD: 0.03-0.2 mg/kg/h
COMMENTS: Caution in adults 60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
P.166
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

177. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Bromazepam
Insomnia,
short-term
treatment
of anxiety or
panic attacks
1.5-3 mg oral up to TID
If a severe condition: 6-12 mg oral BID or TID
Elderly or hepatic
impairment:
lower doses are
recommended
Contraindicated if myasthenia gravis,
severe hepatic impairment, severe
respiratory insufficiency, sleep apnoea
syndrome
Clobazam
Anxiety,
adjunctive
therapy in
epilepsy
Anxiety: 20-30 mg oral daily in divided doses
or as a single dose given at night. Doses up to
60 mg daily have been used in severe anxiety
Epilepsy: starting dose of 20-30 mg oral per
day, increasing up to a max of 60 mg daily
Elderly: lower doses
may be used
Chronic or acute
severe respiratory
insufficiency,
renal or hepatic
impairment:
lower doses are
recommended
Contraindicated if history of drug or
alcohol dependence, myasthenia gravis,
severe respiratory insufficiency, sleep
apnoea syndrome, severe hepatic
impairment
P.167
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

178. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Clonazepam
Epileptic
disease and
seizures
Oral: Initial dose not to exceed 1 mg/day; MD:
4-8 mg
i.v.: 1 mg by slow injection or slow infusion.
Repeat dose if needed (1-4 mg are usually
sufficient)
Elderly: initial dose
should not exceed
0.5 mg/day
Chronic pulmonary
insufficiency, renal
or mild-moderate
hepatic impairment:
may require lower
doses
Contraindicated if acute pulmonary
insufficiency, severe respiratory
insufficiency, sleep apnoea syndrome,
myasthenia gravis, severe hepatic
insufficiency, coma or in patients known
to be abusing pharmaceuticals, drugs or
alcohol
Clorazepate
oral
Anxiety,
insomnia
5-30 mg oral at bedtime
or in divided doses
Elderly, renal and
hepatic impairment:
lower doses may be
required
Contraindicated if myasthenia gravis,
severe decompensated respiratory
insufficiency, sleep apnoea syndrome,
severe hepatic impairment
Caution if alcohol deprivation, give
thiamine before administering glucose
containing i.v. fluids
P.168
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

179. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Clorazepate
injection
Agitation,
confusion,
aggressiveness,
premedication,
tetanus,
alcoholism
Agitation, confusion, aggressiveness:
20-200 mg/day, i.m./i.v. followed by oral therapy
Premedication: 20-50 mg/day i.m./i.v.
Alcoholism: 50-100 mg every 3-4h
Benign tetanus (without tracheostomy)
120-500 mg/day i.v.
Malignant tetanus (with tracheostomy and
assisted ventilation): 500-2,000 mg/day i.v.
Elderly, renal and
hepatic impairment:
lower doses may be
required
Contraindicated if myasthenia gravis,
severe decompensated respiratory
insufficiency, sleep apnoea syndrome,
severe hepatic impairment
Caution if alcohol deprivation, give
thiamine before administering glucose
containing i.v. fluids
Chlordiazepoxide
Anxiety,
muscle spasm,
symptomatic
relief of
acute alcohol
withdrawal
Anxiety: starting dose 5 mg/day oral: usual
dose up to 30 mg in divided doses increasing
to a max of 100 mg/day, in divided doses,
adjusted on an individual basis
Insomnia associated with anxiety: 10-30 mg
oral at bedtime
Muscle spasm: 10-30 mg/day oral in divided doses
Alcohol withdrawal: 25-100 mg, repeated
if necessary, in 2-4h
Elderly and/or
debilitated patients,
renal or hepatic
impairment: dosage
should not exceed
half the adult dose
Contraindicated if acute pulmonary
insufficiency, sleep apnoea, respiratory
depression, phobic and obsessional
states, chronic psychosis, severe hepatic
impairment, myasthenia gravis
P.169
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

180. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Diazepam
(1)
Anxiety 5-30 mg oral daily in divided doses
or
10 mg i.v. or i.m. and repeated after an interval
of not less than 4h
0.5 mg/kg rectal
Dose can be repeated every 4-12h. Max 30 mg
Elderly and
debilitated
patients: half of the
recommended dose
Hepatic impairment
and severe renal
impairment:
a lower dose is
recommended
Contraindicated if phobic or
obsessional states; chronic
psychosis, hyperkinesis, acute
pulmonary insufficiency;
respiratory depression, acute
or chronic severe respiratory
insufficiency, myasthenia gravis,
sleep apnoea, severe hepatic
impairment, acute porphyria
Insomnia associated
with anxiety
5-15 mg oral before retiring
Cerebral palsy 5-60 mg oral daily in divided doses
Upper motor neuronic
spasticity
5-60 mg oral daily in divided doses
P.170
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

181. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Diazepam
(2)
Muscle spasm 5-15 mg oral daily in divided doses or
10 mg i.v. or i.m. and repeated after after an
interval of not less than 4h
0.5 mg/Kg rectal. Dose can be repeated every
4-12h. Max 30 mg
Elderly and
debilitated
patients: half of the
recommended dose
Hepatic impairment
and severe renal
impairment:
a lower dose is
recommended
Contraindicated if phobic or
obsessional states; chronic
psychosis, hyperkinesis, acute
pulmonary insufficiency;
respiratory depression, acute
or chronic severe respiratory
insufficiency, myasthenia gravis,
sleep apnoea, severe hepatic
impairment, acute porphyria
Tetanus 0.1-0.3 mg/Kg i.v. and repeated every 1-4h;
alternatively, a continuous infusion of 3-10 mg/
kg/24h may be used.
0.5 mg/kg rectal. Dose can be repeated every
4-12h. Max 30 mg
P.171
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
9
Sedatives and neuropsychiatric drugs (Cont.)

182. Drug Indications Dose
Dose
adjustments
Comments
Long-acting benzodiazepines
Diazepam
(3)
Epilepsy 2-60 mg oral daily in divided doses
or
10-20 mg i.v.or i.m. The dose can be repeated if
necessary after 30-60min. If indicated, this may
be followed by slow i.v. infusion (max total dose
3 mg/kg over 24h)
or
0.5 mg/kg rectal
Dose can be repeated every 4-12h. Max 30 mg
Elderly and
debilitated
patients: half of the
recommended dose
Hepatic impairment
and severe renal
impairment:
a lower dose is
recommended
Contraindicated if phobic or
obsessional states; chronic
psychosis, hyperkinesis, acute
pulmonary insufficiency;
respiratory depression, acute
or chronic severe respiratory
insufficiency, myasthenia gravis,
sleep apnoea, severe hepatic
impairment, acute porphyria
Alcohol withdrawal 5-20 mg oral, repeated if necessary in 2-4h
0.5 mg/kg rectal
Dose can be repeated every 4-12h. Max 30 mg
Delirium tremens: 10-20 mg i.v. or i.m.
Premedication
before surgery
5-20 mg oral
P.172
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

183. Drug Indications Dose Dose adjustments Comments
Long-acting benzodiazepines
Flurazepam
Insomnia 15 mg oral at bedtime.
If severe insomnia: 30 mg oral but
residual effects on awakening are more
frequent at this dose
Elderly, chronic pulmonary
insufficiency, renal or hepatic
impairment: lower dose is
recommended
Contraindicated if myasthenia
gravis, severe pulmonary
insufficiency, respiratory
depression, phobic or obsessional
states, chronic psychosis,
sleep apnoea, severe hepatic
insufficiency
Other sedatives
Clomethiazole
(1)
Management of
restlessness and
agitation in the
elderly
192 mg (1 capsule) oral TID Elderly, renal impairment, gross
liver damage, decreased liver
function, sleep apnoea and
chronic pulmonary insufficiency:
caution
Contraindicated if acute
pulmonary insufficiency
Alcohol combined with
clomethiazole particularly
in alcoholics with cirrhosis
can lead to fatal respiratory
depression even with short
term use
Severe insomnia in
the elderly
192-384 mg oral (1-2 capsules)
at bedtime
P.173
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

184. Drug Indications Dose Dose adjustments Comments
Other sedatives
Clomethiazole
(2)
INDICATIONS: Alcohol withdrawal
INITIALDOSE :2-4capsulesoral,ifnecessaryrepeatedaftersomehours
Day 1: first 24h: 9-12 capsules,
divided into 3 or 4 doses
Day 2: 6-8 capsules,
divided into 3 or 4 doses
Day 3: 4-6 capsules,
divided into 3 or 4 doses
Days 4-6: A gradual
reduction in dosage until the
final dose
Administration for more than
9 days is not recommended
Elderly, renal impairment, gross
liver damage, decreased liver
function, sleep apnoea and
chronic pulmonary insufficiency:
caution
Contraindicated if acute
pulmonary insufficiency
Alcohol combined with
clomethiazole particularly
in alcoholics with cirrhosis
can lead to fatal respiratory
depression even with short
term use
Dexmedetomidine
Sedation of adult ICU
patients
Switch to dexmedetomidine: initial i.v.
infusion rate of 0.7 mcg/kg/h
Titrate upwards to achieve desired
level of sedation,
range 0.2-1.4 mcg/kg/h
Max dose: 1.4 mcg/kg/h
Max duration: 14 days
Caution if hepatic impairment,
impaired peripheral autonomic
activity, pre-existing
bradycardia
Frail patients: a lower starting
infusion rate should be
considered
The drug provides analgesia
and does not cause respiratory
depression. Associated with a
lower prevalence of ICU delirium
compared to benzodiazepines.
Primary adverse effects are
dose-related bradycardia and
hypotension.
Dexmedetomidine should not
be administered by loading
or bolus dose
P.174
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

185. Drug Indications Dose Dose adjustments Comments
Other sedatives
Doxylamine
Insomnia 12.5-25 mg oral at bedtime
Max duration: 7 days
Renal and hepatic impairment:
caution
Contraindicated if hypersensitive
to other antihistamines
Caution if: asthma, narrow angle
glaucoma, prostatic hypertrophy,
stenosing peptic ulcer, pyloric/
duodenal obstruction, bladder
neck obstruction, concurrent use
with MAOIs
Melatonin
Insomnia in patients
≥55 years
2 mg oral at bedtime
Max duration: 13 weeks
Renal impairment: caution
Hepatic impairment:
not recommended
Do not use in patients
with autoimmune diseases
Do not crush or chew tablets
Propofol
Sedation during
intensive care
Initiate at 5 mcg/Kg/min i.v.
(0.3 mcg/Kg/h) and titrate to achieve
sedation goals by 5 mcg/Kg/min
every 5 min
Maintenace rates of 5-50 mcg/Kg/
min may be required
Avoid prolonged infusions
50 mcg/Kg/min
Elderly: rate of infusion should
be reduced. Rapid bolus
administration is not indicated
in this group of patients
Rapid onset (1-2 min) and short
duration (3-5 min or longer if
prolonged infusion)
Avoid loading doses because of
the risk of hypotension
Monitor blood lipid levels, blood
pressure
Propofol has no analgesic
properties
P.175
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

186. Drug Indications Dose Dose adjustments Comments
Other sedatives
Zolpidem
Insomnia 10 mg oral at bedtime
Max duration: 4 weeks
Elderly, debilitated patients,
hepatic impairment: initial dose
5 mg
Contraindicated if obstructive
sleep apnoea, myasthenia
gravis, severe hepatic
insufficiency, acute and/or
severe respiratory depression
Zopiclone
Insomnia 7.5 mg oral at bedtime
Max duration: 4 weeks
Elderly, hepatic or renal
impairment: initial dose 3.75 mg
Contraindicated if myasthenia
gravis, severe sleep apnoea
syndrome, severe respiratory
or severe hepatic insufficiency
P.176
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

187. Drug Indications Dose
Dose
adjustments
Comments
Neuroleptics: Extrapyramidal symptoms and neuroleptic malignant syndrome may occur with all neuroleptics.
Elderly people with dementia who are treated with antipsychotics are at a small increased risk of death
compared with those who are not treated
Typical neuroleptics
Chlorpromazine
Schizophrenia and
other psychoses
Oral: Initially 25 mg TID or 75 mg at
bedtime increasing by daily amounts of
25 mg to an effective MD (75-300 mg
daily, some patients may require up to 1g)
I.M.: 25-50 mg every 6-8h
Elderly
(schizophrenia,
nausea and
vomiting): start
with ⅓ - ½ usual
adult dose
Contraindicated if liver or renal dysfunction,
epilepsy, Parkinson, hypothyroidism, cardiac
failure, phaeochromocytoma, agranulocytosis
myasthenia gravis, prostate hypertrophy,
history of narrow angle glaucoma
Caution in patients with risk factor for stroke,
seizures, cardiovascular disease or a family
history of QT prolongation
Intractable hiccup Oral: 25-50 mg TID or QD
I.M.: 25-50 mg and if this fails 25-50 mg
by slow i.v. infusion
Nausea and
vomiting in terminal
illness
Oral: 10-25 mg every 4-6h
I.M.: 25 mg initially then 25-50 mg every
3-4h until vomiting stops, then change
to orally
P.177
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

188. Drug Indications Dose
Dose
adjustments
Comments
Typical neuroleptics
Fluphenazine
Schizophrenia and
other psychoses
Patients without previous exposure of
fluphenazine: start 12.5 mg i.m
Next dose depends on patient’s response
(12.5-100 mg)
When administered as maintenance
therapy, a single injection may be
effective for up to 4weeks or longer
Elderly
(over 60):
a lower dose is
recommended
Liver and renal
disease: caution
Contraindicated if comatose states, marked
cerebral atherosclerosis, liver failure, renal
failure, phaeochromocytoma, severe cardiac
insufficiency, severely depressed states,
existing blood dyscrasias
Caution if arrythmias, Parkinson, narrow angle
glaucoma, thyrotoxicosis, hypothyroidism,
epilepsy, myasthenia gravis, prostatic
hypertrophy, severe respiratory disease
P.178
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

189. Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Haloperidol
oral
(1)
Schizophrenia, psychoses
and mania
Acute phase: 2-20 mg/day oral as
a single dose or in divided doses
Chronic phase: 1-3 mg oral TID,
may be increased up to 20 mg/day
in divided doses, depending on the
response
Max daily dose: 20 mg
DOSE ADJUSTMENTS:
Elderly: start with half the dosage stated for adults
and adjusted according to the results if necessary
COMMENTS: Contraindicated if comatose states,
CNS depression, Parkinson, lesions of the basal ganglia,
clinical significant cardiac disorders, QT interval prolongation,
history of ventricular arrhythmia or Torsades de pointes,
clinically significant bradycardia, 2nd
or 3rd
degree heart block,
uncorrected hypokalaemia and use of other QT prolonging drugs
Caution if renal failure, liver disease, epilepsy, hyperthyroidism,
phaeochromocytoma
Bioavailability from the oral route is about 60% of that from
the i.m. route and readjustment of dose may be required
i.v. haloperidol can be associated with QT prolongation and
torsades de pointes
Psychomotor
anti-agitation
Acute phase: Moderate
symptomatology 1.5-3.0 mg oral
BID or TID
Severe symptomatology/resistant
patients 3-5 mg oral BID or TID
Chronic phase: 0.5-1 mg oral TID,
may be increased to 2-3 mg TID,
if required, MD: gradually reduced
to the lowest effective MD
Max daily dose: 20 mg
P.179
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

190. Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Haloperidol
oral
(2)
Gilles de la Tourette
syndrome, severe tics,
intractable hiccup
Starting dose 1.5 mg oral TID
adjusted according to response
A daily MD of 10 mg may be
required in Gilles de la Tourette
syndrome
Max daily dose: 20 mg
DOSE ADJUSTMENTS:
Elderly: start with half the dosage stated for adults
and adjusted according to the results if necessary
COMMENTS: Contraindicated if comatose states,
CNS depression, Parkinson, lesions of the basal ganglia,
clinical significant cardiac disorders, QT interval prolongation,
history of ventricular arrhythmia or Torsades de pointes,
clinically significant bradycardia, 2nd
or 3rd
degree heart block,
uncorrected hypokalaemia and use of other QT prolonging drugs
Caution if renal failure, liver disease, epilepsy, hyperthyroidism,
phaeochromocytoma
Bioavailability from the oral route is about 60% of that from
the i.m. route and readjustment of dose may be required
i.v. haloperidol can be associated with QT prolongation and
torsades de pointes
Haloperidol
injection
Rapid control of the
symptoms of hostility,
aggression, hyperactivity,
disruptive and violent
behaviour, confusion,
emotional withdrawal,
hallucinations and delusions
associated with acute and
chronic schizophrenia,
mania, and hypomania, and
organic brain syndrome
Nausea and vomiting
Initial doses of 2-10 mg i.m.
Depending on the response of the
patients, subsequent doses may
be given every 4-8h up to a max of
18 mg/day
P.180
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

191. Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Levomepromazine
Management of pain,
restlessness or
distress in terminally
ill patient
12.5-25 mg i.m. or i.v. injection. In
cases of severe agitation, up to 50 mg
may be used, repeated every 6-8h
or
25-200 mg/daybycontinuoss.c.infusion
or
12.5-50 mg oral every 4-8h
Elderly: caution Caution if liver dysfunction
or cardiac disease, bradycardia
or 2nd
or 3rd
degree heart block,
risk of QT interval prolongation
Psychiatric
conditions
Bed patients: initially the total
daily dose 100-200 mg oral, usually
divided into 3 doses, gradually
increased to 1g daily if necessary
Pericyazine
Anxiety,
psichiatric conditions
Severe conditions: Initially 75 mg/
day oral in divided doses. Titrate
according to patient response at
weekly intervals; MD: max dose
300 mg/day
Mild or moderate conditions: Initially
15-30 mg/day oral divided in two
doses, with a larger dose being given
in the evening
Elderly
Severe conditions: Initially
15-30 mg/day in divided doses
Mild or moderate conditions:
start 5-10 mg/day. Half or
quarter the normal adult dose
may be sufficient as MD
Cautionifliverorrenal
dysfunction,epilepsy,Parkinson,
hypothyroidism,cardiacfailure,
phaeochromocytoma,myasthenia
gravis, prostrate hypertrophy,
history of narrow angle
glaucoma, agranulocytosis, risk
of QT interval prolongation
Discontinue if unexplained fever
P.181
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

192. Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Perphenazine
Anxiety, psichiatric
conditions, nausea and
vomiting, intractable
hiccup
DOSE: 4 mg oral TID. Titrate according to
patient response. Max daily dose: 24 mg
DOSE ADJUSTMENTS:
Elderly: one quarter or one half of the recommended adult dosage
COMMENTS: Contraindicated if leucopenia, or in association with drugs liable to cause bone marrow
depression, or to patients in comatose states - Caution if liver disease, severe respiratory disease,
renal failure, epilepsy, Parkinson, history of narrow angle glaucoma, hypothyroidism, myasthenia gravis,
phaeochromocytoma, prostatic hypertrophy, risk of QT interval prolongation
Pimozide
Schizophrenia,
other psychoses
DOSE:
Chronic schizophrenia: 2-20 mg oral
daily, with 2 mg as a starting dose
This may be increased according to
response and tolerance
Other psychoses: an initial dose
of 4 mg oral daily which may then
be gradually increased, if necessary,
according to response, max 16 mg
daily
DOSE ADJUSTMENTS:
Elderly: half the normal starting dose
Caution if hepatic, renal impairment or phaeochromocytoma
COMMENTS: Contraindicated if risk of QT interval prolongation,
known uncorrected hypokalaemia, hypomagnesaemia, clinically
significant cardiac disorders, clinically significant bradycardia,
severe central nervous system depression, depression,
Parkinson, concomitant use with CYP3A4 or CYP2D6 inhibiting
drugs, serotonin uptake inhibitors
P.182
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

193. Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Trifluoperazine
Anxiety, depressive
symptoms, agitation,
nausea and vomiting
Low dosage: 2-4 mg/day oral, given
in divided doses, according to the
severity of the patient’s condition
High dosage: 5 mg oral BID, after a
week this may be increased to 15 mg/
day. If necessary, further increases
of 5 mg may be made at three-day
intervals
DOSE ADJUSTMENTS:
Elderly: starting dose should be reduced by at least half
COMMENTS: Contraindicated if comatose patients, existing
blood dyscrasias or known liver damage, uncontrolled cardiac
decompensation
Caution if CV disease , Parkinson, risk of QT interval prolongation
Zuclopenthixol
Acute psychoses 50-150 mg i.m., repeated if necessary
after 2-3 days
Some patients may need an
additional injection between 1-2 days
after the first injection
Max accumulated dosage: 400 mg
DOSE ADJUSTMENTS:
Elderly, renal or hepatic impairment: caution, a lower dose may be
necessary
COMMENTS: Contraindicated if circulatory collapse, depressed
level of consciousness
Caution if Parkinson, epilepsy, risk of QT interval prolongation,
cardiac disease, or arrhythmias, narrow angle glaucoma,
myasthenia gravis, prostatic hypertrophy, hypothyroidism,
hyperthyroidism, phaeochromocytoma
P.183
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

194. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics: 3 differences with typical neuroleptics: the risk of extrapyramidal symptoms is lower,
tardive dyskinesia is reduced and the ability to block serotonin-2 receptors is present. Atypical neuroleptics
have been associated with new-onset diabetes and metabolic syndrome
Amisulpride
Schizophrenia For acute psychotic episodes:
400-800 mg/day oral
In individual cases, the daily dose may
be increased up to 1,200 mg/day
Doses should be adjusted individually
Administered QD at oral doses up
to 300 mg, higher doses BID
Elderly: caution
CrCl 30-60 ml/min:
reduce to a half
CrCl 10-30 ml/min:
reduce to a third
Contraindicated if concomitant
prolactin-dependent tumours,
phaeochromocytoma, combination
with levodopa
Caution if epilepsy, risk of QT
interval prolongation
Asenapine
Severe manic
episodes
associated with
bipolar type I
disorder
5 mg s.l. BID
The dose can be increased to 10 mg BID
based on individual clinical response
and tolerability
Elderly, moderate hepatic
impairment: caution
Caution if Parkinson, risk of QT interval
prolongation, seizures
Do not use in severe hepatic
impairment or CrCl 15ml/min
Do not chew or swallow tablets
P.184
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

195. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Aripiprazole
Schizophrenia,
manic episodes
in bipolar type I
disorder
Oral: 10-15 mg QD with a MD
of 10-30 mg QD
i.m.: Recommended initial dose:
9.75 mg Dose range: 5.25-15 mg
A second injection may be administered
2h after the first injection, on the basis
of individual clinical status and no more
than three injections should be given in
any 24h period
Max daily dose: 30 mg/day
Caution if elderly, severe
hepatic impairment
Orodispersible tablet should be placed
in the mouth, it will rapidly disperse
in saliva
Caution if known CV disease,
history of QT prolongation, epilepsy,
concomitant administration of potent
CYP3A4 or CYP2D6 inhibitors
Olanzapine
Psichiatric
conditions
Schizophrenia: recommended starting
dose 10 mg/day orally
Manic episode:
Starting dose 15 mg QD oral
in monotherapy or 10 mg QD
in combination therapy. Then, adjust
dose according to response:
5-20 mg/day
Elderly, renal or hepatic
impairment: consider
a lower starting dose
(5 mg/day)
Contraindicated if risk of narrow-angle
glaucoma
Caution if Parkinson, low leukocyte and/
or neutrophil counts for any reason,
risk of QT interval prolongation
Orodispersible tablet should be placed
in the mouth, it will rapidly disperse
in saliva
P.185
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

196. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Paliperidone
Schizophrenia,
schizoaffective
disorder
6 mg oral QD, administered in the
morning. Some patients may benefit
from lower or higher doses within the
recommended range of 3-12 mg QD
(6-12 mg for schizoaffective disorder)
Caution if elderly patients
with dementia with risk
factors for stroke
Mild renal impairment:
initial dose 3 mg QD
(max 6 mg)
Moderate-severe renal
impairment:
initial dose 1.5 mg QD
(max 3 mg)
CrCl 10 ml/min:
not recommended
Caution if severe hepatic impairment,
seizures, Parkinson, risk of QT interval
prolongation, low leukocyte and/
or neutrophil counts for any reason,
known CV disease, cerebrovascular
disease or conditions that predispose
the patient to hypotension
Do not chew, divide, or crush
Take it the same way with regard
to meals
P.186
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

197. Drug Indications Dose
Dose
adjustments
Comments
Atypical neuroleptics
Quetiapine
Schizophrenia IRF: Total daily dose for the first 4 days is: 50 mg (Day 1), 100 mg
(Day 2), 200 mg (Day 3) and 300 mg (Day 4), then 150-750 mg/day
Administered in 2 divided doses
PRF: Starting dose 300 mg oral on Day 1 and 600 mg on Day 2
MD: 400-800 mg/day
DOSE ADJUSTMENTS:
Elderly, hepatic impairment: caution,
a lower dose may be necessary
COMMENTS: Contraindicated if
concomitant administration of
cytochrome P450 3A4 inhibitors,
such as HIV-protease inhibitors, azole-
antifungal agents, erythromycin,
clarithromycin and nefazodone
Cautioniflowleukocyteand/orneutrophil
countsforanyreason,historyofseizures,
cerebrovascular disease, cardiovascular
disease, risk of QT interval prolongation
It could be used if Parkinson disease
PRF: tablets should not be split,
chewed or crushed
Moderate-severe
manic episodes
in bipolar
disorder
IRF: Total daily dose for the first 4 days is: 100 mg (Day 1), 200 mg
(Day 2), 300 mg (Day 3) and 400 mg (Day 4)
Further dosage adjustments up to 800 mg/day
Administered in 2 divided doses
PRF: Starting dose 300 mg oral on Day 1 and 600 mg on Day 2
MD: 400-800 mg/day
Depression
in bipolar
disorders
IRF: Total daily dose for the first 4days is: 50 mg (Day 1), 100 mg
(Day 2), 200 mg (Day 3) and 300 mg (Day 4)
The recommended daily dose is 300 mg
Administered at bedtime
PRF: Total daily dose for the first 4 days is: 50 mg oral (Day 1),
100 mg (Day 2), 200 mg (Day 3) and 300 mg (Day 4)
Recommended daily dose: 300 mg
Major depressive
episodes
PRF: 50 mg on Day 1 and 2, and 150 mg on Day 3 and 4 at bedtime
Max dose 300 mg/day
P.187
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

198. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Risperidone
(1)
Schizophrenia Start 2 mg/day oral (QD or in 2 divided doses)
The dosage may be increased on the 2nd
day to 4 mg
MD: 4-6 mg
Elderly: 0.5 mg BID
Caution if renal or
hepatic impairment
Caution if known
cardiovascular disease,
low leukocyte and/or
neutrophil counts for any
reason, Parkinson, risk of
QT interval prolongation
Orodispersable tablet:
place the tablet on the
tongue
Manic episodes
in bipolar disorder
Start with 2 mg oral QD
Dosage adjustments, if needed, should occur
at intervals of not less than 24h and in dosage
increments of 1 mg/day. Max daily dose 6 mg
Elderly: start with
0.5 mg BID
This dosage can be
individually adjusted
with 0.5 mg BID
increments to
1-2 mg BID
Caution if renal
or hepatic impairment
Persistent aggression in
patients with moderate
to severe Alzheimer’s
dementia
Start with 0.25 mg oral BID
This dosage can be individually adjusted by
increments of 0.25 mg BID, not more frequently
than every other day, if needed. Optimum dose is
0.5 mg BID for most patients
Caution if renal
or hepatic impairment
P.188
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

199. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Risperidone
(2)
Conduct disorder ≥50kg: starting dose 0.5 mg oral QD
This dosage can be individually adjusted by
increments of 0.5 mg QD not more frequently
than every other day, if needed. Optimum dose is
1 mg QD for most patients
50kg: starting dose 0.25 mg oral QD
This dosage can be individually adjusted by
increments of 0.25 mg QD not more frequently
than every other day, if needed. Optimum dose
is 0.5 mg QD
Caution if renal or
hepatic impairment
Caution if known
cardiovascular disease,
low leukocyte and/or
neutrophil counts for any
reason, Parkinson, risk of
QT interval prolongation
Orodispersable tablet:
place the tablet on the
tongue
Sulpiride
Acute and chronic
schizophrenia
Starting dose: 400-800 mg oral daily, given as
one or two tablets twice daily (morning and early
evening)
Predominantly positive symptons: starting
dose of at least 400 mg oral BID, increasing
if necessary up to a max of 1,200 mg BID
Predominantly negative symptoms respond to
doses below 800 mg oral daily, a starting dose
of 400 mg BID is recommended
Patients with mixed positive and negative
symptoms: 400-600 mg oral BID
Renal impairment:
caution
Contraindicated if
phaeochromocytoma
and acute porphyria,
concomitant prolactin-
dependent tumours,
association with levodopa
or antiparkinsonian drugs
Caution if Parkinson,
epilepsy, low leukocyte
and/or neutrophil counts
for any reason, risk of QT
interval prolongation
P.189
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

200. Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Tiapride
Behavioral disorders
in dementia patients
Starting dose 50 mg oral/i.m./i.v.
BID, increasing if necessary
to 100 mg TID
Max dose 400 mg/day
Elderly: caution
CrCl 30-60 ml/min:
75% of the normal dose
CrCl 10-30 ml/min:
50% of the normal dose
CrCl 10 ml/min:
25% of the normal dose
Contraindicated if phaeochromocytoma,
concomitant prolactin-dependent
tumours, association with levodopa
or antiparkinsonian drugs
Caution if epilepsy, Parkinson, low
leukocyte and/or neutrophil counts
for any reason, risk of QT interval
prolongation
Huntington’s disease 1,200 mg/day oral/i.m./i.v. divided
in 3 doses
Progressive reduction to a MD
Ziprasidone
Schizophrenia
Bipolar type I disorder
Initial dose 40 mg oral BID
with food
Then, dose may be increased
to 60-80 mg BID
Max dose 80 mg BID
Elderly, renal or hepatic
impairment: caution, a lower
dose may be necessary
Contraindicated if known history of
QT prolongation, decompensated
heart failure, recent MI
It could the parenteral drug of choice
for patients with Parkinson disease
Acute treatment
of agitation in
schizophrenia
10-20 mg i.m. administered as
required up to a max dose of
40 mg/day
Doses of 10 mg may be
administered every 2h
P.190
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9

201. APTT = Activated partial thromboplastin time
AB = Airway and breathing
ABG = Arterial blood gas
AADs = Antiarrhythmic drugs
AAS = Acute aortic syndrome
ACEI = Angiotensin converting enzyme inhibitor
ACLS = Advanced cardiovascular life support
ACS = Acute coronary syndrome
ACT = Activated clotting time
AD = Aortic Dissection
AED = Automated external defibrillator
AF = Atrial fibrillation
Ao = Aortic
aPTT = Activated partial thromboplastin time
ARB = Angiotensin receptor blockers
AS = Aortic stenosis
AV = Atrioventricular
AVN = Atrioventricular node
AVNRT =
Atrioventricular nodal re-entrant
tachycardia
AVNT = Atrioventricular nodal tachycardia
BID = Twice a day
BBB = Bundle branch block
BLS = Basic life support
BNP = Brain natriuretic peptide
BP = Blood pressure
CABG = Coronary artery bypass grafting
CAD = Coronary artery disease
Cath Lab = Catheterisation laboratory
CCB = Calcium channel blockers
CCU = Coronary care unit
CHF = Congestive heart failure
CMR = Cardiovascular magnetic resonance
COPD = Chronic obstructive pulmonary disease
CPAP = Continuous positive airway pressure
CPR = Cardiopulmonary resuscitation
Cr = Creatinine blood level (mg/dL)
CrCl = Creatinine clearance
CS = Cardiogenic shock
CSM = Carotid sinus massage
CSNRT = Corrected sinus node recovery time
CSS = Carotid sinus syndrome
CT = Computed tomography
CT-angio = Computed tomography angiography
cTn = Cardiac troponin
CUS = Compression venous ultrasound
P.191
Abbreviations

202. CV = Cardiovascular
CVA = Cerebrovascular accident
CXR = Chest X-ray
DAPT = Dual antiplatelet therapy
DD = Dyastolic dysfunction
DM = Diabetes mellitus
dTT = Diluted thrombin time
DVT = Deep vein thrombosis
ECG = Electrocardiogram
ECT = Ecarin clotting time
ED = Emergency department
EG = Electrograms
eGFR =
Estimated glomerular filtration rate
(ml/min/1.73 m2
)
EMB = Endomyocardial biopsy
EMS = Emergency medical services
EPS = Electrophysiological study
ERC = European Resuscitation Council
ESR = Erythrocyte sedimentation rate
ETT = Exercice treadmill testing
FFP = Fresh frozen plasma
FMC = First medical contact
GER = Gastroesophageal reflux
GFR = Glomerular flow rate
GI = Gastrointestinal
GP = Glycoprotein
Hb = haemoglobin
HF = Heart failure
HIT = Heparin-induced thrombocytopenia
HOCM = Hypertrophic obstructive cardiomyopathy
HTN = Hypertension
HR = Heart rate
hsTn = High-sensitive troponin
IABP = Intra-aortic balloon pump
ICC = Intensive cardiac care
ICCU = Intensive cardiac care unit
ICD = Implantable cardioverter defibrillator
IHD = Ischemic heart disease
IMH = Intramural hematoma
IRF = Immediate-release formulation
ISFC =
International Society and Federation
of Cardiology
i.o. = Intraosseous
IV = Invasive ventilation
P.192
Abbreviations (Cont.)

203. i.v. = Intravenous
KD = Kidney disease
LBBB = Left bundle branch block
LD = Loading dose
LGE = Late gadolinium enhancement
LMWH = Low-molecular weight heparin
LOC = Loss of consciousness
LV = Left ventricular
LVD = Left ventricular dysfunction
LVEF = Left ventricular ejection fraction
LVH = Left ventricular hypertrophy
LVSD = Left ventricular systolic dysfunction
MCS = Mechanical circulatory support
MD = Maintenance dose
MDCT = Computed tomography with 4 elements
MI = Myocardial infarction
MRA = Mineralocorticoid receptor antagonist
MRI = Magnetic resonance imaging
Mvo = Microvascular obstruction
NIV = Non-invasive ventilation
NOAC = New oral anticoagulants
NSAID =
Non-steroidal anti-inflammatory drugs
NSTE-ACS =
Non ST-segment elevation
acute coronary syndrome
NSTEMI=
NonST-segmentelevationmyocardialinfarction
NTG = Nitroglycerin
NT-proBNP =
N-terminal pro brain natriuretic
peptide
NVAF = Non-valvular atrial fibrillation
NYHA = New York Heart Association
OH = Orthostatic hypotension
PAP = Pulmonary arterial pressure
PAU = Penetrating aortic ulcer
PCI = Percutaneous coronary intervention
PCM = Physical counter-measures
PCP = Pulmonary capillary pressure
PE = Pulmonary embolism
PEA = Pulmonary endarterectomy
PEEP = Positive end expiratory pressure
PPC = Prothrombin complex concentrate
PR = Pulmonary regurgitation
PRECISE-DAPT =
PREdicting bleeding Complications
In patients undergoing Stent
implantation and subsEquent Dual
Anti Platelet Therapy
P.193
Abbreviations (Cont.)

204. PRF = Prolonged-release formulation
ProCT = Procalcitonin
PRN = Pro re nata
PS-PEEP =
Pressure support-positive end-
expiratory pressure
PSVT = Paroxysmal supraventricular tachycardia
QD = Once a day
QPM = Every evening
rFVIIa = Recombinant factor VIIa
rtPA = Recombinant tissue plasminogen activator
RV = Right ventricular
RVOT-VT =
Right ventricular outflow tract
ventricular tachycardia
SBP = Systemic blood pressure
s.c = Subcutaneous
SIRS = systemic inflammatory response syndrome
SLE = Systemic lupus erythematosus
SMU = Syncope management units
STE-ACS =
ST-segment elevation acute
coronary syndrome
STEMI =
ST-segment elevation myocardial
infarction
SVT = Supraventricular tachycardia
Spo2 = Oxygen saturation
TEE = Transesophageal echocardiography
TEVAR =
Thoracic endovascular aortic repair
TIA = Transient ischemic attack
TID = Three times a day
TLOC = Transient loss of consciousness
TOE = Transoesopageal echocardiography
TSH = Thyroid-stimulating hormone
TTE = Transthoracic echocardiography
UA = Unstable angina
UFH = Unfractionated heparin
ULN = Upper limit of normal
VF = Ventricular fibrillation
VR = Vascular resistance
VT = Ventricular tachycardia
VTE = Venous thromboembolism
VVS = Vasovagal syncope
WBC = white blood cell count
WHO = World Health Organization
WPW = Wolff-Parkinson-White
P.194
Abbreviations (Cont.)

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P.195
Notes

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P.196
Notes

207. •
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208. Reproduced With permission of Oxford University Press (UK) © European Society of Cardiology
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Roffi M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients
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210. M Valgimigli et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease
developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery
disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic
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References and copyright acknowledgments (Cont.)

211. This is a publication of the Acute Cardiovascular Care Association (ACCA), a branch of the
European Society of Cardiology. Its content reflects the opinion of the authors based on the
evidence available at the time it was written and does not necessarily imply an endorsement
by ACCA or the ESC.
The guidance suggested in the Clinical Decision Making Toolkit does not override the
individual responsibility of the healthcare professional to make appropriate decisions
according to each patient’s circumstances and profile, as well as local regulations
and licenses.
Some content, illustrations/tables/figures were inspired and/or adapted from ESC Guidelines
and other existing sources, with permission granted by the original publishers.
Acknowledgements
We are indebted to all the authors for their commitment and for the strong effort to
synthesise their wide scientific knowledge and clinical experience into simple algorithms
and schemes using the aim to help clinicians in everyday clinical practice in the easiest
possible manner as the main driver of their work.
The support of this initiative by the ACCA board members was essential to launch this
initiative as was the hard work of the ESC staff to make this project move forward.
January 2018
Disclaimer and Copyrights

212. www.escardio.org/ACCA
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Tel: +33 (0)4 92 94 76 00 - Fax: +33 (0)4 92 94 86 46
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2018 edition