SlideShare a Scribd company logo
1 of 70
Download to read offline
Nicolas PESCHANSKI
MD, PhD – CHI Eure-Seine Evreux
SCA non-ST+
Personne Âgée
@DocNikko
Sanofi©
Lilly©
Daiichi-Sankyo©
AstraZeneca©
Roche Diagnostics©
ThermoFisher©
Verathon© Heartscape™
Nihon-Koden©
Zoll©
Thygesen K. Eur Heart J 2007;28:2525-2538
Reichlin et al./ Keller et al. NEJM 2009
SCA ST+
10% SCA Non
ST+
10%
Angor
Instable
14%
Autres/non-
IDM
66%
Douleur Thoracique
Rapport de la DRESS 2003, 215:1-12
O. Lacroix. Thèse de Médecine, Strasbourg 2008DRESS 2003, 215:1-12
O. Lacroix. Thèse de Médecine, Strasbourg 2008
>70 ans = 12-21% passages
>75 ans = 65% hospitalisation
>80 ans = 38% recours/an
Population à risque !!!
Mêmes pathologies graves
Diminution réserves organiques
Comorbidités importantes
Urgences = Fragilité
Mattu A. Univ of Maryland School of Medicine, 2009
Epidémio(bobo)logie
SCA
Prévalence ⇗⇗
France -> 120000 IDM/an
N-STEMI > STEMI
Mortalité hospitalière = (3 vs 3%)
Mortalité 6 mois ≈ (5,3 vs 6,8%)
Mortalité long terme > N-STEMI
Puymirat E, et al. Circulation 2017
1ère cause mortalité CV
85% décès IDM >65 ans
SCA
Gopta R. Emerg Med Clin N Am 2016;34:523-42
>75 ans + SCA omis
= 50% décès < 72 h
DRESS 2003, 215:1-12
Body R, et al. Resuscitation 2010
Anamnèse
Douleur identique LR+ 0,7
Douleur > 1h LR+ 1,4
Irradiation MSD LR+ 2,3
Sueurs LR+ 6,3
Douleur punctiforme LR- 1,0
Douleur thoracique
Cannon C, et al. Circulation. 2007;115:2549-69
Fanaroff AC, et al. JAMA 2015;314(18):1955-65
Kelly BS. Clin Geriatr Med 2007;23:327-49
Douleur
Absente/Atypique
Imprécise
≠ Irradiations
2nd plan
3ème interrogatoire
= sémiologie sup. 20-75%
Kelly BS. Clin Geriatr Med 2007;23:327-49
65% = DT<7j
IDM « indolore » = 33% DT
Swap CJ. JAMA 2005;294:2623-9
DT+1 1+DT
Rich MW. Am J Geriatr Cardiol 2006;15:7–11
Smith SC. J Am Coll Cardiol. 1990;16:784-92Grave !!!
Kelly BS. Clin Geriatr Med, 2007;23:327-49
Swap CJ. JAMA. 2005;294:2623-9
Définition
Nouveau sous-décalage du segment ST horizontal ou
descendant au niveau du point J dans au moins deux
dérivations contiguës ou adjacentes et ≥ 0,5 mm
Thygesen K, et al. Circula4on 2012
Définition
Onde T inversée ≥ 1 mm dans au moins deux
dérivations contiguës où l’onde R est
proéminente ou R/S > 1
Thygesen K, et al. Circulation 2012
Autres définitions
Sus-décalage de ST non persistant (transitoire), peu ample (< 1 mm)
ou dans une seule dérivation
Pseudo-normalisation sus-décalage de ST ou onde T inversée
Apparition progressive d’une onde Q de nécrose
Wang T, et al. Am Heart J 2009;157:716-23
Kosowsky. Emerg Med Clin N Am 2011;29:721-27
Normal
LR- 0,8
ST- LR+ 3,6
BBG LR+ 1,4
Modif. LR+ 3,4
Diagnostic ECG
Kelly BS. Clin Geriatr Med 2007;23:327-49
Personne Âgée
ECG≠∆ic
Kelly BS. Clin Geriatr Med 2007;23:327-49
Personne Âgée
Personne Âgée
Personne Âgée
Modifications ECG
Cinétique ECG
>>>
Cinétique Troponine
Eskola. J Electrocardiology 2011;44:e1–e64
Biomarqueurs
Troponine HS/US
Troponine 4ème g.
Brush JE, et al. JACC 2016
Algorithme décisionnel
Roffi M, et al. Eur Heart J 2016
Recommandations ESC
Hamm CW, et al. Eur Heart J 2012
Limites détection TnHS/US
NICE Guidelines. 2014
Limites détection TnHS/US
Hammarsten O, et al. Clin Chem 2012
Effets de l’âge
Amélioration ∆ique
Giannitis E, et al. Clin Chem 2010
ROCHE DIAGNOSTICS - 10 000 BIO N°81 - NOVEMBRE 2009
MÉDICALISATION
ous mettre en conformité
ommandations internatio-
éconisent une imprécision
rable de 10% à la valeur du
e d’une population de réfé-
oponine conventionnelle ne
e remplir ces exigences.
e-t-il pour
a troponine THs
’hui?
beaux:De multiples publi-
mmunications orales nous
p appris ces derniers mois,
mes techniquement prêts.
reste à explorer certains
plication cliniques et biolo-
mieux interpréter les résul-
en mesure d’informer nos
de façon exhaustive.
Meune:L a troponine THs
p tôt serait utilisée par les
mme une troponine conven-
nc de manière réductrice.
qu’elle est plus sensible
nostic de l’infarctus et de
ble et qu’un seul dosage
suffit(2)
. Mais nous avons
vail pour parvenir à un algo-
prétation clair et approfon-
stic de l’angor instable, qui
et de notre étude.
mode de prise en charge des patients:
nombre de dosages, interprétation, délai
dans lequel les patients seront mis sous
traitement ou renvoyés chez eux, etc.
Nous attendons des biologistes beaucoup
d’informations: qu’est-ce qui différencie
ce paramètre des autres troponines? L e
dosage est-il robuste en toutes circons-
tances? L e prélèvement est-il simple à réa-
liser et à acheminer? L a qualité du rendu
de résultats est-elle inchangée?, etc.
sation de ce nouveau paramètre: cela fait
partie de mon rôle de conseil.
(1) L aboratoire de biochimie interhospitalier
Cochin-Hôtel-Dieu, service du P r L . Cynober.
(2) Ce point a fait l’objet d’une publication
dans le New England Journal of Medicine.
Contact Roche Diagnostics:
nicolas.zeitoun@roche.com
Retard diagnostique
Seuil de détec=on TnT
RULE-IN
!
Evidence scientifique
10mg/mL (0,01g/mL)
Troponin T
HS-troponin T
35ng/L14ng/L
Sandoval Y, et al. Clin Chem 2017
Twerenbold R, et al. Eur Heart J 2012
Perte de spécificité
Valeur absolue TnTHS
Twerenbold R, et al. Eur Heart J 2012
Evidence clinique
Body R, et al. JACC 2011
Des patients suspects de douleur
thoracique d’origine coronarienne
Et
Qui ont une TnTHS > 0,14 ng/L
Ont un SCA
Mettre les patients dehors
!
RULE-OUT !
Algorithme décisionnel
Roffi M, et al. Eur Heart J 2016
Algorithme décisionnel
Roffi M, et al. Eur Heart J 2016
Cinétique TnTHS/
IUS
Evaluation dynamique
-> Plus de Rule-In
-> Plus de Rule-Out
SCORES
Score GRACEScore TIMI
Backus B, et al. Curr Cardiol Rev 2011;7(1):2-8
GRACE
Chez
le patient
âgé
Granger. Arch Intern Med 2003;163:2345-53
KO !
TIMI N-STEMI
Protocole de diagnostic accéléré
TIMI = 0
ASPECT (2011) = 9,8%
ADAPT (2012) = 20%
New Improved ADP (2012) = 12,3%
TIMI KO
Chez le patient
à bas risque
TIMI et GRACE
n’ont pas leur
place aux
urgences
Than. Emerg Med Australas 2014;26:34-44
HEART
Score
HEART Score
Six. Neth Heart J 2008;16:191-6
Score 2-3
≈20%
HEART Score 0-3
13 études > 17000 pts
Pts ≈40% à bas risque
1,6% ECV à 30–45 j
HEART
atherosclerotic disease:
uspicious 2
ely suspicious 1
uspicious 0
nt ST-deviation 2
cific repolarisation
nce / LBTB / PM
0
rs 2
< 65 years 1
rs 0
actors or history of
lerotic disease*
2
k factors 1
actors known 0
mal limit 2
< 3x normal limit 1
mal limit 0
Total
for chest pain patients
1
mia Cigarette smoking
Positive family history Fanaroff. JAMA. 2015;314(18):1955-65
HEART Taux ECV
Paper Pts HEART
Score ≤3
MACE in
HEART ≤3 (n)
MACE in
HEART ≤3 (%)
Six 2008 120 39 1 2.6%
Backus 2010 880 303 3 0.9%
Mahler 2011 1070 904 5 0.6%
Backus 2013 2388 870 15 1.7%
Mahler 2013 991 200 2 1%
Melki 2013 410 247 1 0.4%
Six 2013 2906 820 14 1.7%
Visser 2014 255 85 5 5.9%
Leite 2015 174 98 2 2%
Mahler 2015 141 66 0 0%
Sun 2016 8255 4039 72 1.8%
TOTAL 17,590 7,671 120 1.6%
Total Mahler 1132 266 2 0.8%
Troponine THS
H0-H3
2 études >1000 pts
≈25% pts à bas risque
0,8% ECV à J30
Comment s’en sortir
HEART
Score
TnTHS/IUS H0-H3
Hess. Circulation Cardiovasc Qual Outcom 2012;5:251-9
Mahler S, et al. Circ Cardiovasc Qual Outcomes. 2015;8:195-203
HEART Pathway
Recommandations ESC
erate increase could not be excluded. Extended DAPT, compared
with 12-month treatment, yielded a significant reduction in MI
[OR 0.53 (95% CI 0.42, 0.66), P , 0.001] and stent thrombosis
[OR 0.33 (95% CI 0.21, 0.51), P , 0.001] while more major bleeds
occurred [OR 1.62 (95% CI 1.26, 2.09), P , 0.001]. In addition, all-
cause death was significantly increased in the extended DAPT group
[OR 1.30 (95% CI 1.02, 1.66), P ¼ 0.03] while CV death did not dif-
fer among the groups.185
The Prevention of Cardiovascular Events in Patients with Prior
Heart Attack Using Ticagrelor Compared to Placebo on a Back-
ground of Aspirin-Thrombolysis in Myocardial Infarction 54
(PEGASUS-TIMI 54) trial randomized 21 162 patients who had had
an MI 1–3 years earlier to ticagrelor at a dose of 90 mg twice daily,
ticagrelor at a dose of 60 mg twice daily or placebo.186
At a median
follow-up of 33 months, the study demonstrated a reduced rate of
CV death, MI or stroke with ticagrelor [HR 0.85 (95% CI 0.75,
0.96), P ¼ 0.008 and HR 0.84 (95% CI 0.74, 0.95), P ¼ 0.004 for
90 mg and 60 mg of ticagrelor vs. placebo, respectively) and increased
rates of major bleeding events (2.60% with 90 mg, 2.30% with 60 mg
and 1.06% with placebo, P , 0.001).186
All-cause mortality did not
differ between the groups. Of importance, most patients began treat-
ment with ticagrelor after an interruption in DAPT and all had prior
MI (context of secondary prevention in high-risk patients), while
patients with a history of ischaemic stroke were excluded. In conclu-
sion, while a 1-year duration of DAPT in NSTE-ACS patients is re-
commended, based on individual patient ischaemic and bleeding
risk profiles, DAPT duration may be shortened (i.e. 3–6 months)
or extended (i.e. up to 30 months) in selected patients if required.
5.2.7 Glycoprotein IIb/IIIa inhibitors
Intravenous GPIIb/IIIa inhibitors block platelet aggregation by
inhibiting fibrinogen binding to a conformationally activated
form of the GPIIb/IIIa receptor on two adjacent platelets.128
A
meta-analysis of six RCTs involving 29 570 NSTE-ACS patients,
mainly medically managed, showed a 9% RRR in death or non-fatal
MI with GPIIb/IIIa inhibitors (10.7% vs. 11.5%, P ¼ 0.02) when
added to heparin.196
The greatest benefit was observed in patients
undergoing PCI while on these agents [10.5% vs. 13.6%; OR 0.74
(95% CI 0.57, 0.96), P ¼ 0.02]. The use of GPIIb/IIIa inhibitors
was associated with an increase in major bleeding complications
without a significant increase in intracranial haemorrhage. Many
of these trials predated the routine use of P2Y12 inhibitors. While
the relative efficacy of prasugrel and ticagrelor in the trials
5.2.9 Recommendations for platelet inhibition in
non-ST-elevation acute coronary syndromes
Recommendations for platelet inhibition in non-ST-
elevation acute coronary syndromes
Recommendations Classa
Levelb
Ref.c
Oral antiplatelet therapy
Aspirin is recommended for all
patients without contraindications at
an initial oral loading dosed
of 150–
300 mg (in aspirin-naive patients) and
a maintenance dose of 75–100 mg/
day long-term regardless of treatment
strategy.
I A
129–
132
A P2Y12 inhibitor is recommended, in
addition to aspirin, for 12 months
unless there are contraindications such
as excessive risk of bleeds.
I A
137,
148,
153
† Ticagrelor (180 mg loading dose,
90 mg twice daily) is recommended,
in the absence of contraindications,e
for all patients at moderate-to-high
risk of ischaemic events (e.g. elevated
cardiac troponins), regardless of
initial treatment strategy and
including those pretreated with
clopidogrel (which should be
discontinued when ticagrelor is
started).
I B 153
† Prasugrel (60 mg loading dose,
10 mg daily dose) is recommended
in patients who are proceeding to
PCI if no contraindication.e
I B
148,
164
† Clopidogrel (300–600 mg loading
dose, 75 mg daily dose) is
recommended for patients who
cannot receive ticagrelor or
prasugrel or who require oral
anticoagulation.
I B 137
P2Y12 inhibitor administration for a
shorter duration of 3–6 months after
DES implantation may be considered in
patients deemed at high bleeding risk.
IIb A
187–
189,
192
Roffi M, et al. Eur Heart J 2016
ticagrelor 180 mg loading dose followed by 90 mg twice a day.153
Patients undergoing PCI were allowed to receive an additional
blinded 300 mg loading dose of clopidogrel (total loading dose
600 mg) or its placebo. Treatment was continued for up to 12
months, with a median duration of drug exposure of 9 months.153
In the NSTE-ACS subgroup (n ¼ 11 080), the primary composite ef-
ficacy endpoint (death from CV causes, MI or stroke) was signifi-
cantly reduced with ticagrelor compared with clopidogrel [10.0%
5.2.2.4 Cangrelor
Cangrelor is an i.v. adenosine triphosphate (ATP) analogue that binds
reversibly and with high affinity to the platelet P2Y12 receptor and has
a short plasma half-life (,10 min) (Table 8). It produces a highly ef-
fective inhibition of ADP-induced platelet aggregation immediately
after i.v. bolus administration and allows for restoration of platelet
function within 1–2 h of infusion discontinuation in NSTE-ACS pa-
tients.157
Cangrelor (30 mg/kg bolus and 4 mg/kg/min infusion) in-
Table 8 P2Y12 inhibitors
Clopidogrel
Chemical class Thienopyridine
Administration Oral
Dose
300–600mg orally
then 75 mg a day
Dosing in CKD
• Stage 3
(eGFR 30–59 mL/min/1.73m2
)
No dose adjustment
• Stage 4
(eGFR 15–29 mL/min/1.73m2
)
No dose adjustment
• Stage 5
(eGFR <15 mL/min/1.73m2
)
Use only for selected indications
(e.g.stent thrombosis prevention)
Binding reversibility Irreversible
Activation
Prodrug,with variable
liver metabolism
Onset of loading dose effecta
2–6 hoursb
Duration of effect 3–10 days
Withdrawal before surgery 5 daysc
Plasma half-life of active P2Y12 inhibitord
30–60 min
Inhibition of adenosine reuptake No
Prasugrel Ticagrelor Cangrelor
Thienopyridine Cyclopentyl-triazolopyrimidine StabilizedATP analogue
Oral Oral Intravenous
60 mg orally then
10 mg a day
180 mg orally then
90 mg twice a day
30 µg/kg bolus and
4 µg/kg/min infusion
No dose adjustment No dose adjustment No dose adjustment
No dose adjustment No dose adjustment No dose adjustment
Not recommended Not recommended No dose adjustment
Irreversible Reversible Reversible
Prodrug,with predictable
liver metabolism
Active drug,with additional
active metabolite
Active drug
30 minb
30 minb
2 min
7–10 days 3–5 days 1–2 hours
7 daysc
5 daysc
1 hour
30–60 mine
6–12 hours 5–10 min
No Yes Yes (‘inactive’ metabolite only)
ADP ¼ adenosine diphosphate; ATP ¼ adenosine triphosphate; CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate.
a
50% inhibition of ADP-induced platelet aggregation.
b
Onset of effect may be delayed if intestinal absorption is delayed (e.g. by opiate).
c
Shortening may be considered if indicated by platelet function tests and low bleeding risk.
d
Affecting the response to platelet transfusion.
e
The distribution phase half-life is reported since it most likely reflects duration of clinically-relevant plasma levels, while the corresponding elimination phase half-life is
approximately 7 hours.
ESC Guidelines284
Recommandations ESC
Roffi M, et al. Eur Heart J 2016
mmended to administer
atients in whom coronary
ot known.
III B 164
s antiplatelet therapy
ibitors during PCI should
d for bailout situations or
complications.
IIa C
ay be considered in P2Y12
ve patients undergoing PCI.
IIb A
158–
161
mmended to administer
bitors in patients in whom
tomy is not known.
III A
198,
199
P2Y12 inhibition
or administration
o aspirin beyond 1 year
idered after careful
of the ischaemic and
s of the patient.
IIb A
184,
186
commendations
mp inhibitor in
with DAPT is
ed in patients at higher
risk of gastrointestinal
istory of gastrointestinal
Table 10 Dosing of glycoprotein IIb/IIIa inhibitors in
patients with normal and impaired renal function
Drug Recommendations
Normal renal
function or stage
1–2 CKD
(eGFR
≥60 mL/
min/1.73m2
)
Stage 3 CKD
(eGFR
30–59 mL/
min/1.73m2
)
Stage 4 CKD
(eGFR
15–29 mL/
min/1.73m2
)
Stage 5 CKD
(eGFR
<15 mL/
min/1.73m2
)
Bolus
180 µg/kg i.v.,
infusion
2 µg/kg/min
No adjustment
of bolus,reduce
infusion rate to
1 µg/kg/min if
eGFR
<50 mL/min/1.73m2
Not
recommended
Not
recommended
Bolus 25 µg/kg
or 10 µg/kg i.v,
infusion
0.15 µg/kg/min
No dose
adjustment
No adjustment
of bolus,reduce
infusion to
0.05 µg/kg/min
Not
recommended
Bolus
0.25 mg/kg i.v.,
infusion
0.125 µg/kg/min
(max.10 µg/min)
or for dose adjustment in the case of renal failure.
Careful evaluation of haemorrhagic risk is needed.
CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate; i.v. ¼
intravenous; kg ¼ kilograms bodyweight.
Recommendations for the use of drugs listed in this table may vary depending on
the exact labeling of each drug in the country where it is used.
287
It is not recommended to administer
prasugrel in patients in whom coronary
anatomy is not known.
III B 164
Intravenous antiplatelet therapy
GPIIb/IIIa inhibitors during PCI should
be considered for bailout situations or
thrombotic complications.
IIa C
Cangrelor may be considered in P2Y12
inhibitor–naive patients undergoing PCI.
IIb A
158–
161
It is not recommended to administer
GPIIb/IIIa inhibitors in patients in whom
coronary anatomy is not known.
III A
198,
199
Long-term P2Y12 inhibition
P2Y12 inhibitor administration
in addition to aspirin beyond 1 year
may be considered after careful
assessment of the ischaemic and
bleeding risks of the patient.
IIb A
184,
186
General recommendations
A proton pump inhibitor in
combination with DAPT is
Table 10 Dosing of glycoprotein IIb/IIIa inhibitors in
patients with normal and impaired renal function
Drug Recommendations
Normal renal
function or stage
1–2 CKD
(eGFR
≥60 mL/
min/1.73m2
)
Stage 3 CKD
(eGFR
30–59 mL/
min/1.73m2
)
Stage 4 CKD
(eGFR
15–29 mL/
min/1.73m2
)
Stage 5 CKD
(eGFR
<15 mL/
min/1.73m2
)
Bolus
180 µg/kg i.v.,
infusion
2 µg/kg/min
No adjustment
of bolus,reduce
infusion rate to
1 µg/kg/min if
eGFR
<50 mL/min/1.73m2
Not
recommended
Not
recommended
Bolus 25 µg/kg
or 10 µg/kg i.v,
infusion
0.15 µg/kg/min
No dose
adjustment
No adjustment
of bolus,reduce
infusion to
0.05 µg/kg/min
Not
recommended
Bolus
0.25 mg/kg i.v.,
infusion
0.125 µg/kg/min
(max.10 µg/min)
or for dose adjustment in the case of renal failure.
Careful evaluation of haemorrhagic risk is needed.
CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate; i.v. ¼
intravenous; kg ¼ kilograms bodyweight.
SC Guidelines 287
Recommandations ESC
early and/or delayed intervention in NSTE-ACS patients.304,328,329
analysis of high-risk patients (i.e. one-third of patients with a GRACE
EMS = emergency medical services; PCI = percutaneous coronary intervention.
Symptoms Onset
First medical contact NSTE-ACS diagnosis
PCI center
Very high
Immediate
Invasive
(<2 hr)
Early
invasive
(<24 hr)
Invasive
(<72 hr)
Non-invasive
testing if
appropriate
High
Intermediate
Immediate transfer to PCI center
Same-day transfer
Transfer
Transfer
optional
Riskstratification
Therapeutic
strategy
Low
EMS or Non–PCI center
Very high
High
Intermediate
Low
Figure 6 Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS) treatment strategy and timing according to initial risk
stratification.
ESC Guidelines296
Roffi M, et al. Eur Heart J 2016
Recommandations ESC
< 2H
acute coronary syndromes
Recommendations for invasive coronary angiography
and revascularization in non-ST-elevation acute
coronary syndromes
Recommendations Classa
Levelb
Ref.c
An immediate invasive strategy
(<2 h) is recommended in patients with
at least one of the following
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 with refractory
angina or ST deviation
– recurrent dynamic ST- or T-wave
changes, particularly with
intermittent ST-elevation.
I C
An early invasive strategy (<24 h)
is recommended in patients with at
least one of the following high-risk
criteria:
– rise or fall in cardiac troponin
compatible with MI
– dynamic ST- or T-wave changes
(symptomatic or silent)
– GRACE score .140.
I A
303,
326,
327
B
C
D
G
e
a
S
T
T
a
C
b
c
R
Roffi M, et al. Eur Heart J 2016
< 24H
Recommandations ESC
Roffi M, et al. Eur Heart J 2016
within the Heart Team if delayed CABG of
an option.
patients with cardiogenic shock
develop in up to 3% of NSTE-ACS patients
d has become the most frequent cause of
his setting.382 – 384
One or more partial or
ns may result in severe heart failure, espe-
ing LV dysfunction, reduced cardiac output
l organ perfusion. More than two-thirds of
el CAD. Cardiogenic shock may also be re-
mplications of NSTEMI, including mitral re-
pillary muscle dysfunction or rupture and
e wall rupture. In patients with cardiogenic
ary angiography is indicated and PCI is the
evascularization modality. If the coronary
or PCI, patients should undergo emergent
ra-aortic balloon counterpulsation in MI
enic shock has been challenged.385
Extra-
xygenation and/or implantable LV assist
ed in selected patients.
An invasive strategy (<72 h) is
recommended in patients with at least
one of the following intermediate-risk
criteria:
– diabetes mellitus
– renal insufficiency (eGFR
,60 mL/min/1.73 m2
)
– LVEF ,40% or congestive heart
failure
– early post-infarction angina
– recent PCI
– prior CABG
– GRACE risk score .109 and
,140,
or recurrent symptoms or known
ischaemia on non-invasive testing.
I A
322,
324
In patients with none of the above
mentioned risk criteria and no
recurrent symptoms, non-invasive
testing for ischaemia (preferably
with imaging) is recommended
before deciding on an invasive
evaluation.
I A
113,
114
In centres experienced with radial
ESC Guidelines
?
non-ST+
Fréquent…
TRÈS grave
Signes
Atypiques…
…mais
TRÈS fréquents
S’appuyer sur
l’ …
…même si cela peut être compliqué
Troponine HS
Même filière
Mêmes traitements
Ecoutez le patient, il est en train de
vous donner le diagnostic.
Sir William Osler
Ne jamais laisser notre savoir prendre
le dessus sur ce qui demeure le plus
important, notre ignorance.
Henry David Thoreau
@DocNikko
Nicolas PESCHANSKI
#FrOAMed

More Related Content

What's hot

Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...Sociedad Española de Cardiología
 
Coronary CTA: The test of choice for obstructive CAD.
Coronary CTA: The test of choice for obstructive CAD.Coronary CTA: The test of choice for obstructive CAD.
Coronary CTA: The test of choice for obstructive CAD.cardiositeindia
 
Land mark trials 2015
Land mark trials 2015Land mark trials 2015
Land mark trials 2015madhusiva03
 
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...ahvc0858
 
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...Sergio Pinski
 
Valve disease in the Pandemic
Valve disease in the PandemicValve disease in the Pandemic
Valve disease in the Pandemicahvc0858
 
Dyslipidemia and CVS by Mohit Soni and Chandan Kumar
Dyslipidemia and CVS by Mohit Soni and Chandan KumarDyslipidemia and CVS by Mohit Soni and Chandan Kumar
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
 

What's hot (20)

Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria p...
 
Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria...
Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria...Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria...
Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria...
 
Reunion Anual Madeira 2015 Estudios en cardiología intervencionista desde el...
Reunion Anual Madeira 2015 Estudios en cardiología intervencionista desde el...Reunion Anual Madeira 2015 Estudios en cardiología intervencionista desde el...
Reunion Anual Madeira 2015 Estudios en cardiología intervencionista desde el...
 
Coronary CTA: The test of choice for obstructive CAD.
Coronary CTA: The test of choice for obstructive CAD.Coronary CTA: The test of choice for obstructive CAD.
Coronary CTA: The test of choice for obstructive CAD.
 
Patel TM 201111
Patel TM 201111Patel TM 201111
Patel TM 201111
 
Jose r lopez minguez novedades cierre laa
Jose r lopez minguez novedades cierre laaJose r lopez minguez novedades cierre laa
Jose r lopez minguez novedades cierre laa
 
Cardiopatía Estructural. - Dr. José María Hernández
Cardiopatía Estructural. - Dr. José María HernándezCardiopatía Estructural. - Dr. José María Hernández
Cardiopatía Estructural. - Dr. José María Hernández
 
Carotid surgery 2014
Carotid surgery 2014Carotid surgery 2014
Carotid surgery 2014
 
Ablación de FA ¿A quién y cómo?
Ablación de FA ¿A quién y cómo?Ablación de FA ¿A quién y cómo?
Ablación de FA ¿A quién y cómo?
 
Land mark trials 2015
Land mark trials 2015Land mark trials 2015
Land mark trials 2015
 
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
Surgical or Transcatheter Valve Surgery: What Your Patients Need To Know In A...
 
04 FFR Johnson aimradial2017 - Hyperhemia
04 FFR Johnson aimradial2017 - Hyperhemia04 FFR Johnson aimradial2017 - Hyperhemia
04 FFR Johnson aimradial2017 - Hyperhemia
 
Patel TM 201110
Patel TM 201110Patel TM 201110
Patel TM 201110
 
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
Rol actual del cardiodesfibrilador implantable subcutáneo en la prevención de...
 
Pancholy SB - AIMRADIAL 2014 Endovascular - Renal denervation
Pancholy SB - AIMRADIAL 2014 Endovascular - Renal denervationPancholy SB - AIMRADIAL 2014 Endovascular - Renal denervation
Pancholy SB - AIMRADIAL 2014 Endovascular - Renal denervation
 
Valve disease in the Pandemic
Valve disease in the PandemicValve disease in the Pandemic
Valve disease in the Pandemic
 
Hahalis G - AIMRADIAL 2013 - Ulnar catheterization
Hahalis G - AIMRADIAL 2013 - Ulnar catheterizationHahalis G - AIMRADIAL 2013 - Ulnar catheterization
Hahalis G - AIMRADIAL 2013 - Ulnar catheterization
 
10 FFR Olivecrona aimradial2017 - iFR-SWEDEHEART
10 FFR Olivecrona aimradial2017 - iFR-SWEDEHEART10 FFR Olivecrona aimradial2017 - iFR-SWEDEHEART
10 FFR Olivecrona aimradial2017 - iFR-SWEDEHEART
 
Novedades en farmacología en intervencionismo
Novedades en farmacología en intervencionismoNovedades en farmacología en intervencionismo
Novedades en farmacología en intervencionismo
 
Dyslipidemia and CVS by Mohit Soni and Chandan Kumar
Dyslipidemia and CVS by Mohit Soni and Chandan KumarDyslipidemia and CVS by Mohit Soni and Chandan Kumar
Dyslipidemia and CVS by Mohit Soni and Chandan Kumar
 

Similar to SCA non-ST+ de la personne âgée - D.U. MUPA 2018

Novel strategies to improve diastolic function
Novel strategies to improve diastolic functionNovel strategies to improve diastolic function
Novel strategies to improve diastolic functiondrucsamal
 
Transfusion trigger in Intensive Care Unit
Transfusion trigger in Intensive Care UnitTransfusion trigger in Intensive Care Unit
Transfusion trigger in Intensive Care UnitYazan Kherallah
 
Renal Artery Denervation Patient Selection and Results
Renal Artery Denervation Patient Selection and ResultsRenal Artery Denervation Patient Selection and Results
Renal Artery Denervation Patient Selection and ResultsPAIRS WEB
 
Vedantham_2008-12-12.ppt
Vedantham_2008-12-12.pptVedantham_2008-12-12.ppt
Vedantham_2008-12-12.pptWilliam823183
 
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...European School of Oncology
 
Left main revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSIC
Left main  revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSICLeft main  revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSIC
Left main revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSICPROFESSOR DR. MD. TOUFIQUR RAHMAN
 
Emergency medicine research
Emergency medicine researchEmergency medicine research
Emergency medicine researchtbf413
 
Post cardiac arrest care in ED
Post cardiac arrest care in EDPost cardiac arrest care in ED
Post cardiac arrest care in EDkellyam18
 
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOs
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOsFriday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOs
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOsEuro CTO Club
 
How to manage delays in stroke treatment Jacek Staszewski
How to manage delays in stroke treatment Jacek StaszewskiHow to manage delays in stroke treatment Jacek Staszewski
How to manage delays in stroke treatment Jacek StaszewskiJacek Staszewski
 
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16Euro CTO Club
 
CTO and low ejection fraction
CTO and low ejection fraction CTO and low ejection fraction
CTO and low ejection fraction Euro CTO Club
 

Similar to SCA non-ST+ de la personne âgée - D.U. MUPA 2018 (20)

HF
HFHF
HF
 
Novel strategies to improve diastolic function
Novel strategies to improve diastolic functionNovel strategies to improve diastolic function
Novel strategies to improve diastolic function
 
TCT 2010: COMPARE Trial
TCT 2010: COMPARE TrialTCT 2010: COMPARE Trial
TCT 2010: COMPARE Trial
 
Antiagregación en los pacientes con Cardiopatía Isquémica
Antiagregación en los pacientes con Cardiopatía IsquémicaAntiagregación en los pacientes con Cardiopatía Isquémica
Antiagregación en los pacientes con Cardiopatía Isquémica
 
Update on Pulmonary Arterial Hypertension in Scleroderma
Update on Pulmonary Arterial Hypertension in SclerodermaUpdate on Pulmonary Arterial Hypertension in Scleroderma
Update on Pulmonary Arterial Hypertension in Scleroderma
 
Wivon
WivonWivon
Wivon
 
Transfusion trigger in Intensive Care Unit
Transfusion trigger in Intensive Care UnitTransfusion trigger in Intensive Care Unit
Transfusion trigger in Intensive Care Unit
 
Resolute International 09.21
Resolute International 09.21Resolute International 09.21
Resolute International 09.21
 
Renal Artery Denervation Patient Selection and Results
Renal Artery Denervation Patient Selection and ResultsRenal Artery Denervation Patient Selection and Results
Renal Artery Denervation Patient Selection and Results
 
Radiologieinterventionnellechctdebaere
RadiologieinterventionnellechctdebaereRadiologieinterventionnellechctdebaere
Radiologieinterventionnellechctdebaere
 
Vedantham_2008-12-12.ppt
Vedantham_2008-12-12.pptVedantham_2008-12-12.ppt
Vedantham_2008-12-12.ppt
 
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...
ECCLU 2011 - H. Van Poppel - Controversy: Locally advanced prostate cancer - ...
 
Left main revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSIC
Left main  revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSICLeft main  revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSIC
Left main revascularization dr md toufiqur rahman DM FSCAI FRCP FAPSIC
 
09 Cohen aimradial20170922 Ventricular support
09 Cohen aimradial20170922 Ventricular support09 Cohen aimradial20170922 Ventricular support
09 Cohen aimradial20170922 Ventricular support
 
Emergency medicine research
Emergency medicine researchEmergency medicine research
Emergency medicine research
 
Post cardiac arrest care in ED
Post cardiac arrest care in EDPost cardiac arrest care in ED
Post cardiac arrest care in ED
 
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOs
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOsFriday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOs
Friday 08:13 – Joner - Drug-eluting stent thrombosis in the treatment of CTOs
 
How to manage delays in stroke treatment Jacek Staszewski
How to manage delays in stroke treatment Jacek StaszewskiHow to manage delays in stroke treatment Jacek Staszewski
How to manage delays in stroke treatment Jacek Staszewski
 
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
Carlo Di Mario - Recent Publications & Research in CTO: 2015-16
 
CTO and low ejection fraction
CTO and low ejection fraction CTO and low ejection fraction
CTO and low ejection fraction
 

More from Nicolas Peschanski, MD, PhD

Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021
Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021
Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021Nicolas Peschanski, MD, PhD
 
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020Nicolas Peschanski, MD, PhD
 
Georges boussignac, un destin hors du commun ESANUM 2020
Georges boussignac, un destin hors du commun ESANUM 2020Georges boussignac, un destin hors du commun ESANUM 2020
Georges boussignac, un destin hors du commun ESANUM 2020Nicolas Peschanski, MD, PhD
 
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020Nicolas Peschanski, MD, PhD
 
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019Nicolas Peschanski, MD, PhD
 
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019Nicolas Peschanski, MD, PhD
 
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019Nicolas Peschanski, MD, PhD
 
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019Nicolas Peschanski, MD, PhD
 
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3Nicolas Peschanski, MD, PhD
 
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...Nicolas Peschanski, MD, PhD
 
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018Nicolas Peschanski, MD, PhD
 
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018Nicolas Peschanski, MD, PhD
 
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...Nicolas Peschanski, MD, PhD
 
Nouveaux zombies - Nouvelles Drogues - Urgences 2018
Nouveaux zombies - Nouvelles Drogues - Urgences 2018Nouveaux zombies - Nouvelles Drogues - Urgences 2018
Nouveaux zombies - Nouvelles Drogues - Urgences 2018Nicolas Peschanski, MD, PhD
 
Controverse Biologie Délocalisée en SMUR Urgences 2018
Controverse Biologie Délocalisée en SMUR Urgences 2018Controverse Biologie Délocalisée en SMUR Urgences 2018
Controverse Biologie Délocalisée en SMUR Urgences 2018Nicolas Peschanski, MD, PhD
 

More from Nicolas Peschanski, MD, PhD (20)

Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021
Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021
Webinaire Détresse respiratoire - spécificité COVID-19 Urgences Le Mensuel 2021
 
Georges boussignac legacy with commentaries
Georges boussignac legacy with commentariesGeorges boussignac legacy with commentaries
Georges boussignac legacy with commentaries
 
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020
Georges Boussignac legacy - Forum Risk Management, Italy Dec 2020
 
Georges boussignac, un destin hors du commun ESANUM 2020
Georges boussignac, un destin hors du commun ESANUM 2020Georges boussignac, un destin hors du commun ESANUM 2020
Georges boussignac, un destin hors du commun ESANUM 2020
 
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
Dos and donts in the emergency pre hospital setting covid-19 eccc 2020
 
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019
DU SAMU Filière et traitements du Syndrome Coronarien Aigu en 2019
 
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019
DU SAMU Diagnostic du Syndrome Coronarien Aigu 2019
 
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019
Controverse - Trauma Crânien Léger avec ou sans S100B ? COMUN 2019
 
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019
Troubles conscience du sujet jeune - Un nouveau regard COMUN 2019
 
Neuro news COMUN 2019
Neuro news COMUN 2019Neuro news COMUN 2019
Neuro news COMUN 2019
 
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3
Escale Coeur & Diabète 2019 Atelier 3 - ECGs en situations critiques v3
 
Quiz ECG Syncope EMC2 2019
Quiz ECG Syncope EMC2 2019Quiz ECG Syncope EMC2 2019
Quiz ECG Syncope EMC2 2019
 
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...
ST+ Mimics - Session Etat de l'Art - Le Syndrome de Takotsubo Congrès Urgence...
 
ECG Quiz Atelier Pré-Congrès Urgences 2019
ECG Quiz Atelier Pré-Congrès Urgences 2019ECG Quiz Atelier Pré-Congrès Urgences 2019
ECG Quiz Atelier Pré-Congrès Urgences 2019
 
Diaporama DPC Urgences SFMU SCA ST+ 2019
Diaporama DPC Urgences SFMU SCA ST+ 2019Diaporama DPC Urgences SFMU SCA ST+ 2019
Diaporama DPC Urgences SFMU SCA ST+ 2019
 
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018
Syncope de la personne âgée : apport de l'ECG - Forum de l'urgence 2018
 
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018
Oxygénation Nasale Humidifiée à Haut Débit - Optiflow aux urgences COMUN 2018
 
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...
Décision diagnostique : apprendre de ses erreurs Journée Médecine d'Urgence N...
 
Nouveaux zombies - Nouvelles Drogues - Urgences 2018
Nouveaux zombies - Nouvelles Drogues - Urgences 2018Nouveaux zombies - Nouvelles Drogues - Urgences 2018
Nouveaux zombies - Nouvelles Drogues - Urgences 2018
 
Controverse Biologie Délocalisée en SMUR Urgences 2018
Controverse Biologie Délocalisée en SMUR Urgences 2018Controverse Biologie Délocalisée en SMUR Urgences 2018
Controverse Biologie Délocalisée en SMUR Urgences 2018
 

Recently uploaded

Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenRaju678948
 
Evidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyEvidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyNehaa Dubey
 
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...marcuskenyatta275
 
5cladba raw material 5CL-ADB-A precursor raw
5cladba raw material 5CL-ADB-A precursor raw5cladba raw material 5CL-ADB-A precursor raw
5cladba raw material 5CL-ADB-A precursor rawSherrylee83
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxDr. Sohan Biswas
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...marcuskenyatta275
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examJunhao Koh
 
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Aditi Pandey i11
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Health Kinesiology Natural Bioenergetics
 
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...Ishita Kashyap
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptxclaviclebrown44
 
Creating Accessible Public Health Communications
Creating Accessible Public Health CommunicationsCreating Accessible Public Health Communications
Creating Accessible Public Health Communicationskatiequigley33
 
Cervical screening – taking care of your health flipchart (Vietnamese)
Cervical screening – taking care of your health flipchart (Vietnamese)Cervical screening – taking care of your health flipchart (Vietnamese)
Cervical screening – taking care of your health flipchart (Vietnamese)Cancer Institute NSW
 
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...janusa9823#S0007
 
Dermatome and myotome test & pathology.pdf
Dermatome and myotome test & pathology.pdfDermatome and myotome test & pathology.pdf
Dermatome and myotome test & pathology.pdfniloofarbarzegari76
 
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale nowSherrylee83
 
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...jiyav969
 
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...marcuskenyatta275
 
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Rabia Malik
 
DR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in IndiaDR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in IndiaNehamehta128467
 

Recently uploaded (20)

Video capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in childrenVideo capsule endoscopy (VCE ) in children
Video capsule endoscopy (VCE ) in children
 
Evidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapyEvidence-based practiceEBP) in physiotherapy
Evidence-based practiceEBP) in physiotherapy
 
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
TEST BANK For Lewis's Medical Surgical Nursing in Canada, 4th Edition by Jane...
 
5cladba raw material 5CL-ADB-A precursor raw
5cladba raw material 5CL-ADB-A precursor raw5cladba raw material 5CL-ADB-A precursor raw
5cladba raw material 5CL-ADB-A precursor raw
 
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptxANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
ANAPHYLAXIS BY DR.SOHAN BISWAS,MBBS,DNB(INTERNAL MEDICINE) RESIDENT.pptx
 
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
TEST BANK For Huether and McCance's Understanding Pathophysiology, Canadian 2...
 
Tips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES examTips and tricks to pass the cardiovascular station for PACES exam
Tips and tricks to pass the cardiovascular station for PACES exam
 
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
Our Hottest 💘 Surat ℂall Girls Serviℂe 💘Pasodara📱 8527049040📱450+ ℂall Girl C...
 
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
Unlocking Holistic Wellness: Addressing Depression, Mental Well-Being, and St...
 
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
HIFI* ℂall Girls In Thane West Phone 🔝 9920874524 🔝 💃 Me All Time Serviℂe Ava...
 
Failure to thrive in neonates and infants + pediatric case.pptx
Failure to thrive in neonates and infants  + pediatric case.pptxFailure to thrive in neonates and infants  + pediatric case.pptx
Failure to thrive in neonates and infants + pediatric case.pptx
 
Creating Accessible Public Health Communications
Creating Accessible Public Health CommunicationsCreating Accessible Public Health Communications
Creating Accessible Public Health Communications
 
Cervical screening – taking care of your health flipchart (Vietnamese)
Cervical screening – taking care of your health flipchart (Vietnamese)Cervical screening – taking care of your health flipchart (Vietnamese)
Cervical screening – taking care of your health flipchart (Vietnamese)
 
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
VVIP Yelahanka ℂall Girls 6350482085 Heat-immolating { Bangalore } Coveted Gi...
 
Dermatome and myotome test & pathology.pdf
Dermatome and myotome test & pathology.pdfDermatome and myotome test & pathology.pdf
Dermatome and myotome test & pathology.pdf
 
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
5CL-ADB powder supplier 5cl adb 5cladba 5cl raw materials vendor on sale now
 
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
Vip ℂall Girls Shalimar Bagh Phone No 9999965857 High Profile ℂall Girl Delhi...
 
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
TEST BANK for The Nursing Assistant Acute, Subacute, and Long-Term Care, 6th ...
 
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
Premium ℂall Girls In Mira Road👉 Dail ℂALL ME: 📞9004268417 📲 ℂall Richa VIP ℂ...
 
DR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in IndiaDR. Neha Mehta Best Psychologist.in India
DR. Neha Mehta Best Psychologist.in India
 

SCA non-ST+ de la personne âgée - D.U. MUPA 2018

  • 1. Nicolas PESCHANSKI MD, PhD – CHI Eure-Seine Evreux SCA non-ST+ Personne Âgée @DocNikko
  • 3. Thygesen K. Eur Heart J 2007;28:2525-2538 Reichlin et al./ Keller et al. NEJM 2009 SCA ST+ 10% SCA Non ST+ 10% Angor Instable 14% Autres/non- IDM 66% Douleur Thoracique
  • 4. Rapport de la DRESS 2003, 215:1-12 O. Lacroix. Thèse de Médecine, Strasbourg 2008DRESS 2003, 215:1-12 O. Lacroix. Thèse de Médecine, Strasbourg 2008 >70 ans = 12-21% passages >75 ans = 65% hospitalisation >80 ans = 38% recours/an Population à risque !!! Mêmes pathologies graves Diminution réserves organiques Comorbidités importantes Urgences = Fragilité
  • 5. Mattu A. Univ of Maryland School of Medicine, 2009 Epidémio(bobo)logie
  • 6. SCA Prévalence ⇗⇗ France -> 120000 IDM/an N-STEMI > STEMI Mortalité hospitalière = (3 vs 3%) Mortalité 6 mois ≈ (5,3 vs 6,8%) Mortalité long terme > N-STEMI Puymirat E, et al. Circulation 2017
  • 7. 1ère cause mortalité CV 85% décès IDM >65 ans SCA Gopta R. Emerg Med Clin N Am 2016;34:523-42 >75 ans + SCA omis = 50% décès < 72 h DRESS 2003, 215:1-12
  • 8.
  • 9. Body R, et al. Resuscitation 2010 Anamnèse Douleur identique LR+ 0,7 Douleur > 1h LR+ 1,4 Irradiation MSD LR+ 2,3 Sueurs LR+ 6,3 Douleur punctiforme LR- 1,0 Douleur thoracique
  • 10. Cannon C, et al. Circulation. 2007;115:2549-69 Fanaroff AC, et al. JAMA 2015;314(18):1955-65
  • 11. Kelly BS. Clin Geriatr Med 2007;23:327-49 Douleur Absente/Atypique Imprécise ≠ Irradiations 2nd plan
  • 12. 3ème interrogatoire = sémiologie sup. 20-75% Kelly BS. Clin Geriatr Med 2007;23:327-49 65% = DT<7j IDM « indolore » = 33% DT
  • 13. Swap CJ. JAMA 2005;294:2623-9 DT+1 1+DT
  • 14. Rich MW. Am J Geriatr Cardiol 2006;15:7–11
  • 15. Smith SC. J Am Coll Cardiol. 1990;16:784-92Grave !!!
  • 16. Kelly BS. Clin Geriatr Med, 2007;23:327-49
  • 17. Swap CJ. JAMA. 2005;294:2623-9
  • 18.
  • 19. Définition Nouveau sous-décalage du segment ST horizontal ou descendant au niveau du point J dans au moins deux dérivations contiguës ou adjacentes et ≥ 0,5 mm Thygesen K, et al. Circula4on 2012
  • 20. Définition Onde T inversée ≥ 1 mm dans au moins deux dérivations contiguës où l’onde R est proéminente ou R/S > 1 Thygesen K, et al. Circulation 2012
  • 21. Autres définitions Sus-décalage de ST non persistant (transitoire), peu ample (< 1 mm) ou dans une seule dérivation Pseudo-normalisation sus-décalage de ST ou onde T inversée Apparition progressive d’une onde Q de nécrose Wang T, et al. Am Heart J 2009;157:716-23
  • 22. Kosowsky. Emerg Med Clin N Am 2011;29:721-27 Normal LR- 0,8 ST- LR+ 3,6 BBG LR+ 1,4 Modif. LR+ 3,4 Diagnostic ECG
  • 23. Kelly BS. Clin Geriatr Med 2007;23:327-49 Personne Âgée ECG≠∆ic
  • 24. Kelly BS. Clin Geriatr Med 2007;23:327-49 Personne Âgée
  • 27. Modifications ECG Cinétique ECG >>> Cinétique Troponine Eskola. J Electrocardiology 2011;44:e1–e64
  • 28. Biomarqueurs Troponine HS/US Troponine 4ème g. Brush JE, et al. JACC 2016
  • 29. Algorithme décisionnel Roffi M, et al. Eur Heart J 2016
  • 30. Recommandations ESC Hamm CW, et al. Eur Heart J 2012
  • 33. Hammarsten O, et al. Clin Chem 2012 Effets de l’âge
  • 34. Amélioration ∆ique Giannitis E, et al. Clin Chem 2010 ROCHE DIAGNOSTICS - 10 000 BIO N°81 - NOVEMBRE 2009 MÉDICALISATION ous mettre en conformité ommandations internatio- éconisent une imprécision rable de 10% à la valeur du e d’une population de réfé- oponine conventionnelle ne e remplir ces exigences. e-t-il pour a troponine THs ’hui? beaux:De multiples publi- mmunications orales nous p appris ces derniers mois, mes techniquement prêts. reste à explorer certains plication cliniques et biolo- mieux interpréter les résul- en mesure d’informer nos de façon exhaustive. Meune:L a troponine THs p tôt serait utilisée par les mme une troponine conven- nc de manière réductrice. qu’elle est plus sensible nostic de l’infarctus et de ble et qu’un seul dosage suffit(2) . Mais nous avons vail pour parvenir à un algo- prétation clair et approfon- stic de l’angor instable, qui et de notre étude. mode de prise en charge des patients: nombre de dosages, interprétation, délai dans lequel les patients seront mis sous traitement ou renvoyés chez eux, etc. Nous attendons des biologistes beaucoup d’informations: qu’est-ce qui différencie ce paramètre des autres troponines? L e dosage est-il robuste en toutes circons- tances? L e prélèvement est-il simple à réa- liser et à acheminer? L a qualité du rendu de résultats est-elle inchangée?, etc. sation de ce nouveau paramètre: cela fait partie de mon rôle de conseil. (1) L aboratoire de biochimie interhospitalier Cochin-Hôtel-Dieu, service du P r L . Cynober. (2) Ce point a fait l’objet d’une publication dans le New England Journal of Medicine. Contact Roche Diagnostics: nicolas.zeitoun@roche.com Retard diagnostique Seuil de détec=on TnT RULE-IN !
  • 35. Evidence scientifique 10mg/mL (0,01g/mL) Troponin T HS-troponin T 35ng/L14ng/L Sandoval Y, et al. Clin Chem 2017
  • 36.
  • 37. Twerenbold R, et al. Eur Heart J 2012 Perte de spécificité
  • 38. Valeur absolue TnTHS Twerenbold R, et al. Eur Heart J 2012
  • 39. Evidence clinique Body R, et al. JACC 2011 Des patients suspects de douleur thoracique d’origine coronarienne Et Qui ont une TnTHS > 0,14 ng/L Ont un SCA
  • 40. Mettre les patients dehors ! RULE-OUT !
  • 41. Algorithme décisionnel Roffi M, et al. Eur Heart J 2016
  • 42. Algorithme décisionnel Roffi M, et al. Eur Heart J 2016
  • 43. Cinétique TnTHS/ IUS Evaluation dynamique -> Plus de Rule-In -> Plus de Rule-Out
  • 44. SCORES Score GRACEScore TIMI Backus B, et al. Curr Cardiol Rev 2011;7(1):2-8
  • 45. GRACE Chez le patient âgé Granger. Arch Intern Med 2003;163:2345-53 KO !
  • 46. TIMI N-STEMI Protocole de diagnostic accéléré TIMI = 0 ASPECT (2011) = 9,8% ADAPT (2012) = 20% New Improved ADP (2012) = 12,3%
  • 47. TIMI KO Chez le patient à bas risque
  • 48. TIMI et GRACE n’ont pas leur place aux urgences Than. Emerg Med Australas 2014;26:34-44
  • 50. HEART Score Six. Neth Heart J 2008;16:191-6 Score 2-3 ≈20%
  • 51. HEART Score 0-3 13 études > 17000 pts Pts ≈40% à bas risque 1,6% ECV à 30–45 j HEART atherosclerotic disease: uspicious 2 ely suspicious 1 uspicious 0 nt ST-deviation 2 cific repolarisation nce / LBTB / PM 0 rs 2 < 65 years 1 rs 0 actors or history of lerotic disease* 2 k factors 1 actors known 0 mal limit 2 < 3x normal limit 1 mal limit 0 Total for chest pain patients 1 mia Cigarette smoking Positive family history Fanaroff. JAMA. 2015;314(18):1955-65
  • 52. HEART Taux ECV Paper Pts HEART Score ≤3 MACE in HEART ≤3 (n) MACE in HEART ≤3 (%) Six 2008 120 39 1 2.6% Backus 2010 880 303 3 0.9% Mahler 2011 1070 904 5 0.6% Backus 2013 2388 870 15 1.7% Mahler 2013 991 200 2 1% Melki 2013 410 247 1 0.4% Six 2013 2906 820 14 1.7% Visser 2014 255 85 5 5.9% Leite 2015 174 98 2 2% Mahler 2015 141 66 0 0% Sun 2016 8255 4039 72 1.8% TOTAL 17,590 7,671 120 1.6% Total Mahler 1132 266 2 0.8%
  • 53. Troponine THS H0-H3 2 études >1000 pts ≈25% pts à bas risque 0,8% ECV à J30
  • 54. Comment s’en sortir HEART Score TnTHS/IUS H0-H3 Hess. Circulation Cardiovasc Qual Outcom 2012;5:251-9
  • 55. Mahler S, et al. Circ Cardiovasc Qual Outcomes. 2015;8:195-203 HEART Pathway
  • 56.
  • 57. Recommandations ESC erate increase could not be excluded. Extended DAPT, compared with 12-month treatment, yielded a significant reduction in MI [OR 0.53 (95% CI 0.42, 0.66), P , 0.001] and stent thrombosis [OR 0.33 (95% CI 0.21, 0.51), P , 0.001] while more major bleeds occurred [OR 1.62 (95% CI 1.26, 2.09), P , 0.001]. In addition, all- cause death was significantly increased in the extended DAPT group [OR 1.30 (95% CI 1.02, 1.66), P ¼ 0.03] while CV death did not dif- fer among the groups.185 The Prevention of Cardiovascular Events in Patients with Prior Heart Attack Using Ticagrelor Compared to Placebo on a Back- ground of Aspirin-Thrombolysis in Myocardial Infarction 54 (PEGASUS-TIMI 54) trial randomized 21 162 patients who had had an MI 1–3 years earlier to ticagrelor at a dose of 90 mg twice daily, ticagrelor at a dose of 60 mg twice daily or placebo.186 At a median follow-up of 33 months, the study demonstrated a reduced rate of CV death, MI or stroke with ticagrelor [HR 0.85 (95% CI 0.75, 0.96), P ¼ 0.008 and HR 0.84 (95% CI 0.74, 0.95), P ¼ 0.004 for 90 mg and 60 mg of ticagrelor vs. placebo, respectively) and increased rates of major bleeding events (2.60% with 90 mg, 2.30% with 60 mg and 1.06% with placebo, P , 0.001).186 All-cause mortality did not differ between the groups. Of importance, most patients began treat- ment with ticagrelor after an interruption in DAPT and all had prior MI (context of secondary prevention in high-risk patients), while patients with a history of ischaemic stroke were excluded. In conclu- sion, while a 1-year duration of DAPT in NSTE-ACS patients is re- commended, based on individual patient ischaemic and bleeding risk profiles, DAPT duration may be shortened (i.e. 3–6 months) or extended (i.e. up to 30 months) in selected patients if required. 5.2.7 Glycoprotein IIb/IIIa inhibitors Intravenous GPIIb/IIIa inhibitors block platelet aggregation by inhibiting fibrinogen binding to a conformationally activated form of the GPIIb/IIIa receptor on two adjacent platelets.128 A meta-analysis of six RCTs involving 29 570 NSTE-ACS patients, mainly medically managed, showed a 9% RRR in death or non-fatal MI with GPIIb/IIIa inhibitors (10.7% vs. 11.5%, P ¼ 0.02) when added to heparin.196 The greatest benefit was observed in patients undergoing PCI while on these agents [10.5% vs. 13.6%; OR 0.74 (95% CI 0.57, 0.96), P ¼ 0.02]. The use of GPIIb/IIIa inhibitors was associated with an increase in major bleeding complications without a significant increase in intracranial haemorrhage. Many of these trials predated the routine use of P2Y12 inhibitors. While the relative efficacy of prasugrel and ticagrelor in the trials 5.2.9 Recommendations for platelet inhibition in non-ST-elevation acute coronary syndromes Recommendations for platelet inhibition in non-ST- elevation acute coronary syndromes Recommendations Classa Levelb Ref.c Oral antiplatelet therapy Aspirin is recommended for all patients without contraindications at an initial oral loading dosed of 150– 300 mg (in aspirin-naive patients) and a maintenance dose of 75–100 mg/ day long-term regardless of treatment strategy. I A 129– 132 A P2Y12 inhibitor is recommended, in addition to aspirin, for 12 months unless there are contraindications such as excessive risk of bleeds. I A 137, 148, 153 † Ticagrelor (180 mg loading dose, 90 mg twice daily) is recommended, in the absence of contraindications,e for all patients at moderate-to-high risk of ischaemic events (e.g. elevated cardiac troponins), regardless of initial treatment strategy and including those pretreated with clopidogrel (which should be discontinued when ticagrelor is started). I B 153 † Prasugrel (60 mg loading dose, 10 mg daily dose) is recommended in patients who are proceeding to PCI if no contraindication.e I B 148, 164 † Clopidogrel (300–600 mg loading dose, 75 mg daily dose) is recommended for patients who cannot receive ticagrelor or prasugrel or who require oral anticoagulation. I B 137 P2Y12 inhibitor administration for a shorter duration of 3–6 months after DES implantation may be considered in patients deemed at high bleeding risk. IIb A 187– 189, 192 Roffi M, et al. Eur Heart J 2016 ticagrelor 180 mg loading dose followed by 90 mg twice a day.153 Patients undergoing PCI were allowed to receive an additional blinded 300 mg loading dose of clopidogrel (total loading dose 600 mg) or its placebo. Treatment was continued for up to 12 months, with a median duration of drug exposure of 9 months.153 In the NSTE-ACS subgroup (n ¼ 11 080), the primary composite ef- ficacy endpoint (death from CV causes, MI or stroke) was signifi- cantly reduced with ticagrelor compared with clopidogrel [10.0% 5.2.2.4 Cangrelor Cangrelor is an i.v. adenosine triphosphate (ATP) analogue that binds reversibly and with high affinity to the platelet P2Y12 receptor and has a short plasma half-life (,10 min) (Table 8). It produces a highly ef- fective inhibition of ADP-induced platelet aggregation immediately after i.v. bolus administration and allows for restoration of platelet function within 1–2 h of infusion discontinuation in NSTE-ACS pa- tients.157 Cangrelor (30 mg/kg bolus and 4 mg/kg/min infusion) in- Table 8 P2Y12 inhibitors Clopidogrel Chemical class Thienopyridine Administration Oral Dose 300–600mg orally then 75 mg a day Dosing in CKD • Stage 3 (eGFR 30–59 mL/min/1.73m2 ) No dose adjustment • Stage 4 (eGFR 15–29 mL/min/1.73m2 ) No dose adjustment • Stage 5 (eGFR <15 mL/min/1.73m2 ) Use only for selected indications (e.g.stent thrombosis prevention) Binding reversibility Irreversible Activation Prodrug,with variable liver metabolism Onset of loading dose effecta 2–6 hoursb Duration of effect 3–10 days Withdrawal before surgery 5 daysc Plasma half-life of active P2Y12 inhibitord 30–60 min Inhibition of adenosine reuptake No Prasugrel Ticagrelor Cangrelor Thienopyridine Cyclopentyl-triazolopyrimidine StabilizedATP analogue Oral Oral Intravenous 60 mg orally then 10 mg a day 180 mg orally then 90 mg twice a day 30 µg/kg bolus and 4 µg/kg/min infusion No dose adjustment No dose adjustment No dose adjustment No dose adjustment No dose adjustment No dose adjustment Not recommended Not recommended No dose adjustment Irreversible Reversible Reversible Prodrug,with predictable liver metabolism Active drug,with additional active metabolite Active drug 30 minb 30 minb 2 min 7–10 days 3–5 days 1–2 hours 7 daysc 5 daysc 1 hour 30–60 mine 6–12 hours 5–10 min No Yes Yes (‘inactive’ metabolite only) ADP ¼ adenosine diphosphate; ATP ¼ adenosine triphosphate; CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate. a 50% inhibition of ADP-induced platelet aggregation. b Onset of effect may be delayed if intestinal absorption is delayed (e.g. by opiate). c Shortening may be considered if indicated by platelet function tests and low bleeding risk. d Affecting the response to platelet transfusion. e The distribution phase half-life is reported since it most likely reflects duration of clinically-relevant plasma levels, while the corresponding elimination phase half-life is approximately 7 hours. ESC Guidelines284
  • 58. Recommandations ESC Roffi M, et al. Eur Heart J 2016 mmended to administer atients in whom coronary ot known. III B 164 s antiplatelet therapy ibitors during PCI should d for bailout situations or complications. IIa C ay be considered in P2Y12 ve patients undergoing PCI. IIb A 158– 161 mmended to administer bitors in patients in whom tomy is not known. III A 198, 199 P2Y12 inhibition or administration o aspirin beyond 1 year idered after careful of the ischaemic and s of the patient. IIb A 184, 186 commendations mp inhibitor in with DAPT is ed in patients at higher risk of gastrointestinal istory of gastrointestinal Table 10 Dosing of glycoprotein IIb/IIIa inhibitors in patients with normal and impaired renal function Drug Recommendations Normal renal function or stage 1–2 CKD (eGFR ≥60 mL/ min/1.73m2 ) Stage 3 CKD (eGFR 30–59 mL/ min/1.73m2 ) Stage 4 CKD (eGFR 15–29 mL/ min/1.73m2 ) Stage 5 CKD (eGFR <15 mL/ min/1.73m2 ) Bolus 180 µg/kg i.v., infusion 2 µg/kg/min No adjustment of bolus,reduce infusion rate to 1 µg/kg/min if eGFR <50 mL/min/1.73m2 Not recommended Not recommended Bolus 25 µg/kg or 10 µg/kg i.v, infusion 0.15 µg/kg/min No dose adjustment No adjustment of bolus,reduce infusion to 0.05 µg/kg/min Not recommended Bolus 0.25 mg/kg i.v., infusion 0.125 µg/kg/min (max.10 µg/min) or for dose adjustment in the case of renal failure. Careful evaluation of haemorrhagic risk is needed. CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate; i.v. ¼ intravenous; kg ¼ kilograms bodyweight. Recommendations for the use of drugs listed in this table may vary depending on the exact labeling of each drug in the country where it is used. 287 It is not recommended to administer prasugrel in patients in whom coronary anatomy is not known. III B 164 Intravenous antiplatelet therapy GPIIb/IIIa inhibitors during PCI should be considered for bailout situations or thrombotic complications. IIa C Cangrelor may be considered in P2Y12 inhibitor–naive patients undergoing PCI. IIb A 158– 161 It is not recommended to administer GPIIb/IIIa inhibitors in patients in whom coronary anatomy is not known. III A 198, 199 Long-term P2Y12 inhibition P2Y12 inhibitor administration in addition to aspirin beyond 1 year may be considered after careful assessment of the ischaemic and bleeding risks of the patient. IIb A 184, 186 General recommendations A proton pump inhibitor in combination with DAPT is Table 10 Dosing of glycoprotein IIb/IIIa inhibitors in patients with normal and impaired renal function Drug Recommendations Normal renal function or stage 1–2 CKD (eGFR ≥60 mL/ min/1.73m2 ) Stage 3 CKD (eGFR 30–59 mL/ min/1.73m2 ) Stage 4 CKD (eGFR 15–29 mL/ min/1.73m2 ) Stage 5 CKD (eGFR <15 mL/ min/1.73m2 ) Bolus 180 µg/kg i.v., infusion 2 µg/kg/min No adjustment of bolus,reduce infusion rate to 1 µg/kg/min if eGFR <50 mL/min/1.73m2 Not recommended Not recommended Bolus 25 µg/kg or 10 µg/kg i.v, infusion 0.15 µg/kg/min No dose adjustment No adjustment of bolus,reduce infusion to 0.05 µg/kg/min Not recommended Bolus 0.25 mg/kg i.v., infusion 0.125 µg/kg/min (max.10 µg/min) or for dose adjustment in the case of renal failure. Careful evaluation of haemorrhagic risk is needed. CKD ¼ chronic kidney disease; eGFR ¼ estimated glomerular filtration rate; i.v. ¼ intravenous; kg ¼ kilograms bodyweight. SC Guidelines 287
  • 59. Recommandations ESC early and/or delayed intervention in NSTE-ACS patients.304,328,329 analysis of high-risk patients (i.e. one-third of patients with a GRACE EMS = emergency medical services; PCI = percutaneous coronary intervention. Symptoms Onset First medical contact NSTE-ACS diagnosis PCI center Very high Immediate Invasive (<2 hr) Early invasive (<24 hr) Invasive (<72 hr) Non-invasive testing if appropriate High Intermediate Immediate transfer to PCI center Same-day transfer Transfer Transfer optional Riskstratification Therapeutic strategy Low EMS or Non–PCI center Very high High Intermediate Low Figure 6 Selection of non-ST-elevation acute coronary syndrome (NSTE-ACS) treatment strategy and timing according to initial risk stratification. ESC Guidelines296 Roffi M, et al. Eur Heart J 2016
  • 60. Recommandations ESC < 2H acute coronary syndromes Recommendations for invasive coronary angiography and revascularization in non-ST-elevation acute coronary syndromes Recommendations Classa Levelb Ref.c An immediate invasive strategy (<2 h) is recommended in patients with at least one of the following 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 with refractory angina or ST deviation – recurrent dynamic ST- or T-wave changes, particularly with intermittent ST-elevation. I C An early invasive strategy (<24 h) is recommended in patients with at least one of the following high-risk criteria: – rise or fall in cardiac troponin compatible with MI – dynamic ST- or T-wave changes (symptomatic or silent) – GRACE score .140. I A 303, 326, 327 B C D G e a S T T a C b c R Roffi M, et al. Eur Heart J 2016 < 24H
  • 61. Recommandations ESC Roffi M, et al. Eur Heart J 2016 within the Heart Team if delayed CABG of an option. patients with cardiogenic shock develop in up to 3% of NSTE-ACS patients d has become the most frequent cause of his setting.382 – 384 One or more partial or ns may result in severe heart failure, espe- ing LV dysfunction, reduced cardiac output l organ perfusion. More than two-thirds of el CAD. Cardiogenic shock may also be re- mplications of NSTEMI, including mitral re- pillary muscle dysfunction or rupture and e wall rupture. In patients with cardiogenic ary angiography is indicated and PCI is the evascularization modality. If the coronary or PCI, patients should undergo emergent ra-aortic balloon counterpulsation in MI enic shock has been challenged.385 Extra- xygenation and/or implantable LV assist ed in selected patients. An invasive strategy (<72 h) is recommended in patients with at least one of the following intermediate-risk criteria: – diabetes mellitus – renal insufficiency (eGFR ,60 mL/min/1.73 m2 ) – LVEF ,40% or congestive heart failure – early post-infarction angina – recent PCI – prior CABG – GRACE risk score .109 and ,140, or recurrent symptoms or known ischaemia on non-invasive testing. I A 322, 324 In patients with none of the above mentioned risk criteria and no recurrent symptoms, non-invasive testing for ischaemia (preferably with imaging) is recommended before deciding on an invasive evaluation. I A 113, 114 In centres experienced with radial ESC Guidelines ?
  • 62.
  • 64.
  • 66. S’appuyer sur l’ … …même si cela peut être compliqué
  • 69. Ecoutez le patient, il est en train de vous donner le diagnostic. Sir William Osler Ne jamais laisser notre savoir prendre le dessus sur ce qui demeure le plus important, notre ignorance. Henry David Thoreau