1. The document discusses the management of elderly patients presenting with possible acute coronary syndrome (ACS). Biomarkers like high-sensitivity troponin have improved detection of myocardial infarction in this population, but interpretation can be challenging due to age-related changes.
2. Risk stratification tools like the HEART score and evaluation of troponin kinetics can help identify low-risk elderly patients for early discharge. A pathway integrating HEART score, high-sensitivity troponin levels, and clinical judgement may optimize care for these patients.
3. Guidelines recommend aspirin, a P2Y12 inhibitor like clopidogrel, and consideration of extended dual antiplatelet therapy based on risk assessment for secondary prevention
Presentación "Update de los estudios de ABSORB hasta 2014" del Dr. Flavio Ribichini durante la Mesa Redonda sobre Scaffolds reabsorbibles de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
Presentación "Update de los estudios de ABSORB hasta 2014" del Dr. Flavio Ribichini durante la Mesa Redonda sobre Scaffolds reabsorbibles de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
SOLACI Chile Congress 2011. Dr.Ajay Kirtane. Drug-Eluting Stents for Multivessel PCI: Indications and Outcomes. Find more presentations on the web site: www.solaci.org/
Novedades en el manejo del paciente con FA: actualización tras AHA 2016
22/11/2016 19:30h Casa del Corazón, Madrid
http://manejofa.secardiologia.es
#manejoFA
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria percutánea. Guías y preguntas abiertas
Dr. Antonio Fernández Ortiz, Hospital Universitario Clínico San Carlos (Madrid)
Presentación "Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria. Experiencia, Resultados y futuro de un programa nacional" del Dr. Daniel Aradi durante la Mesa Redonda de Antiagregación de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
Presentación "Cardiopatía Estructural" del Dr. José María Hernández durante la Mesa Redonda "Novedades en cardiología Intervencionista del último Congreso a este" de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
Novedades en el manejo del paciente con FA: actualización tras AHA 2016
22/11/2016 19:30h Casa del Corazón, Madrid
http://manejofa.secardiologia.es
#manejoFA
Pacientes con FA que sufren un SCA y son sometidos a intervención coronaria percutánea. Guías y preguntas abiertas
Dr. Antonio Fernández Ortiz, Hospital Universitario Clínico San Carlos (Madrid)
Presentación "Manejo de la antiagregación ajustada a las pruebas de reactividad plaquetaria. Experiencia, Resultados y futuro de un programa nacional" del Dr. Daniel Aradi durante la Mesa Redonda de Antiagregación de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
Presentación "Cardiopatía Estructural" del Dr. José María Hernández durante la Mesa Redonda "Novedades en cardiología Intervencionista del último Congreso a este" de la XXV Reunión Anual de la Sección de Hemodinámica y Cardiología Intervencionista (SHCI) de 2014 en Córdoba.
XXVII Reunión anual de la sección de Hemodinámica y Cardiología Intervencionista
16 y 17 de junio de 2016 León
http://secardiologia.es/xxvii-reunion-anual-de-la-seccion-de-hemodinamica-y-cardiologia-intervencionista
Novedades en farmacología en intervencionismo
Antonio Fernández Ortiz (Hosp. Clínico San Carlos. Madrid)
Dyslipidemia and CVS by Mohit Soni and Chandan KumarOlgaGoryacheva4
My students Mohit Soni and Chandan Kumar had presented this topic in our 22nd Student Scientific Society Conference in the department of Propaedeutic of Internal Diseases No.2
Excelencia en el Manejo del Síndrome Coronario Agudo.
Cambiando el paradigma de tratamiento de los pacientes con Cardiopatía Isquémica.
15/04/2015 18:00h - 20:00h Casa del corazón. Sociedad Española de Cardiología
http://cvvt.secardiologia.es
Antiagregación en los pacientes con Cardiopatía Isquémica
Dr. Héctor Bueno Zamora. Hospital General Universitario Gregorio Marañón (Madrid)
Dr. Roberto Machado from the University of Illinois at Chicago presented an update on PAH at a Patient Education Conference on March 15, 2014 hosted by the Scleroderma Foundation, Greater Chicago Chapter.
This presentation discusses the latest evidence for blood transfusion triggers in the intensive care unit of various clinical condition including severe sepsis, GI bleed, post surgical cases, and post cardiac surgery among other cnditions
Survival after cardiac arrest is poor but some therapies can make a difference. This presentation discusses the evidence for therpauetic hypothermia, normoxia, management of blood pressure and early cardiac catherterisation. It also makes the case that these might be elements of a bundle of care.
Quelles sont les particularités de la détresse respiratoire aiguë de la pneumopathie COVID-19 ? Physiopathologie, présentation clinique et prise en charge par les supports d'oxygénation aux urgences et en extra-hospitalier
My presentation about the history, the life, the genius, and the legacy of Georges Boussignac, inventor of the Boussignac-CPAP.
A Man, a Physician, and a Friend.
My presentation about the history, the life, the genius, and the legacy of Georges Boussignac, inventor of the Boussignac-CPAP.
A Man, a Physician, and a Friend.
Le SCA typique ne représente que 10 à 15% des présentations cliniques, électrocardiographiques et biologiques. Apprendre à le détecter pour que les atypiques vous deviennent évidents.
Si nous portions un nouveau regard sur le syndrome d'encéphalite aiguë chez le sujet jeune ? Il faut penser aujourd'hui à évoquer l'Encéphalite Auto-Immune à Anticorps Anti-Récepteurs NMDA ! Vous sauverez des vies à l'évoquer devant toute épilepsie atypique et/ou psychose inaugurale associée à un signe discordant.
Une série de cas-cliniques ECG pour s'entraîner à reconnaître les situation où les connaissances ECG sauvent des vies aux urgences, en SMUR et ailleurs en cardiologie ou dans d'autre services de soins
Formation DPC Urgences Syndrome Coronarien Aigu - Critères de gravité, ECG, filière, orientation et traitement. Comment aller plus loin que les recommandations au bénéfice du patient. Comment repérer l'occlusion sur l'ECG même quand les millimètres ne sont pas présents...
L'ECG est un élément essentiel de la démarche diagnostique de la syncope du sujet âgé. Cette présentation passe en revue les principales anomalies rencontrées et celles à côté desquelles il ne faut pas passer !
Quelle est la place de l'Optiflow aux urgences ?
Où en est-on des études cliniques ?
Peut-on traiter les patients des urgences comme ceux de réanimation avec l'oxygénation haut-débit ?
De nouvelles perspectives avec l'Optiflow ?
Elles ressemblent à des grands classiques mais possèdent des effets plus puissants et envahissent le marché. Quelles sont ces nouvelles drogues, leurs effets... et doit-on en avoir peur ? World War Z aux Urgences !
BNP/Troponine en POC dans le VL ou l'UMH SMUR ? Cela a t-il encore un sens aujourd'hui ? NON ! Un combat épique au congrès Urgences 2018. Enfin une controverse HARDCORE !
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
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263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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
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
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
!
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
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
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
?
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