Cardiology Hot Sessions During ESC, AHA, ACC, TCT, ACCA, EHRA, and HFA Congresses by Farzin BEYGUI, MD, PhD

1. ESC 2O15

2. Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or
without Reperfusion to improve Outcome and Survival at Six months follow-up
F. Beygui, G. Cayla, V. Roule, F. Roubille, N. Delarche, J. Silvain, E. Van
Belle, L. Belle, M. Galinier, P. Motreff, L. Cornillet, JP Collet, A. Furber, P.
Goldstein, P. Ecollan, D. Legallois, A. Lebon, H. Rousseau, J.
Machecourt, F. Zannad, E. Vicaut, G. Montalescot
on behalf of the ALBATROSS investigators

3. Years
Tertile 3
Tertile 1
Death according to tertiles
of aldosterone in MI
Log rank P = 0.005
CumulativeSurvivalRate,%
Beygui F, et al. Circulation. 2006;114:2604-2610.
70
75
80
85
90
95
100
1 11 21 31 41 51 61 71 81 91 101 111 121 131 141 151 161 171 181
Days
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Death according to quartiles
of aldosterone in STEMI
Palmer B, et al. Eur Heart J. 2008; 29:2489-96Beygui F, et al. Circulation 2006; 114:2604-10
Aldosterone levels and death in AMI

4. ALBATROSS study design
1° End Point: death, resuscitated cardiac death,
VF/VT, indication for defibrillator, heart failure
up to 6-month FU
control
Randomized
Open label
N=1600
AMI (ST+ or ST-) in the first 72hrs
clinicaltrials.gov registration number NCT 01059136
ALBATROSS study protocol - Beygui et al. Am Heart J 2010
iv K+ canrenoate*
then
spironolactone**
* Soludactone200mg
** Aldactone 25mg od
Aldosterone blockade

5. Standard treatment
(N=801)
MRA regimen
(N=802)
Age (median) 58 58
Current smoking (%) 52 47
Diabetes (%) 16 16
Hypertension (%) 44 42
Dyslipidemia (%) 46 47
Prior MI (%) 9 8
Prior HF (%) 1 1
STEMI (n) 617 612
NSTEMI (n) 183 186
Killip I (%) 91 93
PCI (%) 81 82
LV ejection fraction (median in %) 50 50
Baseline characteristics

6. HR = 0,97 [0,73-1,28]
p= 0. 81
Primaryendpoint
N at risks
Standard Therapy 801 687 669 645 273
MRA Regimen 802 705 683 660 183
Follow-up (days)
In CYP2C19 Extensive &
Standard Therapy
MRA regimen
Primary End Point
Death, resuscitated death, VF/VT, indication for ICD or heart failure
MRA: Mineralocorticoid Receptor Antagonist;VF:Ventricular Fibrillation;VT:Ventricular Tachycardia;ICD:ImplantableCardioverter Defibrillator

7. Standard therapy
(n=801)
MRA regimen
(n=802)
P
value
Significant ventricular
arrhythmia (%) 6 5.6 0.75
New or worsening heart
failure (%) 5.6 5.9 0.85
Death (%)
2.1 1.4 0.26
Death or resuscitated
cardiac arrest (%) 2.4 1.6 0.28
Secondary End Points
Hyperkalemia > 5.5mmol.L-1 (%) 0.2 3 <0.0001

8. HR = 0,20 [0,06-0,69]
p= 0. 0044
Death
N at risks
Standard Therapy 617 587 579 556 236
MRA Regimen 612 595 587 571 162
Follow-up (days)
In e &
Standard Therapy
MRA regimen
Death in STEMI patients (n=1229)

9. Does Cyclosporine ImpRove Clinical oUtcome
in ST-elevation myocardial infarction patients ?
(the CIRCUS study)
Michel OVIZE, MD, PhD
Louis Pradel Hospital and Claude Bernard University,
Lyon, France

10. Reperfusion injury contributes to MI
Reperfusion injury
Ca2+
Transition pore
REPERFUSION NECROSIS
Ischemia / Reperfusion
-
ATP
Pi
Ca2+
ROS
Cyclosporine
Mitochondria
Onset of
chest pain
CORONARY ARTERY OCCLUSION - TIMI flow grade =0-1
WINDOWTO START
TREATMENT OF REPERFUSION INJURY
30 minutes to 12 hours
First medical
care
Cath lab
admission
AMBULANCE PCI CARDIOLOGIST
PCI Reperfusion
Ischemia injury

11. LAD occluded (TIMI 0-1)
Coronary angiography
e-randomization
CicloMulsion® (Neurovive Pharmaceuticals): lipid emulsion of cyclosporine (no cremophor content)
Initial
Echo
Final
Echo
Discharge
PCICicloMulsion® :
(2.5 mg/kg, IV bolus)
1 year
Anterior STEMI
Experimental design
• > 18 years
• symptom onset < 12 hrs
• ST shift ≥ 0.2 mV in two contiguous anterior leads
• LAD as culprit artery with TIMI flow grade : 0 – 1

12. ITT Analysis
Primary endpoint
Analysis
Anterior STEMIs
Randomized
(n= 970)
Control
(n=495)
No informed content (n=1)
Imprisoned andthereforeineligible (n=1)
Did not receive anytreatment (n=4)
Missing or poor echographic data(n=74)
Did not receive anytreatment (n=4)
Missing or poor echographic data(n=95)
Cyclosporine
(n = 475)
Cyclosporine
(n = 395)
Control
(n=396)
modified as treated
analysis
Consort Diagram
(80% power to detect a 20% relative risk reduction)

13. Primary outcome at 1 year
Combined incidence of [all-cause mortality; worsening of heart failure during initial
hospitalization or re-hospitalisation for heart failure ; LV remodeling] within 1 year after
acute MI
(LV remodeling (echo): increase > 15% of LVEDV at 1 year versus initial discharge)
Cyclosporine
(n=395)
Control
(n=396)
Odds Ratio
(95% CI)
P value
(Death / HF / LV remodeling) 233 (59.0 %) 230 (58.1%) 1.04 [0.78; 1.39] 0.77

14. Secondary outcomes at 1 year
Cyclosporine
(n=395)
Control
(n=396)
Odds Ratio
(95% CI)
P value
Death: all-cause 7.1 % 6.6 %
1.09
[0.63 ; 1.90]
0.76
Death: cardiovascular 6.1 % 6.1 %
1.01
[0.56 ; 1.81]
0.98
HF worsening or re-hospitalization for HF 22.8 % 22.7 %
1.01
[0.72 ; 1.41]
0.97
HF worsening 15.7 % 16.9 %
0.92
[0.63 ; 1.34]
0.65
Re-hospitalization for HF 10.6 % 10.4 %
1.03
[0.65 ; 1.63]
0.89
Cardiogenic shock 6.6 % 6.1 %
1.09
[0.61 ; 1.94]
0.77
Recurrent Myocardial infarction 2.3 % 3.8 %
0.59
[0.26 ; 1.37]
0.22
Stroke 1.8 % 3.0 %
0.58
[0.22 ; 1.48]
0.25
Major bleeding 1.8 % 2.3 %
0.73
[0.27 ; 2.00]
0.54
HF: heartfailure

15. Results From The Minimizing
Adverse Haemorrhagic Events By
Transradial Access Site And
Systemic Implementation
of Angiox-MATRIX
Treatment Duration Program
M. Valgimigli, MD, PhD
Swiss Cardiovascular Center Bern,
Inselspital, Bern, Switzerland
on behalf of the MATRIX Group
NCT01433627

16. 1:1
1:1
NSTEACS or STEMI with invasive management
Aspirin+P2Y12 blocker
Trans-Femoral Access
Heparin
±GPI
Bivalirudin
Mono-Tx
Stop
Infusion
Prolong≥ 4 hs
infusion
1:1
Trans-Radial Access
MATRIX Program NCT01433627
http://www.cardiostudy.it/matrix
Lancet. 2015; 385(9986):2465-76
ACC 2015, oral presentation
ACCESS
ANTITHROMBIN
TYPE
TREATMENT
DURATION

17. Primary EP: NACE
11.0%
No post-PCI bivalirudin
Post-PCI bivalirudin
RR: 0.91; 95% CI: 0.74-1.11; P=0.34
11.9%
Treatment Duration Study

18. TCT
Effect of Thrombus Aspiration in
Patients With Myocardial
Infarction Presenting
Late After Symptom Onset
Steffen Desch, MD
Thomas Stiermaier, MD; Suzanne de Waha, MD;
Philipp Lurz, MD, PhD; Matthias Gutberlet, MD; Marcus Sandri, MD;
Norman Mangner, MD; Enno Boudriot, MD;
Michael Woinke, MD; Sandra Erbs, MD; Gerhard Schuler, MD; Georg
Fuernau, MD; Ingo Eitel, MD; Holger Thiele, MD

19. Background
• Recent trials on thrombus aspiration in STEMI
reported disappointing results with no reduction
in mortality and possibly an increase in stroke.
↓
Frobert et al. N Engl J Med 2013;369:1587-97.
Jolly et al. N Engl J Med 2015;372:1389-98.
0 12 h 24 h 36 h 48 h
?
Symptom onset:
TASTE
TOTAL

20. Study Flow
152 patients with subacute STEMI 12 and 48 hours after symptom onset
Thrombus aspiration
(n=70)
Standard PCI Only
(n=74)
No CMR (n=14) No CMR (n=19)
Final diagnosis other than STEMI (n=8)
1:1 randomization
Received allocated treatment (n=70) Received allocated treatment (n=69)
Intention-to-treat (n=56) Intention-to-treat (n=55)
Primary endpoint: Microvascular obstruction

21. Results
Primary Endpoint: Microvascular Obstruction
0
Thrombus
aspiration
Microvascularobstruction,%LV
Standard PCI
only
p=0.47
5
4
3
1
2
2.5 ± 4.0
3.1 ± 4.4

22. AHA

23. The-First-In-Man Randomized Trial of a ß3-
adrenoceptor Agonist in Chronic Heart Failure
BEAT-HF
Henning Bundgaard, Anna Axelsson, Jakob H Thomsen, Mathias Sørgaard,
Klaus Kofoed, Nana Køber, Rasmus B Hasselbalch, Henry Krum,
Søren Boesgaard, Finn Gustafsson, Lars Køber, Kasper Iversen,
Helge Rasmussen

24. • Raised levels of intracellular sodium (Nai) in the cardiomyocytes
contribute to contraction abnormalities in heart failure (HF)
• The Na-K pump in the cardiomyocytes mediates Nai export –
and evidence-based HF treatments stimulate the Na-K pump (ß
blockers, ACE inhibitors, aldosterone antagonists)
• ß3 adrenoceptor (AR) agonists stimulate the Na-K pump
through the NO/cGMP/PKG pathway – mediating Nai export
(Bundgaard et al, Circulation 2010)
Background – chronic heart
failure (HF) and intracellular Na+
BEAT-HF

25. • Mirabegron; (BETMIGA)
- FDA and EMA approved for overactive bladder (OAB)
- Dose (25-)50 mg x 1
- T1/2 =22-25 h, Cmax 3-4 h
• Side effects;
– Increased BP and HR (off-target ß1/2 AR stimulation),
– “Cold” symptoms,
– Gastrointestinal discomfort
• Maximum reported dosage for OAB over12 weeks: 300 mg/day
• Doses administered in this study:
– Start; 25 mg x 2 – then – if tolerated - weekly increases;
– 50 mg x 2, 100 mg x 2, 150 mg x 2 (after a week 300 mg x1)
BEAT-HF
Study drug and dose

26. Study design
BEAT-HF
Screened (n=142)
37 declined
participation
33 Screen failure
12 ejection fraction ≥ 40%
5 Renal failure
5 Atrial fibrillation
4 BMI > 35
3 Drug contra-indications
6 Other
Eligible (n=107)
Randomized
(n=70)
Placebo (n=35)
Mirabegron
(n=35)
2 Deaths
1 Adverse effects
1Admitted - endocarditis
1 Admitted - urinary tract
infection
1 Reduced complianceFollow-up data
analyzed (n=29)
1 Adverse effects
2 Reduced compliance
Follow-up data
analyzed (n=32)
Follow up
6 months

27. • All 61 patients completing the study were compliant by pill count (> 98%)
• 66 patients (94%) reached target dose of 300 mg daily, 3 patients 200 mg
(Mirabegron), 1 patient 100 mg daily (Placebo).
Compliance and safety
BEAT-HF
mmHg
Beatsprmin
Mirabegron
Placebo
Baseline 6 months Baseline 6 months Baseline 6 months
Mean difference
2.2 (95% CL, -5.2 to 9.5)
P=0.55
Mean difference
-0.3 (95% CL, -6.0 to 5.5)
P=0.91
Systolic BP Diastolic BP
Mean difference
0.6 (95% CL, -3.2 to 6.3)
P=0.52
Heart rate
20
0
40
60
80
100
120
140
20
0
40
60
80
100
120
140
mmHg
20
0
40
60
80
100

28. Primary endpoint
BEAT-HF
Left ventricular ejection fraction
P= 0.82
Mean difference
0.4% (95% CL, -3.5 to 3.8)
LVEF(%)
Mirabegron
Placebo
Baseline 6 months

29. Exploratory analyses
BEAT-HF
Baseline 6 months 6 monthsBaseline
Baseline LVEF (CT) < 40% Baseline LVEF (CT) ≥ 40%
P= 0.40
Mean difference
-2.0% (95% CL, -6.8 to 2.8)
P<0.03
Mean difference
5.5% (95% CL, 0.6-10.4)
Mirabegron
Placebo

30. 30
ANNEXA™-R Part 2: A Phase 3 Randomized, Double-Blind, Placebo-
Controlled Trial Demonstrating Sustained Reversal of Rivaroxaban-
Induced Anticoagulation in Older Subjects by Andexanet alfa
(PRT064445), a Universal Antidote for Factor Xa (fXa) Inhibitors
Mark Crowther, MD, MSc, FRCPC
Professor of Medicine, McMaster University, Canada
Co-authors
Alex Gold1
, Genmin Lu1
, Janet M. Leeds1
, Brian L. Wiens1
, Vandana Mathur2
, Janice Castillo1
,
Pamela B. Conley1
, Stuart J. Connolly3
, John T. Curnutte1
1Portola Pharmaceuticals employee; 2Portola Pharmaceuticals consultant; 3McMaster University, Canada

31. 31
Andexanet: Designed to Reverse Activity of Factor Xa Inhibitors
Nature Medicine (2013),19(4): 446-51
Factor Xa Andexanet Alfa
Catalytic DomainGla
Recombinant engineered version of human factor Xa produced in CHO cells
S S
S419
S S
A419
Factor Xainhibitor Factor Xainhibitor
• No known interaction with other coagulation factors except Tissue Factor Pathway
Inhibitor (TFPI)
• Retains high affinity for Antithrombin III-inhibitor complex and can reverseATIII-
dependent anticoagulant effects of enoxaparin and fondaparinux in vitro and in vivo
• Acts as a fXa decoy and retains high affinity for all direct fXa inhibitors
• Change of serine to alanine to eliminate catalytic activity and prevent
prothrombin cleavage
• GLA domain removed to prevent anticoagulant effect
Gla

32. 32
AndexanetHas Demonstrated Deep and Rapid Reversal of
Biomarkersof Anticoagulation for Four fXa Inhibitors to Date
▸ Multiple Phase 2 Proof-of-Concept Studies
Apixaban 5 mg PO Q12 – completed; successful
Rivaroxaban 20 mg PO QD - completed; successful
Enoxaparin 40 mg SQ QD – completed; successful
Edoxaban 60 mg PO QD – completed; successful for cohorts analyzed to date
Betrixaban 80 mg PO QD – ongoing
▸ Phase 3 and Confirmatory Registration-enabling Studies
Phase 3 studies: older healthy subjects treated with apixaban or rivaroxaban –
completed; successful
Phase 4 “Confirmatory study” with bleeding patients – ongoing
Planning enrollment of bleeding patients with
rivaroxaban, apixaban, edoxaban, and enoxaparin
þ
þ
þ
þ
þ
o
þ

33. 33
Andexanet Bolus Only
Placebo
Rn ~ 35 per Xa
Andexanet Bolus + Infusion (x 2hrs)
Placebo
R
apixaban- 400mg andexanet
rivaroxaban- 800mg andexanet
Part I: Bolus
Andexanet Alfa: ANNEXA™ Registration-Enabling Studies
Accelerated Approval Phase 3 Design for Apixaban and Rivaroxaban
apixaban- 400mg + 480mg (4mg/min) andexanet
rivaroxaban- 800mg + 960mg (8mg/min) andexanet
Anti-fXa levels
(Biomarker
endpoint)
n ~ 35 per Xa
þ apixaban
________
rivaroxabanþ
apixaban
________
rivaroxaban
R: Randomization
Part 2: Bolus + Infusion
þ
þ

34. 34
Anti-fXa (ng/mL)
ANNEXA™-R (Rivaroxaban, Bolus + Infusion)
Primary Endpoint: Anti-fXa
Met Primary Endpoint:
▸Mean percent change in anti-fXa from
baseline to post-infusion nadir was 97%
▸p< 0.0001 vs. placebo
Met First Secondary Endpoint:
▸Mean percent change in anti-fXa from
baseline to post-bolus nadir was 95%
▸p< 0.0001 vs. placebo
Met Second Secondary Endpoint:
▸Occurrence of subjects with ≥ 80%
reduction in anti-fXa activity post-
infusion nadir:
AnXa (n= 26/26) vs. Placebo (n=0/13)
▸p< 0.0001 vs. placebo
Time after bolus (hr)
Anti-fXa(ng/mL)
0.0 0.2 0.4 0.6
0
100
200
300
400
1 2 3 4 5 6 7 8 9 10 1112
End of Bolus
Placebo (n=13)
800 mg bolus + 960 mg x 2hr infusion (n=26)
End of Infusion

35. Providing Rapid Out of Hospital
Acute Cardiovascular Treatment:
PROACT-4
Justin A. Ezekowitz, Robert C. Welsh, Dale Weiss, Michael Chan,
William Keeble, Fadi Khadour, Sanjay Sharma, Wayne Tymchak,
Sunil Sookram, Neil Brass, Darren Knapp, Thomas I. Koshy,
Yinggan Zheng, Paul W. Armstrong
on behalf of the PROACT-4 Investigators
20 November 2015
ClinicalTrials.gov NCT01634425

36. Trial Design
Arrival on scene;
Standard Care;
In/Exclusion;
Verbal Consent
POC relayed
to ER staff
POC-Troponin
in ambulance
Usual Care
R
9-1-1 Call
Ambulance
Ambulance ER
Primary outcome:
time to disposition
First medical
contact
Patient
disposition

37. Methods: Troponin & Ambulances
• POC device (Alere Inc, San Diego)
– Cardio2 Troponin I
– analytical sensitivity = 0.01 ng/mL
– 99th %ile = 0.02 ng/mL
• assay & device Health Canada approved
– result within ~15-18 minutes
– Installed on ~25 ambulances
• Edmonton: 3600 km2, 1.1m people, 5 hospitals
(2 PCI)
• EMS System: >300 paramedics, 88
ambulances, ~4000 calls/yr for CP

38. Assessed for eligibility
Randomized (n=601)
Allocated to POC-Troponin (n=305)
•Received POC-Troponin testing (n=250)
•Did not rec’v POC-Troponin testing (n= 55)
Allocated to Usual Care (n=296)
• Received POC-Troponin testing (n=2)
Loss to follow-up (n=0)
Withdrew consent* (n=2)
Loss to follow-up (n=0)
Withdrew consent* (n=2)
ITT Analysis (n=296)
Per protocol analysis (n=294)
ITT Analysis (n=305)
Per protocol analysis (n=250)
July 2013 –Feb 2015
Results

39. Troponin results
Usual care POC-Troponin
n 296 305
First troponin available, minutes 138 (101-218) 38 (28-55)*
POC-troponin I, ng/ml, n (%)
≤0.01 - 196 (64.3)
>0.01 - 53 (17.4)
>0.03 - 30 (9.8)
Not done/missing 55 (18.4)
1st In-Hospital# troponin I, ng/ml, %
>0.1 9.5% 14%
#In-hospital clinical troponin is the Beckman AccuTnI; *p<0.001

40. Primary endpoint: ITT
Usual care POC-Troponin p p adj*
N 296 305
First medical contact
to final disposition,
hours
9.14 (9h08)
(6.68, 11.17)
8.85 (8h51)
(6.22, 10.76)
0.069 0.074
Discharged from ED
9.32 (9h19)
(7.37, 11.00)
8.88 (8h50)
(6.65, 10.23)
0.021 0.017
Admitted to hospital
8.73
(5.43, 11.95)
8.62
(5.25, 12.55)
0.959 0.908
72.5% of all patients were discharged home. Adjustment by modified GRACE score (age, heart rate,
systolic blood pressure, creatinine, cardiac arrest at admission, elevated cardiac enzymes, Killip class)

41. Secondary endpoints: ITT
Usual care POC-Troponin p
N 296 305
Events within 30 days, n (%)
All-cause death 4 (1.4) 4 (1.3) 0.966
Re-ED visit 34 (11.6) 43 (14.2) 0.338
Re/initial hospitalization 18 (6.1) 21 (6.9) 0.690
ED visit or rehospitalization 47 (16.0) 59 (19.5) 0.265
Per protocol analysis all non-significant differences

42. Results
POC-Troponin
>0.03 ng/ml in 9.8%
ACS: 22 patients (73.3%)
AHF: 2 patients (6.7%)
Other: 6 patients (20%)
Using threshold for POC-troponin >0.03 ng/ml for ACS,
compared to all other groups:
Sensitivity 44% and Specificity 96%
PPV 73% and NPV 87%

43. Robert W. Yeh, Eric A. Secemsky, Dean J. Kereiakes, Sharon-Lise T.
Normand, Anthony H. Gershlick, David J. Cohen, John A. Spertus, P.
Gabriel Steg, Donald E. Cutlip, Michael J. Rinaldi, Edoardo Camenzind,
William Wijns, Patricia K. Apruzzese, Yang Song, Joseph M. Massaro,
and Laura Mauri, for the Dual Antiplatelet Therapy (DAPT) Study
Investigators
Individualizing Treatment Duration of Dual
Antiplatelet Therapy after Percutaneous
Coronary Intervention: An Analysis from the
DAPT Study

44. Background
44
• In the DAPT Study, continuation of dual antiplatelet therapy beyond 12
months reduced ischemic complications after coronary stenting compared
with aspirin alone, yet increased moderate or severe bleeding.
Mauri, Kereiakes, Yeh et al. NEJM. 2014 Dec 4:371:2155-66.
-1,0%
-1,6%
-2,0%
1,0%
0,5%
-3,0%
-2,0%
-1,0%
0,0%
1,0%
2,0%
3,0%
HR 0.29
(0.17–0.48)
P<0.001
HR 1.36
(1.00–1.85)
P=0.05
HR 1.61
(1.21–2.16)
P=0.001
Stent
Thrombosis
Death, MI,
Or Stroke
(MACCE)
Myocardial
Infarction
GUSTO
Mod/Severe
Bleed
Death
HR 0.71
(0.59–0.85)
P<0.001
HR 0.47
(0.37–0.61)
P<0.001
Risk Difference (Continued
Thienopyridine –Placebo), 12-30M

45. *The ischemia model C-statistic: 0.70 in DAPT Study; 0.64 in PROTECT
**The bleeding model C-statistic: 0.68 in DAPT Study; 0.64 in PROTECT
45
Multivariable Prediction Models
Predictors of Myocardial
Infarction or Stent Thrombosis
Predictors of
Moderate/Severe Bleeding
Predictors of Events HR (95% CI) P HR (95% CI) P
Continued Thienopyridine
vs. Placebo
0.52 (0.42 – 0.65) <0.001 1.66 (1.26 - 2.19) <0.001
MI at Presentation 1.65 (1.31 – 2.07) <0.001 - -
Prior PCI or Prior MI 1.79 (1.43 – 2.23) <0.001 - -
CHF or LVEF < 30% 1.88 (1.35 – 2.62) <0.001 - -
Vein Graft PCI 1.75 (1.13 – 2.73) 0.01 - -
Stent Diameter < 3 mm 1.61 (1.30 – 1.99) <0.001 - -
Paclitaxel-Eluting Stent 1.57 (1.26 – 1.97) <0.001 - -
Cigarette Smoker 1.40 (1.11 – 1.76) 0.01 - -
Diabetes 1.38 (1.10 – 1.72) 0.01 - -
Peripheral Arterial Disease 1.49 (1.05 – 2.13) 0.03 2.16 (1.46, 3.20) <0.001
Hypertension 1.37 (1.03 – 1.82) 0.03 1.45 (1.00, 2.11) 0.05
Renal Insufficiency 1.55 (1.03 – 2.32) 0.04 1.66 (1.04, 2.66) 0.03
Age (per 10 years) - - 1.54 (1.34, 1.78) <0.001

46. The DAPT Score
46
Variable Points
Patient Characteristic
Age
≥ 75 -2
65 - <75 -1
< 65 0
Diabetes Mellitus 1
Current Cigarette Smoker 1
Prior PCI or Prior MI 1
CHF or LVEF < 30% 2
Index Procedure
Characteristic
MI at Presentation 1
Vein Graft PCI 2
Stent Diameter < 3mm 1
Distribution of DAPT Scores among all
randomized subjects in the DAPT Study

47. 47
Continued Thienopyridine vs. Placebo
DAPT Score <2 (Low); N=5731
1.7% vs. 2.3%
P=0.07
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
ST/MI
12 15 18 21 24 27 30
Months After Enrollment
3.7% vs. 3.8%
P=0.73
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
MACCE
12 15 18 21 24 27 30
Months After Enrollment
3.0% vs. 1.4%
P<0.001
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
GUSTOModerate/
SevereBleed
12 15 18 21 24 27 30
Months After Enrollment
Myocardial Infarction or Stent Thrombosis Death, MI, or Stroke (MACCE)
GUSTO
Moderate/
Severe
Bleeding

48. 48
Continued Thienopyridine vs. Placebo
DAPT Score ≥ 2 (High); N=5917
2.7% vs. 5.7%
P<0.001
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
ST/MI
12 15 18 21 24 27 30
Months After Enrollment
4.9% vs. 7.6%
P<0.001
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
MACCE
12 15 18 21 24 27 30
Months After Enrollment
1.8% vs. 1.4%
P=0.26
Continued Thienopyridine
Placebo
10%
8%
6%
4%
2%
0%
CumulativeIncidenceof
GUSTOModerate/
SevereBleed
12 15 18 21 24 27 30
Months After Enrollment
Myocardial Infarction or Stent Thrombosis Death, MI or Stroke (MACCE)
GUSTO
Moderate/
Severe
Bleeding

49. DAPT Score Calculator
DAPT Score calculator
www.daptstudy.org
Thank you!
49

50. ESC GUIDELINES
2015 ESC Guidelines for the management
of acute coronary syndromes in patients
presenting without persistent ST-segment
elevation – Web Addenda
Task Force for the Management of Acute Coronary Syndromes in
Patients Presenting without Persistent ST-Segment Elevation of the
European Society of Cardiology (ESC)
Authors/Task Force Members: Marco Roffi* (Chairperson) (Switzerland),
Carlo Patrono* (co-Chairperson) (Italy), Jean-Philippe Collet† (France),
Christian Mueller†
(Switzerland), Marco Valgimigli†
(The Netherlands),
Felicita Andreotti (Italy), Jeroen J. Bax (The Netherlands), Michael A. Borger (Germany),
Carlos Brotons (Spain), Derek P. Chew (Australia), Baris Gencer (Switzerland),
Gerd Hasenfuss (Germany), Keld Kjeldsen (Denmark), Patrizio Lancellotti (Belgium),
Ulf Landmesser (Germany), Julinda Mehilli (Germany), Debabrata Mukherjee (USA),
Robert F. Storey (UK), and Stephan Windecker (Switzerland)
Document Reviewers: Helmut Baumgartner (CPG Review Coordinator) (Germany), Oliver Gaemperli (CPG Review
Coordinator) (Switzerland), Stephan Achenbach (Germany), Stefan Agewall (Norway), Lina Badimon (Spain),
Colin Baigent (UK), He´ctor Bueno (Spain), Raffaele Bugiardini (Italy), Scipione Carerj (Italy), Filip Casselman
(Belgium), Thomas Cuisset (France), Çetin Erol (Turkey), Donna Fitzsimons (UK), Martin Halle (Germany),
Christian Hamm (Germany), David Hildick-Smith (UK), Kurt Huber (Austria), Efstathios Iliodromitis (Greece),
Stefan James (Sweden), Basil S. Lewis (Israel), Gregory Y. H. Lip (UK), Massimo F. Piepoli (Italy), Dimitrios Richter
European Heart Journal
doi:10.1093/eurheartj/ehv320

51. hs-cTn no change
Discharge/Stress testing
∆ changea
(1 value >ULN)
Invasive management
Painfree, GRACE <140,
differential diagnoses excluded
Work-up differential
diagnoses
hs-cTn no change
Pain >6h Pain <6h
hs-cTn <ULN hs-cTn >ULN
Highlyabnormalhs-cTn
+clinicalpresentation
hs-cTn no change
Discharge/Stress testing
∆ changea
(1 value >ULN)
Invasive management
Painfree, GRACE <140,
differential diagnoses excluded
Work-up differential
diagnoses
hs-cTn no change
Pain >6h
Re-test hs-cTn: 3h
Pain <6h
hs-cTn <ULN hs-cTn >ULN
Acute Chest Pain
GRACE = Global Registry of Acute Coronary Events score; hs-cTn = high sensitivity cardiac troponin; ULN = upper limit of normal, 99th percentile of healthy controls.
a
Figure 2 0 h/3 h rule-out algorithm of non-ST-elevation acute coronary syndromes using high-sensitivity cardiac troponin assays.
ESC GuidelinesPage 10 of 59

52. Ticagrelor † Unstable angina † Vorapaxar
The table of contents of these guidelines can be found in the
full text document this addenda refers to.
2.1 Definitions, pathophysiology
and epidemiology
2.1.3 Pathophysiology and epidemiology
Plaque rupture or erosion with overlying thrombosis is considered
to be the main initiating mechanism of ACS. Inflammation is believed
to play a key role in plaque disruption, although the stimuli that ini-
tiate the acute inflammatory process remain elusive.14,15
Platelet ac-
tivation and aggregation onto the exposed thrombogenic surface of
a ruptured plaque is an early important event in the pathogenesis of
ACS.15,16
Activated platelets release inflammatory and mitogenic
substances into the microenvironment, primarily altering the
chemotactic, adhesive and proteolytic properties of the endo-
thelium.16
Healthy vascular endothelium releases prostacyclin and
nitric oxide, both of which inhibit platelet activation and aggregation.
It is likely that, when intact, these counterregulatory mechanisms of
endothelial thromboresistance limit the extent and duration of
platelet activation in response to vascular injury.16
This hypothesis
would explain why only a small fraction of disrupted plaques may
elicit symptoms while the majority heal silently. The episodic nature
of platelet activation, supported by transient increases in thromb-
oxane biosynthesis, is consistent with the concept of coronary
atherothrombosis as a dynamic process, in which repeated episodes
of thrombus formation and fragmentation occur over a disrupted
plaque.16
Finally, focal or diffuse spasm of normal or atherosclerotic
coronary arteries, predominantly caused by vasoconstrictor
stimuli acting on hyperreactive vascular smooth muscle cells, may
3.3 Diagnostic tools
3.3.3 ‘Rule-in’ and ‘rule-out’ algorithms
Table 5 Characteristics of the 0 h/3 h and the 0 h/1 h
algorithms
0h/3 h algorithm 0h/1 h algorithm
Negative
predictive value
for acute MI
98–100% 98–100%
Positive
predictive value
for acute MI
Unknown,depending on
delta change and assay
75–80%
Effectivenessa
++ +++
Feasibility
++
requires GRACE score
+++
Challenges
Pain onset cannot be
patients
Cut-off levels are assay-
from the 99th percentile
Validation in
large multicentre
studies
+ +++
Additional
advantages
Already used clinically Shorter time to decision
GRACE ¼ Global Registry of Acute Coronary Events; MI ¼ myocardial infarction.
a
Effectiveness is quantified by the percentage of consecutive chest pain patients
clearly classified as rule-out or rule-in of acute MI (i.e., approximately 60% for the
0 h/3 h algorithm and approximately 75% for the 0 h/1 h algorithm).
ardiac troponin; ULN = upper limit of normal, 99th percentile of healthy controls.
ry syndromes using high-sensitivity cardiac troponin assays.
Suspected NSTEMI
0h <A ng/l Other
0h ≥D ng/l
or
0-1h ≥E ng/l
ObserveRule-out Rule-in
or
0h <B ng/l
and
0-1h <C ng/l
A B C D E
hs-cTnT (Elecsys) 5 12 3 52 5
hs-cTnl (Architect) 2 5 2 52 6
hs-cTnl (DimensionVista) 0.5 5 2 107 19
Figure 3 0 h/1 h rule-in and rule-out algorithms using high-
sensitivity cardiac troponins (hs-cTn) assays in patients presenting
with suspected non-ST-elevation myocardial infarction (NSTEMI)
to the emergency department. 0 h and 1 h refer to the time from
first blood test. NSTEMI can be ruled-out already at presentation,
byguestonSeptember8,2015Downloadedfrom

53. European Heart Journal: Acute Cardiovascular Care
1–23
© The European Society of Cardiology 2015
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/2048872615604119
acc.sagepub.com
EUROPEAN
SOCIETY OF
CARDIOLOGY®
Pre-hospital management of
patients with chest pain and/
or dyspnoea of cardiac origin.
A position paper of the Acute
Cardiovascular Care Association
(ACCA) of the ESC.
Writing committee
Farzin Beygui1 (Chair), Maaret Castren2, Natale Daniele Brunetti3,
Fernando Rosell-Ortiz4, Michael Christ5, Uwe Zeymer6, Kurt Huber7,
Fredrik Folke8, Leif Svensson9, Hector Bueno10, Arnoud van’t Hof11,
Nikolaos Nikolaou12, Lutz Nibbe13, Sandrine Charpentier14,
Eva Swahn15, Marco Tubaro16 and Patrick Goldstein17
119ACC0010.1177/2048872615604119European Heart Journal: Acute Cardiovascular CareBeygui et al.
Original scientific paper

54. 6 European Heart Journal: Acute Cardiovascular Care
evidence for the benefit of pre-hospital versus in-hospital
antithrombotic therapy, a fast transfer with no administra-
tion of any antithrombotic medication to a PCI-capable
centre could be the most reasonable decision in patients
with active bleeding or at very high risk of bleeding.
Caution should be taken in general, based on the risk assess-
ment, not to initiate a treatment pre-hospital which might
be administered more safely in the hospital setting after fur-
ther evaluation. In such situations a rapid and secure trans-
fer in stable conditions to the appropriate facility is the best
option.
Reperfusion therapy and STEMI networks. Reperfusion ther-
apy is widely discussed in the ESC guidelines for the man-
agement of STEMI9 and for myocardial revascularization.18
The care of STEMI in the pre-hospital setting should be
based on regional STEMI networks. Such networks include
one or more hospitals and EMS organizations which have a
shared protocol for the choice of reperfusion strategy
adjunctive therapy and patient transfer in order to provide
consistent treatment to patients. Such protocols should be
formally discussed between all components of the network
that can provide both reperfusion strategies should balance
the benefit and the risk of pre-hospital fibrinolysis >6 h
after symptom onset. The choice between PPCI and
fibrinolysis in the individual patient should be based on the
estimated time for PCI (first medical contact to balloon
time), the patient’s bleeding risk, time since symptom
onset, STEMI location and the haemodynamic status of the
patient, as outlined in the ESC guidelines.20 It is especially
relevant in elderly patients with non-extensive STEMI to
consider switching to a PPCI strategy if it can be done with-
out an ‘unacceptable’ increase in reperfusion delay.
Direct telephone contact between the pre-hospital team,
the emergency medical communication centre and inter-
ventional cardiology team, with ECG teletransmission if
necessary, may be very useful in planning reperfusion ther-
apy in the safest and most efficient way in borderline cases.
The use of nitrates and beta-blockers in the pre-hospital
setting has not been studied and may be associated with
hypotension and heart failure. The routine use of intrave-
nous beta-blockers as well as routine oxygen supplementa-
tion early after myocardial infarction are associated with
adverse events.21,22 Therefore, the routine use of nitrates,
Table 4. Pre-hospital adjunctive therapy in a primary percutaneous coronary intervention strategy for ST elevation myocardial
infarction.
Pain control
Titration of i.v. opioids (limited to the lowest dose required)
Anticoagulant
Enoxaparine: 0.5mg/kg or UFH 70–100 IU/kg i.v. bolus only
(Bivalirudin may be considered in patients at high risk of bleeding.)
Antiplatelet therapy
Aspirin LD 150–300 mg p.o. or 250–500 mg i.v.
And
P2Y12 inhibitor
Ticagrelora 180 mg LD p.o.
Or
Prasugrel 60 mg LD p.o. (if no past history of stroke and age <75 years)
Or
Clopidogrel 600 mg LD p.o. if ticagrelor and prasugrel unavailable or contra-indicated
aOnly the pre-hospital administration of ticagrelor has been compared with its in-hospital administration in an adequately sized random controlled
trial (RCT) showing its safety. Small RCTs have assessed the pre-hospital administration of clopidogrel, and prasugrel’s pre-hospital use has been
assessed only in non-RCT cohort studies.
i.v.: intravenous; p.o.: per os; LD: Loading dose.Beygui et al. 7
Table 5. Pre-hospital fibrinolysis in ST elevation myocardial infarction.
Pre-hospital fibrinolysis strategy
Pain control
Titration of i.v. opioids (limited to the lowest dose required)
Age <75 years:
- Aspirin 150–300 mg p.o. or i.v.
- Clopidogrel 300 mg p.o.
- Enoxaparin: 30mg i.v. + 1mg/kg s.c. (max 100mg) 15 min after i.v. bolus
- Tenecteplase weight adjusted dosea
Age ⩾75:
- Aspirin 150–300 mg p.o. or i.v.
- Clopidogrel 75 mg p.o.
- Enoxaparin: 1mg/kg s.c. (max. 75mg), no i.v. bolus
- Tenecteplase half weight adjusted doseb
In all cases a direct transfer to a PCI-capable centre for rescue PCI for fibrinolysis failure or routine PCI should be preferred to
transfer to a non-PCI facility.
aWeight adjusted dose: 30mg ⩽60kg, 35mg >60 to ⩽70 kg, 40mg >70 to ⩽80 kg, 45mg >80 to ⩽90kg, 50 mg if >90 kg.
bReducing the dose by 50% in elderly patients was associated with an improvement of outcome in the STREAM trial.
i.v.: intravenous; p.o.: per os; s.c.: subcutaneous; PCI: percutaneous coronary intervention.

55. 21
d
)
-
-
d
-
2
s
e
-
-
g
d
s
y
k
s
Point of care troponin tests may be considered in the
setting of NSTE-ACS.
In the case of chest pain at first medical contact, sub-
lingual or intravenous nitrates titrated to blood pres-
sure are recommended.
Transfer to the appropriate facility without any ‘en
route’ treatment or aspirin alone is recommended in
the absence of need for urgent (<2 h) invasive
assessment.
In EMSs where emergency physicians are on board
and in the case of an early invasive strategy (<2 h),
an antithrombotic therapy including aspirin, ticagre-
lor or clopidogrel loading dose and anticoagulation
by enoxaparin or UFH may be considered.
The use of prasugrel in the pre-hospital setting is not
recommended.
A management similar to STEMI is recommended in
NSTE-ACS patients with cardiogenic shock, life-
threatening arrhythmias or persistent ischaemia
despite initial management, with an antithrombotic
regimen including aspirin, ticagrelor or clopidogrel
loading dose and anticoagulation by enoxaparin or
UFH, and immediate invasive strategy.
In the case of stable NSTE-ACS, transfer to an emer-
gency department or a chest pain unit is recom-
nd 75 mg dose in ≥ 75 years old) in combination
ith pre-hospital fibrinolysis is mandatory.
weight adjusted dose of tenecteplase as the first
ne pre-hospital fibrinolytic regimen is recom-
ended with a half dose regimen in > 75 years old.
nticoagulation is mandatory at the time of pre-hos-
tal fibrinolysis with fibrin specific agents.
noxaparin is highly recommended as the anticoagu-
nt of choice in this setting.
ivalirudin and fondaparinux are not recommended
combination with pre-hospital fibrinolysis.
ACS
hrombotic and bleeding risk assessment is highly
ecommended in the setting of NSTE-ACS.
Aortic dissection
The use of ADD score in the pre-hospital setting is
highly recommended.
FoCUS echocardiography may be considered to
support the diagnosis of aortic dissection in the pre-
hospital setting.
A treatment limited to pain relief and blood pressure
control is recommended in suspected aortic
dissection.
The recommended target heart rate and systolic
blood pressure are <60 beats/min and between 100
and 120 mmHg respectively in the absence of neuro-
logical complications.
by guest on August 28, 2015acc.sagepub.comDownloaded from
Starting beta-blockers before other antihypertensive
drugs is highly recommended.
In the case of complications life support and rapid
transfer are recommended.
Withholding antithrombotic therapy in suspected
aortic dissection is mandatory.
Transfer of patients with a very high probability of
aortic dissection (ADD score ≥ 1) to a centre with
24/7 available aortic imaging and cardiac surgery is
mandatory.
Activation of aortic imaging and cardiac surgery and
admission directly to radiology before proceeding to
the operating theatre may be considered.
Transfer to a non-surgical centre for imaging before
transfer to a facility with cardiac surgery is not
recommended.
onary embolism
The use of clinical prediction scores developed to
determine the likelihood of pulmonary embolism is
highly recommended.
The use of point of care D-dimer, troponin and BNP
tests is not recommended.
In patients with suspected pulmonary embolism con-
tinuous ECG and blood oxygen saturation monitor-
ing, and an intravenous access during transfer are
highly recommended.
Point of care FoCUS echocardiography may be
ment, chest pain unit, cardiology unit) in facilities
where echocardiography and pericardiocentesis are
available is recommended.
AHF
Risk assessment in the pre-hospital setting based on
the following characteristics is mandatory:
Presence of cardiogenic shock; haemodynamic
instability (heart rate > 130 beats/min or <40,
systolic blood pressure <90 mmHg); respi-
ratory distress (respiration rate > 25, blood
oxygen saturation <90%); ECG findings (ven-
tricular or supraventricular arrhythmia, bra-
dycardia, on-going ischaemia (i.e. STEMI,
NSTE-ACS)).
FoCUS pulmonary and cardiac ultrasound may be
considered in the pre-hospital setting if competent
staff are on board.
The point-of care BNP tests may be considered in
the pre-hospital setting.
Delaying transfer for ultrasound or BNP testing in
the pre-hospital setting is not recommended.
In the absence of cardiogenic shock the recom-
mended treatment is:
Oxygen with a target saturation >94%;
Sublingual/intravenous nitrates titrated accord-
ing to blood pressure;
Intravenous diuretics (furosemide).
Starting beta-blockers before other antihypertensive
drugs is highly recommended.
In the case of complications life support and rapid
transfer are recommended.
Withholding antithrombotic therapy in suspected
aortic dissection is mandatory.
Transfer of patients with a very high probability of
aortic dissection (ADD score ≥ 1) to a centre with
24/7 available aortic imaging and cardiac surgery is
mandatory.
Activation of aortic imaging and cardiac surgery and
admission directly to radiology before proceeding to
the operating theatre may be considered.
Transfer to a non-surgical centre for imaging before
transfer to a facility with cardiac surgery is not
recommended.
onary embolism
The use of clinical prediction scores developed to
determine the likelihood of pulmonary embolism is
highly recommended.
The use of point of care D-dimer, troponin and BNP
tests is not recommended.
In patients with suspected pulmonary embolism con-
tinuous ECG and blood oxygen saturation monitor-
ing, and an intravenous access during transfer are
highly recommended.
Point of care FoCUS echocardiography may be
ment, chest pain unit, cardiology unit) in facilities
where echocardiography and pericardiocentesis are
available is recommended.
AHF
Risk assessment in the pre-hospital setting based on
the following characteristics is mandatory:
Presence of cardiogenic shock; haemodynamic
instability (heart rate > 130 beats/min or <40,
systolic blood pressure <90 mmHg); respi-
ratory distress (respiration rate > 25, blood
oxygen saturation <90%); ECG findings (ven-
tricular or supraventricular arrhythmia, bra-
dycardia, on-going ischaemia (i.e. STEMI,
NSTE-ACS)).
FoCUS pulmonary and cardiac ultrasound may be
considered in the pre-hospital setting if competent
staff are on board.
The point-of care BNP tests may be considered in
the pre-hospital setting.
Delaying transfer for ultrasound or BNP testing in
the pre-hospital setting is not recommended.
In the absence of cardiogenic shock the recom-
mended treatment is:
Oxygen with a target saturation >94%;
Sublingual/intravenous nitrates titrated accord-
ing to blood pressure;
Intravenous diuretics (furosemide).
The pre-hospital risk assessment based on the fol-
lowing characteristics is mandatory:
Presence of cardiogenic shock; haemodynamic
instability (heart rate > 130 beats/min or <40, sys-
tolic blood pressure <90 mmHg); signs of acute
right ventricular compression and increased sys-
temic venous pressure (jugular vein distension);
respiratory distress (respiration rate > 25, blood
oxygen saturation <90%); low voltage, and/or
electrical alternans on the ECG.
The pre-hospital use of echocardiography in this set-
ting may be considered if expertise is available and
if it does not delay patient transfer.
Ultrasound-guided pericardiocentesis may be consid-
ered in the pre-hospital setting if ultrasound devices
and medical expertise are available on board.
Blind pericardiocentesis may be considered by highly
trained medical operators in the absence of ultrasound
in severe cases with refractory cardiac or ‘near-
cardiac’arrest with very high likelihood of tamponade.
Rapid transfer of patients with suspicion of tam-
ponade to the nearest centre with the possibility of
ultrasound-guided pericardiocentesis and/or cardiac
surgery on-site is mandatory.
Chest pain or dyspnoea in relation with
cardiac arrhythmia
Continuous ECG monitoring and venous access are
mandatory in all patients with any type of cardiac
arrhythmia.
ant angina pectoris.
Pharmacological treatment of cardiac arrhythmias in
the pre-hospital setting may be considered in selected
conditions.
Intravenous amiodarone may be considered for
patients with resuscitated cardiac arrest as a pre-
vention of recurrent life-threatening ventricular
arrhythmia.
Intravenous amiodarone may be considered in pre-
vention of recurrent supraventricular arrhythmia
with haemodynamic compromise after urgent elec-
trical cardioversion.
Intravenous adenosine may be considered in selected
cases of re-entrant supraventricular tachycardia.
In the case of very rapid, irregular wide QRS
tachycardia – possible atrial fibrillation with pre-
excitation – the use of AV slowing agents is not
recommended (contraindicated). In these patients
electrical cardioversion is recommended.
Atropine, adrenaline, isoprenaline and external pac-
ing are recommended in the pre-hospital setting in
patients with severe bradycardia associated with
haemodynamic instability (hypotension, shock) and/
or loss of consciousness.
A direct transfer of well tolerated arrhythmia with-
out any specific treatment to adequate structures is
recommended.
Transfer to a facility with continuous ECG monitor-
ing (emergency department, chest pain unit, inten-
sive or continuous care unit) is mandatory for all
patients with symptomatic cardiac arrhythmia.
23
Specific ECG training and ECG tele-transmission by
EMS teams not including emergency physicians
skilled in identification of dysrhythmias is highly
recommended.
Pre-hospital electrical cardioversion is recom-
mended in patients with rapid ventricular or
supraventricular arrhythmias associated with haemo-
dynamic instability, loss of consciousness or resist-
ant angina pectoris.
Pharmacological treatment of cardiac arrhythmias in
the pre-hospital setting may be considered in selected
conditions.
Intravenous amiodarone may be considered for
patients with resuscitated cardiac arrest as a pre-
vention of recurrent life-threatening ventricular
arrhythmia.
Intravenous amiodarone may be considered in pre-
vention of recurrent supraventricular arrhythmia
with haemodynamic compromise after urgent elec-
trical cardioversion.
Intravenous adenosine may be considered in selected

56. Introduction
Since 2000, the International Liaison Committee on
Resuscitation (ILCOR) has published the International
Consensus on Cardiopulmonary Resuscitation and
Emergency Cardiovascular Care Science With Treatment
Recommendations (CoSTR) every 5 years based on review
of cardiopulmonary resuscitation (CPR) science. Seven task
forces with representatives from the 7 member resuscitation
organizations create the CoSTR that enables regional resusci-
tation organizations to create their individual guidelines. The
different guidelines are based on the scientific evidence and
incorporate or adjust for regional considerations.
Why Acute Coronary Syndromes?
Coronary heart disease remains among the leading causes of
mortality globally. There is considerable research focus world-
wide on improving outcomes in patients with acute coronary
syndromes (ACS). Undoubtedly, this has led to improved
of patients was based on extrapolation of in-hospital evidence.
There is now increasing interest and evidence on the prehos-
pital decisions and management of ACS. The time-sensitive
nature of ACS forces us to scrutinize not only the time goals
to deliver the interventions but also the proper sequencing of
them. For these reasons, the ACS Task Force emphasized the
evidence review for 2015 on the management of ACS before
the patient is admitted.
There has been renewed interest of late in focusing less on
the individual aspects of STEMI care and more on the systems
of care. This is in recognition that the system may be more
than the sum of its parts. In STEMI care, this system integrates
awareness and prevention, prehospital care, in-hospital care,
specialty centers, and rehabilitation and secondary prevention.
The ACS Task Force concentrated on the questions that will
inform regional systems-of-care decisions. If a patient with
ACS or STEMI presents to prehospital care, a local hospital,
or a specialty center, there needs to be a common but nuanced
approach to diagnosis and treatment. However, the specifics of
Part 5: Acute Coronary Syndromes
2015 International Consensus on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care Science With Treatment
Recommendations
Michelle Welsford, Co-Chair*; Nikolaos I. Nikolaou, Co-Chair*; Farzin Beygui; Leo Bossaert;
Chris Ghaemmaghami; Hiroshi Nonogi; Robert E. O’Connor; Daniel R. Pichel; Tony Scott;
Darren L. Walters; Karen G. H. Woolfrey; on behalf of the Acute Coronary Syndrome Chapter Collaborators
Circulation. 2015;132[suppl 1]:S146–S176. DOI: 10.1161/CIR.0000000000000274.
Resuscitation 95 (2015) 264–277
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation
European Resuscitation Council Guidelines for Resuscitation 2015
Section 8. Initial management of acute coronary syndromes
Nikolaos I. Nikolaoua,∗
, Hans-Richard Arntzb
, Abdelouahab Bellouc
, Farzin Beyguid
,
Leo L. Bossaerte
, Alain Cariouf
, on behalf of the Initial management of acute coronary
syndromes section Collaborator1

57. Welsford et al Part 5: Acute Coronary Syndromes S151
context of strong initial education programs, quality assurance
programs, and ongoing oversight.
As was pointed out in the public comments, it is difficult
to perform head-to-head comparisons or combine data from
these studies, because they have used different proprietary
computer interpretation algorithms and different gold stan-
dards. It is likely that different algorithms perform differently.
Computer interpretation algorithms can be updated periodi-
cally, which may change their effectiveness, making previ-
ous studies less relevant unless the algorithm and version are
the same as is used in your setting. Last, some of the algo-
rithms can now be adjusted to favor either lower FP results or
lower FN results, depending on the needs or how it is used.
Therefore, in choosing to use such a computer algorithm as
an adjunct, careful consideration of the individual algorithm’s
reported performance and evaluation of this in your own set-
ting are key.
The use of computer ECG interpretation did not yield
equally effective performances across the various systems of
care where it has been used with observed sensitivities rang-
ing from 0.58 to 0.78 and specificity ranging from 0.91 to 1.
This may be due to the algorithm performance (different per-
existing options of ECG interpretation such as transmission of
ECG for interpretation by an experienced provider.
Knowledge Gaps
Different computer algorithms have not been compared.
The optimal ECG computer algorithm for implemen-
tation with adjunctive nonexpert interpretation has not
been determined.
Nonphysician STEMI ECG Interpretation (ACS 884)
Among adult patients with suspected STEMI outside of a hos-
pital (P), do nonphysicians (eg, nurses and paramedics) (I),
compared with physicians (C), change identification of STEMI
on an ECG with acceptable rates of FNs to allow earlier iden-
tification and FPs, minimizing unnecessary angiography (O)?
Consensus on Science
For the important outcomes of FP and FN results, we have
identified very-low-quality evidence (downgraded for risk of
bias, inconsistency, and publication bias) from 3 studies34–36
including 1360 ECGs of FP results of STEMI recognition
ranging from 0.3% to 30.5% (under the assumption of a dis-
Figure 1. Thirty-day mortality in STEMI patients undergoing PPCI with and without prehospital ECG and hospital notification (random
effects model). Intervention = prehospital ECG; control = without prehospital ECG.
S152 Circulation October 20, 2015
Values, Preferences, and Task Force Insights
In making this recommendation, we adopt a balanced
approach in between minimizing treatment delays of patients
with STEMI and avoiding excess waste of resources resulting
catheterization laboratory (C), change mortality, major bleed-
ing, stroke, reinfarction (O)?
Introduction
Figure 3. Thirty-day mortality for prehospital STEMI activation of the catheterization laboratory versus no prehospital activation.
Experimental = prehospital STEMI activation of the catheterization laboratory; control = no prehospital STEMI activation of the
catheterization laboratory.
Pre-hospital ECG
Pre-hospital cathlab activation

58. S156 Circulation October 20, 2015
a topic requiring further research. Our a priori outcomes did
not include stent thrombosis; thus, this was not included in
the 2015 consensus on science. However, where post hoc
evidence of increased stent thrombosis rates were available,
inclusion in treatment recommendations was considered.
The concomitant administration of adjunctive anti-
thrombotic therapy in association with reperfusion therapy
is recommended widely based on consistent evidence in
international specialty guidelines.56,57
Nevertheless, whether
effort should be undertaken to include such additional therapy
in the prehospital management of STEMI patients, particu-
larly in a planned primary PCI strategy, remains to be evalu-
ated and is the subject of this section. Two related questions
reviewed the evidence for administration of anticoagulants
in the prehospital setting. One reviewed prehospital versus
in-hospital use, and the other reviewed prehospital adminis-
tration of different agents. Interestingly, only UFH has been
evaluated directly in a comparison of prehospital versus in-
hospital use despite other agents being used in the prehospi-
tal setting. We encourage prospective RCTs on the relative
benefits of prehospital versus in-hospital administration of
anticoagulants. While stent thrombosis was not an a priori
outcome in our evaluations, it remains a major complication
of PCI, and, thus, where post hoc evidence of increased stent
thrombosis rates were available, this was considered for the
were available for only 1 of these trials. The other 2 studies
were not yet published.
Prehospital ADP-Receptor Antagonists in
STEMI (ACS 335)
Among adult patients with suspected STEMI outside of the
hospital (P), does prehospital administration of an ADP-
receptor antagonist (clopidogrel, prasugrel, or ticagrelor) in
addition to usual therapy (I), compared with administration
of an ADP-receptor antagonist in-hospital (C), change death,
intracranial hemorrhage, revascularization, stroke, major
bleeding, reinfarction (O)?
Consensus on Science
For the critical outcome of 30-day mortality, we have identi-
fied very-low-quality evidence (downgraded for imprecision
and reporting bias) from 3 RCTs58–60
enrolling 2365 patients
showing no additional benefit with prehospital administra-
tion of an ADP-receptor antagonist compared with in-hospital
administration (OR, 1.58; 95% CI, 0.90–2.78) (Figure 4).
For the important outcome of major bleeding, we have
identified very-low-quality evidence (downgraded for impre-
cision and reporting bias) from 3 RCTs58–60
enrolling 2365
patients showing no additional benefit with prehospital
administration of an ADP-receptor antagonist compared with
Figure 4. Thirty-day mortality for prehospital versus in-hospital ADP-antagonist administration. Experimental = prehospital ADP-antagonist
administration; control = in-hospital ADP-antagonist administration.
S166 Circulation October 20, 2015
elevation after OHCA may be temporary and does not always
correlate with an acute coronary artery occlusion.
In 2010, ILCOR completed a single evidence review to
examine all adult patients with OHCA and ROSC, inclusive
of patients with and without ST elevation. In clinical practice,
ACS with and without ST elevation are clinically distinct syn-
dromes that are managed with guidelines that promote specific
time to intervention targets for STEMI, while less time-sensi-
benefit of emergency cardiac catheterization versus cardiac
catheterization later in the hospital stay or no catheterization
(OR, 2.54; 95% CI, 2.17–2.99).
Treatment Recommendation
We recommend emergency† cardiac catheterization labora-
tory evaluation in comparison with cardiac catheterization
later in the hospital stay or no catheterization in select†† adult
Figure 13. Hospital mortality for patients with ROSC after cardiac arrest with ST elevation: emergency cardiac catheterization versus
delayed or no cardiac catheterization. Experimental = emergency cardiac catheterization; control = delayed or no cardiac catheterization.
S168 Circulation October 20, 2015
Figure 14. Hospital mortality for patients with ROSC after cardiac arrest without ST elevation: emergency cardiac catheterization versus
delayed or no cardiac catheterization. Experimental = emergency cardiac catheterization; control = delayed or no cardiac catheterization.
Pre-hospitalP2Y12inhibitorsAngioafterROSC&NSTAngiographyafterROSC&ST

59. AHA/ACC guidelines STEMI update 2015
2015 ACC/AHA/SCAI Focused Update on Primary PCI
2. Culprit Artery–Only Versus Multivessel PCI
(See Section 5.2.2.2 of 2011 PCI guideline and Section 4.1.1 of 2013 STEMI guideline for
recommendations.)
2013 Recommendation
2015 Focused Update
Recommendation
Class III: Harm
PCI should not be performed in a
noninfarct artery at the time of
primary PCI in patients with
STEMI who are
hemodynamically stable (11-13).
(Level of Evidence: B)
Class IIb
PCI of a noninfarct artery may be
considered in selected patients with
STEMI and multivessel disease who are
hemodynamically stable, either at the
time of primary PCI or as a planned
staged procedure (11-24). (Level of
Evidence: B-R)
Modified r
(changed c
to “IIb” an
frame in w
could be pe
PCI indicates percutaneous coronary intervention; and STEMI, ST-elevation myocardial infarction.
Approximately 50% of patients with STEMI have multivessel disease (25,26). PCI options
STEMI and multivessel disease include: 1) culprit artery–only primary PCI, with PCI of no
for spontaneous ischemia or intermediate- or high-risk findings on predischarge noninvasiv
multivessel PCI at the time of primary PCI; or 3) culprit artery–only primary PCI followed
nonculprit arteries. Observational studies, randomized controlled trials (RCTs), and meta-an
culprit artery–only PCI with multivessel PCI have reported conflicting results (11,12,14-24,
of differing inclusion criteria, study protocols, timing of multivessel PCI, statistical heteroge
endpoints (Data Supplement).
Previous clinical practice guidelines recommended against PCI of nonculprit artery
primary PCI in hemodynamically stable patients with STEMI (9,10). Planning for routine, s
Levine GN, et al.
2015 ACC/AHA/SCAI Focused Update on Primary PCI
2011/2013 Recommendation
2015 Focused Update
Recommendations
Class IIa
Manual aspiration
thrombectomy is reasonable for
patients undergoing primary
PCI (29-32). (Level of
Evidence: B)
Class IIb
The usefulness of selective and bailout
aspiration thrombectomy in patients
undergoing primary PCI is not well
established (33-37). (Level of
Evidence: C-LD)
Class III: No Benefit
Routine aspiration thrombectomy
before primary PCI is not useful (33-
37). (Level of Evidence: A)
Modified
changed
selective
thrombec
New reco
No Bene
aspiration
PCI).
PCI indicates percutaneous coronary intervention; and LD, limited data.