Recomandari pentru managmentul

invaziv a pacientilor cu SCA fara

supradenivelare segment ST
 Acute Coronary Syndrome (ACS)
 Definition: The spectrum of acute ischemia
related syndromes ranging from UA to MI
with or without ST elevation that are
secondary to acute plaque rupture or plaque
erosion.
 Pe termen lung riscul de deces al pacientului cu
NSTEMI depășește riscul celor cu STEMI1,2

12 NSTEMI
11
Incidența decesului din momentul externarii

10 STEMI
9
8
pana la 6 luni (%)

NSTEMI
7
6 11.6%
5 STEMI
4 9%
AI
3
2
1
Studiul GRACE, n=21.6881
0
16 26 36 46 56 66 76 86 96 106 116 126 136 146 156 166 176 186

6 luni (începând cu ziua 16 post SCA) 1 an

Adaptat după Fox et al., 2010 Adaptat după Montalescot et al., 2007

1. Fox KAA et al, Nat Clin Pract Cardiovasc Med. 2008 Sep;5(9):580-9.
2. Montalescot G et al. European Heart Journal 2007 28;1409–1417.
 Riscul CV pe termen lung la pacienții cu SCA
rămâne inacceptabil de mare1

18.3%
~ 1 din 5 pacienți prezintă risc
de IM, AVC sau deces CV în
primul an post SCA1

N=97.254 pacienți externați care au supraviețuit după primul IM

(registru suedez).

Terapia antiplachetară cu Brilique +AAS este recomandată până la 12 luni.2

1. Jernberg T et al. Eur Heart J 2015;[ePub ahead of print] ; 2. RCP Brilique, ultima revizuire iulie 2015
 Diagnostic algorithm and triage in acute coronary syndrome

Eur Heart J, ehaa575, https://doi.org/10.1093/eurheartj/ehaa575

 Non ST - SCA treatment strategy and timing

Eur Heart J, ehaa575, https://doi.org/10.1093/eurheartj/ehaa575

 0 h/1 h rule-out and rule-in algorithm using
high-sensitivity cardiac troponin

Eur Heart J, ehaa575, https://doi.org/10.1093/eurheartj/ehaa575

ESC Guidelines
Eur Heart J 2015 Aug 29
Haemodynamic instability or cardiogenic shock
Recurrent or refractory chest pain despite medical
treatment
Life-threatening arrhythmias or cardiac arrest
Mechanical complications of MI
Heart failure clearly related to NSTE-ACS
Presence of ST-segment depression >1 mm in ≥6 leads
additional to ST-segment elevation in aVR and/or V1

Dynamic or presumably new contiguous ST/S-segment changes

suggesting ongoing ischemia
Transient ST-segment elevation
GRACE risk score >140

ESC Guidelines
Eur Heart J 2015/2020
Routine Manual Thrombectomy

N Engl J Med 2015; 372:1389-1398

Manual Thrombectomy
 Routine
Manual
Thrombectomy

TOTAL
ClinicalTrials

N Engl J Med 2015; 372:1389-1398

Fractional flow reserve (FFR) is the current standard for the
functional assessment of lesion severity in patients with intermediate grade
stenosis (40-90%) without evidence of ischaemia in noninvasive
testing, or in those with multivessel disease. Due to
microvascular obstruction, the haemodynamic relevance of the
culprit lesion in NSTE-ACS may be underestimated. However, it
appears reliable for non-culprit lesion estimation when compared to
postponed repeat FFR, CMR perfusion, or SPECT. In ACS
patients, deferred revascularization based on FFR or instantaneous
wave-free ratio (iFR) is associated with worse clinical outcome compared
to patients with stable CAD. Persistent instability of
non-haemodynamically significant stenoses or presence of more than
one unstable lesionmay account for the higher risk.
Nature Reviews Cardiology 2015;12, 383–385

PROTECT II

IABP-SHOCK II, Lancet 2013 ISAR-SHOCK

Meta-analysis of Intervention Trials

Fox et al. Lancet 2002;360:743-751

 Survival Benefits of
Revascularisation
Single Vessel Disease

Two Vessel Disease

Three Vessel Disease

75% Left Main Stem

95% Left Main Stem

0.0 0.5 1.0 1.5 2.0 2.5

Harzard Ratio
Pacient 58 ani, IMA non-ST, angina refractara
Hipertensiv, fumator, Nondiabetic
Pacient 58 ani, IMA non-ST, instabil hemodinamic
Hipertensiv, fumator, Nondiabetic
Abord interventional/tehnica??
Etapa I Wiring + PTCA ADA mediu
Etapa II PTCA TACS-ADA-ACX
Rezultatul final
Pacient 55 ani, IMA non-ST, instabil hemodinamic
Hipertensiv, fumator, Diabetic, trivascular
Abord interventional ?Tehnica?
 Tentativa dezobstructie ACD , esec
Stop procedura ->redirectionare Chir
Barbat , 49 ani , nefumator , hipercolesterolemie familiala,
IM nonST, hsTropI ~ 89ng/ml, fara comorbidit
Abord Terapeutic?? Procedeu interventional?
Rezultatul final
Impact of chronic kidney disease on survival in patients who had
diabetes and were treated with PCI

Williams ME, CJASN 2006;1:209-220

Fem, 81 ani , DZ, supra 0.2mm aVR, trop+, angina refractara
Abord therapeutic? Tehnica?
N Engl J Med 2013;
368:254-265
MACE (death, non-fatal infarction or reintervention) during the
first month after DES or BVS implantation in ACS

EuroIntervention 2014 Jan 22;9(9):1036-41

 IVUS-defined Criteria for The
Optimal Stent Deployment

1. Minimal lumen CSA in stented segment

>5.0 mm2, or 90% of distal reference
lumen CSA;

2. Plaque burden at the 5-mm proximal or

distal to the stent edge <50%;

3. no edge dissection involving media with

length >3mm.

JJ Zhang et al. JACC. 2018.

Three-year Clinical FU
Survival - Immediate or Delayed Coronary Angiography
after Cardiac Arrest and Non - STEMI

N Engl J Med 2019; 380:1397-1407

 Determinants of antithrombotic treatment in coronary artery
disease.

Eur Heart J, ehaa575, https://doi.org/10.1093/eurheartj/ehaa575

 Trial Design

Stop P2Y12 inh. if Primary EP

A prospective, single-arm, multicenter,

Enrollment event-free† Follow-up End of study

X90 Baseline 3M 6M 12 M
open-label, non-randomized trial

Index PCI P2Y12 inhibitor + ASA* ASA only

Primary analysis period:

from 3 to 12 months

Stop P2Y12 inh. if Primary EP

Enrollment event-free† Follow-up Follow-up End of study
X28 Baseline 1M 3M 6M 12 M

P2Y12 inhibitor
Index PCI ASA only
+ ASA*
Primary analysis period:
from 1 to 6 months

* For patients on chronic OAC, dual therapy (OAC plus P2Y12 inhibitor) might be considered for the first 1 or 3 months
†
“Event-free” defined as free from MI, repeat revascularization, stroke, or ST and compliant with DAPT in the first 1 or 3 months
 Conclusions

Among HBR patients undergoing PCI with the XIENCE stent, a short DAPT
regimen of 1 or 3 months compared with standard DAPT up to 12 months
resulted in:
• non-inferior ischemic outcomes
• similar rates of clinically relevant (BARC 2-5) bleeding, with a significant
reduction in major (BARC 3-5) bleeding
• very low incidence of stent thrombosis
Terapia antiplachetară duală se menține până la 12 luni,
indiferent de tipul de stent1-6
Clasă de Nivel de
INDICAȚII cRECOMANDĂRI
recomandare dovezi
ESC (STEMI)1, 2012 Terapia duală antiplachetară trebuie continuată până la 12 luni, cu un
minim strict de: I C
1 lună pentru pacienții care au primit BMS I C
6 luni pentru pacienții care au primit DES IIb B
ESC (SCA NST)2, 2015 Terapia duală antiplachetară trebuie menținută timp de 12 luni,
independent de strategia de revascularizare sau de tipul de stent.
I A
Administrarea inhibitorilor P2Y12 pentru o durată mai scurtă, de 3-6 luni,
după implantarea unui stent DES ar putea fi luată in considerare pentru IIb A
pacienții cu risc crescut de sângerare.

ESC/EACTS STEMI și SCA NST

(revascularizare
miocardică)3 , 2014
Terapia duală antiplachetară timp de 12 luni cu excepția cazurilor cu risc I A/B
excesiv de hemoragii.

ACCF/AHA/SCAI La pacienții cu SCA tratați cu PCI cu stent (BMS sau DES) tratamentul cu
(PCI)4, 2011 inhibitori P2Y12 trebuie administrat cel puțin 12 luni. I B
ACCF/AHA Terapia cu inhibitor P2Y12 trebuie administrată timp de 12 luni la pacienții
(STEMI)5, 2013 cu STEMI tratați prin PCI primar cu stent (BMS sau DES). I B
AHA/ACC Terapia cu inhibitor P2Y12 trebuie administrată timp de cel puțin 12 luni la
(SCA NST)6, 2014 pacienții care au primit un stent. I B

1. Steg G et al. Eur Heart J.(2012) 33, 2569-2619; 2. Roffi M et al, Euro Heart J 2015 doi:10.1093/eurheartj/ehv320;
3. Windecker S.,Kohl P. et al, Eur Heart J. 2014 Oct 1;35(37):2541-619; 4. Levine GN et al. Circulation 2011; 124:e574-e651;
5. O`Gara PT, et al. Circulation.2013 Jan 29;127(4):e362-425; 6. Amsterdam EA et al. Circulation 2014;130:2354-2394.
 Diagnosis and treatment of patients with acute coronary
syndrome related to spontaneous coronary artery dissection

Eur Heart J, ehaa575, https://doi.org/10.1093/eurheartj/ehaa575

Sharonne N. Hayes. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific
Statement. The American Heart Association. Circulation 2018;137 (19): e523-e557
 Coronary Calcification Impacts PCI

Impairs device crossing Delamination Under expansion

Balloon: Atheroablative technologies

Insufficient force Atherectomy: Wire bias Laser: Unpredictable
Barbat, 64 ani, fumator , DZ, IMA nonST PTCA(~11ani) dublu bypass AoC,
AMIS patent, GVSI ocluzat. Strategie invaziva??
Reconstituire TACS-ACX-OMI (Cullote spre SB OMI)
 PROVE-IT Trial
All-Cause Death or Major CV Events
in All Randomized Subjects
30
Pravastatin 40mg
25 (26.3%)

20
%
Atorvastatin 80mg
with 15 (22.4%)
Event
10
16% RR
5 (P =
0.005)
0
0 3 6 9 12 15 18 21 24 27 30
Months of Follow-up