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ESC ESSENTIAL MESSAGES FROM ESC GUIDELINES Committee for Practice GuidelinesTo improve the quality of clinical practice and patient care in Europe
Εισαγωγή
Δεν υπάρχει αμφιβολία ότι η ασκούμενη σήμερα ιατρική πρέπει να βασίζεται σε αποδείξεις-αποτελέσματα μεγάλων κλινικών μελετών ( evidence based medicine ).Η Ευρωπαϊκή καρδιολογική εταιρεία μας ενημερώνει συνεχώς με όλες τις σύγχρονες οδηγίες σε όλους τους τομείς της καρδιολογίας με απώτερο στόχο στόχο τη βελτίωση της παρεχόμενης περίθαλψης στους πολίτες της Ευρώπης.Τα συνήθως εκτενή κείμενα των οδηγιών αποτελούν ίσως ένα εμπόδιο στην κατανόησή τους.Για το λόγο αυτό και επειδή όμως φαίνεται υπάρχει πράγματι πρόβλημα στην εφαρμογή των κατευθυντήριων οδηγιών στην κλινική πράξη η ΕΚΕ μας ενημερώνει τώρα άμεσα απελευθερώνοντας σε ηλεκτρονική μορφή τα βασικότερα σημεία ( take home massages ) όλων των οδηγιών. Βρίσκω ιδιαίτερα ενδιαφέρον το γεγονός ότι η αρμόδια επιτροπή παραθέτει και τονίζει μαζί με τις οδηγίες και τα σημεία στα οποία υπάρχει κενό,διχογνωμία ή μη επαρκής τεκμηρίωση για να διευκολύνει έτσι τον θεράποντα ιατρό στην άσκηση της ιατρικής στην κλινική πράξη. Δυστυχώς σήμερα το θέμα εφαρμογής των οδηγιών
μπορεί να έχει και νομικές προεκτάσεις όπως φαίνεται ότι είχε και στην αρχαιότητα,όπως φαίνεται από σχετικά δημοσιεύματα : ……if Egyptian military doctors go contrary to the laws prescription in any respect they must submit to a trial as a penalty. Greek philosopher Plato was the first to predict that guidelines may lead to legal consequenses. He considered guidelines even as humillating for physicians because they: 1st. focus on an average and not to individualization and 2nd.guidelines prouded from others cannot taken root and cannot be harmonised with the personality methods and experience of each one physician. Diodorus Siculus, 2nd century BC
Clinical guidelines can operate legally as a sword, in that doctors can be criticized for not adhering to them, or as a shield to rebut criticism of inadequate treatment. Dr D Hart, Heart 2002
Finally,in presenting these guidelines the committee recognises that the responsible physician’s judgment remains paramaount. JNC VII guidelines, JAMA 2003;289:2560-2572
Προσωπικά συμφωνώντας με τη θέση που εκφράζεται στις τελευταίες αμερικανικές οδηγίες για την υπέρταση,έχω τη γνώμη ότι πρέπει να διαβάζουμε όλες τις οδηγίες αλλά εκείνος που αποφασίζει τελικά είναι ο θεράπων ιατρός με βάση τις οδηγίες,την απαιτούμενη εκάστοτε εξατομόκευση αλλά και την προσωπική του εμπειρία και γνώση.
Σήμερα στο κείμενο που ακολουθεί δημοσιεύουμε τα βασικά μηνύματα από τις οδηγίες για το οξύ έμφραγμα και τα συγκοπτικά επεισόδια.
ESC ESSENTIAL MESSAGES FROM ESC GUIDELINES FOR THE DIAGNOSIS AND MANAGEMENT OF ACUTE MYOCARDIAL INFARCTION ( STEMI )
Take home messages
Emergency care
- Management, including diagnosis and treatment, starts at the point of first medical contact.
- A 12-lead ECG must be obtained as soon as possible with a target delay of ≤ 10 min.
- ECG monitoring must be initiated as soon as possible in all patients with suspected STEMI.
- In patients with signs and symptoms of ongoing myocardial ischemia, atypical ECG presentation deserve prompt management.
- The pre-hospital management of STEMI patients must be based on regional networks designed to deliver reperfusion therapy expeditiously and effectively, with efforts made to make primary PCI available to as many as possible.
- Primary PCI-capable centres must deliver 24/7 service, be able to start primary PCI as soon as possible and within 60 min from the initial call.
- All hospitals and EMSs participating in the care of patients with STEMI must record and monitor delay times and work to achieve and maintain the following quality targets:
<!--[if !supportLists]-->v <!--[endif]-->First medical contact to first ECG ≤10 min;<!--[if !supportLists]-->v <!--[endif]-->First medical contact to reperfusion therapy;For fibrinolysis ≤30 min;For primary PCI ≤90 min (≤60 min if the patients presents within 120 minutes of symptom onset or directly to a PCI-capable hospital).
Reperfusion therapy<!--[if !supportLists]-->§ <!--[endif]-->Reperfusion therapy is indicated in all patients with symptoms of <12 hours duration and persistent ST-segment elevation or (presumed) mew LBBB.<!--[if !supportLists]-->§ <!--[endif]-->Reperfusion therapy (preferably primary PCI) is indicated if there is evidence of ongoing ischaemia, even if symptoms may have started >12 hours beforehand or if pain and ECG changes have been stuttering.
Primary PCI<!--[if !supportLists]-->§ <!--[endif]-->Primary PCI is the recommended reperfusion therapy over fibrinolysis if performed by an experienced team within 120 minutes of FMC.<!--[if !supportLists]-->§ <!--[endif]-->Primary PCI is indicated for patients with severe acute heart failure or cardiogenic shock, unless the expected PCI related delay is excessive and the patient presents early after symptom onset.<!--[if !supportLists]-->§ <!--[endif]-->Stenting is recommended (over balloon angioplasty alone) for primary PCI.<!--[if !supportLists]-->§ <!--[endif]-->Routine PCI of a totally occluded artery >24 hours after symptom onset in stable patients without signs of ischaemia (regardless of whether fibrinolysis was given or not) is not recommended.<!--[if !supportLists]-->§ <!--[endif]-->If the patient has no contraindications to prolonged DAPT and is likely to be compliant, DES should be preferred over BMS.<!--[if !supportLists]-->§ <!--[endif]-->Dual antiplatelet therapy with aspirin and an ADP-receptor blocker is recommended with<!--[if !supportLists]-->v <!--[endif]-->Prasugrel in clopidogrel-native patients, if no history of prior stroke/TIA and age <75<!--[if !supportLists]-->v <!--[endif]-->Ticagrelor<!--[if !supportLists]-->v <!--[endif]-->Or Clopidogrel, if prasugrel are not available or contraindicated<!--[if !supportLists]-->§ <!--[endif]-->An injectable anticoagulant must be used.<!--[if !supportLists]-->v <!--[endif]-->Bivalirudin is preferred over heparin and a GPIIb/llla blocker<!--[if !supportLists]-->v <!--[endif]-->Enoxaparin may be preferred over unfractionated heparin<!--[if !supportLists]-->v <!--[endif]-->Unfractionated heparin must be used in patients not receiving either bivalirudin or enoxaparin.
Fibrinolytic therapy<!--[if !supportLists]-->§ <!--[endif]-->Fibrinolytic therapy is recommended within 12 hours of symptom onset in patients without contraindications if primary PCI cannot be performed by an experienced team within 120 min of first medical contact.<!--[if !supportLists]-->§ <!--[endif]-->In patients presenting early (<12 hours after symptom onset) with a large infarct and low bleeding risk, fibrinolysis should be considered if time from first medical contact to balloon inflation is >90 min.<!--[if !supportLists]-->§ <!--[endif]-->If possible, fibrinolysis should start in the pre-hospital setting.<!--[if !supportLists]-->§ <!--[endif]-->A fibrin-specific agent (tenecteplase, alteplase, reteplase) is recommended (over non-fibrin specific agents).<!--[if !supportLists]-->§ <!--[endif]-->Oral or i.v. aspirin must be administered. Clopidogrel is indicated in addition to aspirin.<!--[if !supportLists]-->§ <!--[endif]-->Anticoagulation is recommended in STEMI patients treated with lytics until revascularization (if performed) or for the duration of hospital stay up to 8 days. The anticoagulant can be:<!--[if !supportLists]-->v <!--[endif]-->Enoxaparin i.v. followed by s.c. (preferred over unfractionated heparin),<!--[if !supportLists]-->v <!--[endif]-->Unfractionated heparin given as a weight adjusted IV bolus and infusion,<!--[if !supportLists]-->v <!--[endif]-->In patients treated with streptokinase, Fondaparinux i.v. bolus followed by s.c. dose 24 hours later.
<!--[if !supportLists]-->§ <!--[endif]-->Transfer to a PCI-capable centre following fibrinolysis is indicated in all patients after fibrinolysis .<!--[if !supportLists]-->§ <!--[endif]-->Rescue PCI is indicated in the case of recurrent ischaemia or evidence of re-occlusion after initial successful fibrinolysis.<!--[if !supportLists]-->§ <!--[endif]-->Emergency angiography with a view to revascularization is indicated in hear failure/shock patients after initial fibrinolysis.<!--[if !supportLists]-->§ <!--[endif]-->Optimal timing of angiography for stable patients after successful lysis: 3-24 hours.
Special subjects<!--[if !supportLists]-->§ <!--[endif]-->Both genders must be managed in similar fashion<!--[if !supportLists]-->§ <!--[endif]-->A high index of suspicion for MI must be maintained in women. Diabetes and elderly patients with atypical symptoms.<!--[if !supportLists]-->§ <!--[endif]-->Special attention must be given to proper dosing of antithrombotics in elderly and renal failure patients.
Logistics <!--[if !supportLists]-->§ <!--[endif]-->All hospitals participating in the care of STEMI patients should have a coronary care unit equipped to provide all aspects of care, including treatment of ischaemia, severe heart failure, arrhythmias and common comorbidities.<!--[if !supportLists]-->§ <!--[endif]-->Patients undergoing uncomplicated successful reperfusion therapy should be kept in the coronary care unit for a minimum of 24 hours, after which they may be moved to a step-down monitored bed for another 24-48 hours.
Risk assessment and imaging<!--[if !supportLists]-->§ <!--[endif]-->In the acute phase, when diagnosis is uncertain, emergency echocardiography may be useful. However, if inconclusive or unavailable and persistent doubt, emergency angiography should be considered.<!--[if !supportLists]-->§ <!--[endif]-->After the acute phase, all patients should have an echocardiography for assessment of infarct size and resting LV function, If echocardiography is not feasible, MRI may be used as an alternative.<!--[if !supportLists]-->§ <!--[endif]-->For patients with multivessel disease, or in whom revascularization of other vessels is considered, stress testing or imaging for ischaemia and viability is indicated.
Long term therapies<!--[if !supportLists]-->§ <!--[endif]-->Risk factor control, particularly smoking,must be stringent.<!--[if !supportLists]-->§ <!--[endif]-->Antiplatelet therapy is indicated indefinitely.<!--[if !supportLists]-->§ <!--[endif]-->Dual antiplatelet therapy is indicated up to 12 months.<!--[if !supportLists]-->§ <!--[endif]-->Oral treatment with beta-blockers is indicated in patients with heart failure or left ventricular dysfunction.<!--[if !supportLists]-->§ <!--[endif]-->A fasting lipid profile must be obtained in all patients.<!--[if !supportLists]-->§ <!--[endif]-->A high-dose statin should be initiated or continued early after admission in all patients without contraindication or history of intolerance.<!--[if !supportLists]-->§ <!--[endif]-->ACE inhibitors are indicated in patients with heart failure. LV systolic dysfunction diabetes or an anterior infarct.<!--[if !supportLists]-->§ <!--[endif]-->An ARB is an alternative to ACE inhibitors.<!--[if !supportLists]-->§ <!--[endif]-->Aldosterone antagonists are indicated if EF ≤40% or heart failure or diabetes, provided there is no renal failure or hyperkalaemia.
Major gaps in evidence
<!--[if !supportLists]-->§ <!--[endif]-->Strategies to minimize early cardiac arrest.<!--[if !supportLists]-->§ <!--[endif]-->Improving patient and public awareness of STEMI symptoms.<!--[if !supportLists]-->§ <!--[endif]-->Optimizing clinical pathways for high-quality, homogeneous early STEMI diagnosis and management.<!--[if !supportLists]-->§ <!--[endif]-->Reducing or minimizing myocardial injury and left ventricular dysfunction following STEMI.<!--[if !supportLists]-->§ <!--[endif]-->Defining the optimal management strategy for non-culprit vessels in primary PCI patients.<!--[if !supportLists]-->§ <!--[endif]-->Defining the optimal long-term antithrombotic regimen in patients receiving stents and who have an indication for oral anticoagulants.<!--[if !supportLists]-->§ <!--[endif]-->Defining the optimal combination and duration of antithrombotic therapies.<!--[if !supportLists]-->§ <!--[endif]-->Defining the optimal glucose-management goals and strategy in patients with known diabetes or acute hyperglycaemia.<!--[if !supportLists]-->§ <!--[endif]-->Developming percutaneous techniques for managing ventricular septal defects.<!--[if !supportLists]-->§ <!--[endif]-->Effective and safe of cell therapy to replace myocardium or minimize the consequences of myocardial injury.<!--[if !supportLists]-->§ <!--[endif]-->Strategy to minimize risk of sudden death in patients with ventricular tachycardia or ventricular fibrillation during or after STEMI.
<!--[if !supportLists]-->§ <!--[endif]-->Effective strategies to achieve and maintain long-term effective risk factor control.
ESC ESSENTIAL MESSAGES FROM ESC GUIDELINES
FOR THE DIAGNOSIS AND MANAGEMENT OF SYNCOPE Take home messages 1. Syncope is a transiet loss of consciousness (T-LOC) due to transient global cerebral hypoperfusion characterized by - rapid onset, - short duration and - spontaneous complete recovery
2. Syncope can be classified as - neurally-mediated (reflex syncope), - secondary to orthostatic hypotension, or - secondary to cardiac causes.
3. Reflex syncope traditionally refers to a heterogeneous group of conditions in which cardiovascular reflexes that are normally useful in controlling the circulation become intermittently inappropriate, in response to a trigger.
4. Orthostatic intolerance syndromes are a common cause of syncope in elderly population and are usually secondary to autonomic failure, to the use of vasodilator drugs or to volume depletion.
5. Arrhythmias are the most common cause of cardiac syncope. But structural cardiovascular disease can also cause syncope in some circumstances.
6. There is a bimodal distribution of patient age on presentation: in adolescents and young adults a reflex mechanism is the most common and above the age of 65 a cardiac cause or orthostatic hypotension should be suspected.
7. The initial evaluation after T-LOC consists of: - a careful history, - physical examination, including orthostatic blood pressure measurements - and electrocardiogram (ECG). - Based on these findings, simple additional examinations such as, carotid sinus massage, echocardiogram, ECG monitoring or orthostatic challenge can be indicated.
8. The initial evaluation can define the cause of syncope in 23-50% of patients and should answer three key questions: - Is it a true syncopal episode or not? - Has the aetiological diagnosis been determined? - Are there findings suggestive of a high risk of cardiovascular events or death?
9. Increased cardiac risk may be indicated by: - severe structural or coronary heart disease, - syncope on exertion or supine, - palpitations at the time of syncope, - family history of sudden cardiac death or non sustained ventricular tachycardia, - abnormal ECG (see full text). - Patients with high risk criteria require prompt hospitalization or intensive evaluation.
10. In low risk patients the degree of investigation depends on the frequency of syncope and its impact on quality of life. In those low risk patients with T-LOC of unknown origin and frequent recurrences, either a strategy consisting on early implant of a loop recorder and wait for new T-LOC or to perform cardiac or neurally mediated tests, can be followed.
11. The principal goals of treatment for patients with syncope are to prolong survival, mainly by decreasing the risk of sudden cardiac death, limit physical injuries, and prevent recurrences. The importance and priority of these different goals depend on the cause of syncope.
12. Evaluation of T-LOC should ideally be performed by Syncope Management Units: The main objectives of such units are to provide state-of-the-art guideline-based assessment of symptomatic patients, in order to risk-stratify them, obtain an accurate aetiological diagnosis and assess prognosis.
Major gaps in evidence
<!--[if !supportLists]-->1. <!--[endif]-->The literature on syncope evaluation and treatment is largely composed of case series, cohort studies or retrospective analysis of already existing data.<!--[if !supportLists]-->2. <!--[endif]-->The impact of these approaches on guiding therapy and reducing syncope recurrences is difficult to discern without randomization and blinding. For some of the recommendations related to diagnostic processes, controlled trials have never been performed.
<!--[if !supportLists]-->3. <!--[endif]-->Consequently, some of these recommendations are based on brief observational studies, accepted clinical practice, expert consensus and sometimes common sense. In those cases, according to the current format of recommendations, a level of evidence C is given.
Επιμέλεια : Αντωνακούδης Χαρίτων Διευθυντής ΕΣΥ
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