Cardiology Quiz New ESC Guidelines 2017

2017 ESC Guidelines for
the management of acute myocardial
infarction in patients presenting with
ST-segment elevation
Stefan James
Professor of Cardiology
Uppsala University Uppsala, Sweden
2017 ESC Guidelines for the management
of acute myocardial infarction in patients
presenting with ST-segment elevation
The Task Force for the management of acute myocardial infarction in patients presenting
with ST-segment elevation of the European Society of Cardiology
Chairpersons: Borja Ibanez (Spain), Stefan James (Sweden).
Authors/Task Force Members: Stefan Agewall (Norway), Manuel J. Antunes (Portugal),
Chiara Bucciarelli-Ducci (UK), Héctor Bueno (Spain), Alida L. P. Caforio (Italy), Filippo Crea
(Italy), John A. Goudevenos (Greece), Sigrun Halvorsen (Norway), Gerhard Hindricks
(Germany), Adnan Kastrati (Germany), Mattie J. Lenzen (The Netherlands), Eva Prescott
(Denmark), Marco Roffi (Switzerland), Marco Valgimigli (Switzerland), Christoph Varenhorst
(Sweden), Pascal Vranckx (Belgium), Petr Widimský (Czech Republic).
2
www.escardio.org/guidelines 2017 ESC Guidelines for the Management of AMI-STEMI (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx095)
TF Members
ESC
v ACCA - Acute Cardiovascular Care Association
19 Authors v EAPCI - European Association of PCI
ESC EAPC -- European Association of Preventive cardiology
EHRA - European Heart Rhythm Association
v 30 Reviewers EACVI - European Association of Cardiovascular Imaging
-1224 comments v vv HFA - Heart Failure Association v

v
and requests v v Council - Cardiovascular Nursing and Allied Professions
vv v v vv Council – for Cardiology practice
v v WG - Myocardial and Pericardial Diseases
v vv
WG - Thrombosis
v v
v v v v
WG - Cardiovascular Pharmacotherapy
v WG - Cardiovascular Surgery
v
v v
v
3
Level of evidence
159 recommendations
based
21%
on 477 references
Data derived from multiple randomized 37 A
A
clinical trials or meta-analyses. 23%
Data derived from a single randomized 78
B clinical trial or large non-randomized C 49%
studies.
Consensus of opinion of the experts
C and/or small studies, retrospective 44
studies, registries. 28%
B
4
Classes of recommendations
159 recommendations
Classes Definition
Suggested
wording
III
16
Class I Evidence and/or general agreement that Recommended/
a given treatment or procedure is is indicated.
IIb 13
10%
beneficial, useful, effective. 8%
Class IIa Weight of evidence/opinion is in favour Should be
of usefulness/efficacy. considered.
Class IIb Usefulness/efficacy is less well May be 92

established by evidence/opinion. considered. 38
58%
Class III Evidence or general agreement that the Not
IIa 24%
I
given treatment or procedure is not recommended.
useful/effective, and in some cases may
be harmful.
What is new in 2017 Guidelines on AMI-STEMI
2017 NEW / REVISED CONCEPTS
MINOCA AND QUALITY INDICATORS:
• New chapters dedicated to these topics.
STRATEGY SELECTION AND TIME DELAYS:
• Clear definition of first medical contact (FMC).
• Definition of “time 0” to choose reperfusion strategy (i.e. the strategy clock starts at the time of
“STEMI diagnosis”).
• Selection of PCI over fibrinolysis: when anticipated delay from “STEMI diagnosis” to wire crossing is ≤120 min.
• Maximum delay time from “STEMI diagnosis” to bolus of fibrinolysis agent is set in 10 min.
• “Door-to-Balloon” term eliminated from guidelines.
TIME LIMITS FOR ROUTINE OPENING OF AN IRA:
• 0-12h (Class I); 12-48h (Class IIa); >48h (Class III).
ELECTROCARDIOGRAM AT PRESENTATION:
• Left and right bundle branch block considered equal for recommending urgent angiography if ischaemic
symptoms.
TIME TO ANGIOGRAPHY AFTER FIBRINOLYSIS:
• Timeframe is set in 2-24h after successful fibrinolysis.
PATIENTS TAKING ANTICOAGULANTS:
• Acute and chronic management presented.
6
symptoms.
7
Modes of patient presentation, components of ischaemic time
and flowchart for reperfusion strategy selection
Total ischaemic time
Patient delay EMS delay System delay
FMC: EMS
<10’
Primary <90’ Reperfusion
≤120 min PCI (Wire crossing)
strategy
STEMI
diagnosis Time
to PCI?
<10’
>120 min Fibrinolysis <10’ Reperfusion
FMC: strategy (Lytic bolus)
Non-PCI centre
<10’ Primary <60’ Reperfusion

PCI (Wire crossing)
STEMI strategy
FMC: PCI centre diagnosis
Patient delay System delay
8
FMC: EMS
Term Definition
<10’ STEMI The time at which the ECG of a
diagnosis patient with ischaemic symptoms is
strategy
STEMI
diagnosis Time interpreted as presenting ST-
to PCI? segment elevation or equivalent.
<10’ Fibrinolysis Reperfusion <10’
Ambiguous terms are eliminated:
>120 min
strategy (Lytic bolus)
FMC: “Door-to-balloon”
Non-PCI centre
“Door to door”
PCI (Wire crossing)
STEMI strategy
10
Left and right bundle branch block are considered equal
Atypical ECG presentations
for recommending urgent angiography if ischaemic
§ Bundle branch block, symptoms.
FMC: EMS
§ Ventricular pacing, <10’
§ Hyper-acute T waves, strategy
STEMI
diagnosis Time
§ Isolated depression in anterior leads, to PCI?
<10’
§ Universal ST depression with aVR elevationIn >120 min Fibrinolysis <10’ Reperfusion
In the presence of symptoms, a primary PCI
Non-PCI centre
strategy (urgent angiography and PCI if Primary <60’
<10’
PCI Reperfusion
(Wire crossing)
indicated) should be followed.FMC: PCI centre STEMI strategy
diagnosis
11
2012 CHANGE IN RECOMMENDATIONS 2017
Radial access
MATRIX
DES over BMS EXAMINATION, COMFORTABLE-AMI,

NORSTENT
Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

CVLPRIT, Compare-Acute
Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin
ATOLL, Meta-analysis
Early Hospital Discharge

Small trials & observational data
Oxygen when SaO2 <90%

Oxygen when SaO2 <95% OXYGEN
AVOID, DETO2X
Half dose i.V. in Pts ≥75 years
Same dose i.V in all patients TNK-tPA
STREAM
14
Radial access
MATRIX
Valgimigli et al. Lancet 2015;385:2465-76

NORSTENT

Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
15
Radial access
MATRIX

NORSTENT
Sabate et al. Lancet 2012;380:1482-90
Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
16
Radial access
MATRIX

NORSTENT

Thrombus Aspiration
Engstrom et al, Lancet 2015 TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
17
Radial access
MATRIX

NORSTENT

Thrombus Aspiration
TOTAL, TASTE
Frobert et al, NEJM 2013
Bivalirudin Jolly et al, NEJM 2015
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
18
Radial access
MATRIX

NORSTENT
Complete
Valgimigli et al, NEJM 2015 Revascularization PRAMI, DANAMI-3-PRIMULTI, Shazad et al, Lancet 2014
Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
19
Radial access
MATRIX

NORSTENT
Silvain et al, BMJ 2012 Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
20
Radial access
MATRIX

NORSTENT

Thrombus Aspiration
TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
21
Radial access
MATRIX

NORSTENT

Stubb et al, Circ 2015 Thrombus Aspiration

TOTAL, TASTE
Bivalirudin
MATRIX, HEAT-PPCI
Enoxaparin


AVOID, DETO2X
STREAM
22
2017 NEW RECOMMENDATIONS
• Additional lipid lowering therapy if • Complete revascularization during
LDL >1.8 mmol/L (70 mg/dL) despite index primary PCI in STEMI patients
on maximum tolerated statins. in shock.
IMPROVE-IT, FOURIER Expert opinion
• Cangrelor if P2Y12 inhibitors have not been given. • Routine use of deferred
CHAMPION stenting. DANAMI 3-DEFER
• Switch to potent P2Y12 inhibitors 48 hours after
fibrinolysis. Expert opinion I
• Extend Ticagrelor up to 36 months in high-risk IIa
patients. PEGASUS-TIMI 54
IIb
• Use of polypill to increase adherence. FOCUS
III
23
Bhatt et al, NEJM 2013
IIb
III
24
Bonaca et al, NEJM 2015
IIb
III
25
“Do not forget”
interventions in STEMI
patients undergoing a
primary PCI strategy
26
2017 ESC Guidelines for
the management of acute myocardial
infarction in patients presenting with
ST-segment elevation
Borja Ibanez MD PhD FESC
- Clinical Research Director, National Center for Cardiovascular Research Carlos III
(CNIC)
- Fundación Jiménez Díaz University Hospital & CIBERCV
Madrid, Spain
2
Fibrinolytic therapy
Recommendations Class Level
When fibrinolysis is the reperfusion strategy, it is recommended
to initiate this treatment as soon as possible after STEMI diagnosis,
I A
preferably in the prehospital setting.
TARGET TIME: STEMI DIAGNOSIS TO BOLUS 10 MIN
A fibrin-specific agent (i.e. tenecteplase, alteplase, reteplase) is
I B New
recommended.
A half-dose of tenecteplase should be considered in patients
IIa B
≥75 years of age.
Co-therapies
ACUTE
Aspirin (IB), Clopidogrel (IA), Enoxaparin (IA)
MAINTENANCE
DAPT 1 year (IC). After 48hr, switch to potent P2Y12 inh may be considered (IIbC)
Fibrinolysis Strategy = Pharmacoinvasive
Strategy clock
ECG:
STEMI
0 diagnosis When time to PCI >120 min
Fibrinolysis strategy
10 min Bolus of
fibrinolytic
60-90 min
Routine angio Transfer to PCI centre
±PCI
≥120 min
90 min
2012 GL: IIaA Rescue

PCI No Meet reperfusion criteria? Yes
2 hours
Routine PCI strategy
2017 GL: IA 24 hours

Doses of anti-thrombotic agents (including
CKD, age adjustment)
interactive tool
-Calculators
-Charts & scores
Summary Cards
Essential Messages
Online & Offline

ROUTINE MAINTENANCE THERAPIES:
Antiplatelet therapy
Lipid lowering therapy
Beta-blockers
ACE inhibitors/ARBs
MRA
Maintenance antithrombotic strategy after STEMI
Routine therapies: lipid lowering

Lipid lowering therapies
It is recommended to start high-intensity statin therapy as early as
I A
possible, unless contra-indicated, and maintain it long term.
An LDL-C goal of 70 mg/dL or a reduction of at least 50% if the
I B New
baseline LDL-C is between 70 and 135 mg/dL is recommended.
(IMPROVE-IT
It is recommended to obtain a lipid profile in all STEMI patients as FOURIER)
I C
soon as possible after presentation. (NO NEED A FASTING PROFILE)
In patients with LDL-C ≥70 mg/dL despite a maximally tolerated statin
dose who remain at high risk, further therapy to reduce LDL-C should IIa A
be considered.
Routine therapies: Beta-blockers
EARLY INTRAVENOUS Beta-blockers
Intravenous beta-blockers should be considered at the time of
presentation in patients undergoing primary PCI without contra-
IIa A
indications, with no signs of acute heart failure, and with an
SBP >120 mmHg.
Intravenous beta-blockers must be avoided in patients with
III B
hypotension, acute heart failure or AV block or severe bradycardia.

MAINTENANCE oral Beta-blockers
Oral treatment with beta-blockers is indicated in patients with heart
I A
failure and/or LVEF ≤40% unless contra-indicated.
Routine oral treatment with beta-blockers should be considered
during hospital stay and continued thereafter in all patients without IIa B
Contra-indications.
Routine therapies: ACE inhibitors / MRA
ACE inhibitors/ARBs: LVEF ≤ 40% and/or Heart Failure
ACE inhibitors are recommended, starting within the first 24 hours
of STEMI in patients with evidence of heart failure, LV systolic I A
dysfunction, diabetes, or an anterior infarct.
An ARB, preferably valsartan, is an alternative to ACE inhibitors in
patients with heart failure or LV systolic dysfunction, particularly those I B
who are intolerant of ACE inhibitors.
ACE inhibitors should be considered in all patients in the absence of lla A
contra-indications.
MRAs: LVEF ≤ 40% and Heart Failure
MRAs are recommended in patients with an LVEF ≤40% and heart
failure or diabetes, who are already receiving an ACE inhibitor and I B
a beta-blocker, provided there is no renal failure or hyperkalaemia.
Acute Heart Failure and Cardiogenic shock:
a “LOE C zone”
Routine complete revascularization
Acute Heart Failure and Cardiogenic shock
IC Opiates to relief dyspnea and anxiety IIbB
IIaC Inotropic/vasopressor agents IIbC
IIaB Ultrafiltration IIbB
IIbC Mechanical support IIbC
routine IIIB
IIbB IABP Mechanical complications IIaC
Reperfusion Strategy selection in Cardiogenic
shock: a super “LOE C zone”

Fibrinolysis should be considered in patients presenting with
cardiogenic shock if a primary PCI strategy is not available within
IIa C
120 min from STEMI diagnosis and mechanical complications have
been ruled out.
Strategy guided as in other STEMI patients (if time from STEMI
diagnosis to
wire crossing is >120min  Immediate fibrinolysis & transfer to PCI center)
Urgent angiography upon arrival regardless time from lytics
Management of atrial fibrillation
Acute rate control of AF
Intravenous beta-blockers are indicated for rate control if necessary
I C
and there are no clinical signs of acute heart failure or hypotension.
Intravenous amiodarone is indicated for rate control if necessary in
I C
the presence of concomitant acute heart failure and no hypotension.
Intravenous digitalis should be considered for rate control if necessary
Ila B
in the presence of concomitant acute heart failure and hypotension.
Cardioversion
Immediate electrical cardioversion is indicated when adequate rate
control cannot be achieved promptly with pharmacological agents
I C
in patients with AF and ongoing ischaemia, severe haemodynamic
compromise or heart failure.
14
Management of atrial fibrillation

Intravenous amiodarone is indicated to promote electrical
cardioversion and/or decrease risk for early recurrence of AF after I C
electrical cardioversion in unstable patients with recent onset AF. New
In patients with documented de novo AF during the acute phase of
STEMI, long-term oral anticoagulation should be considered
IIa C
depending on CHA2DS2-VASc score and taking concomitant
antithrombotic therapy into account.
Transient, self-terminating AF during STEMI relates to a significantly

higher stroke rate during long-term follow-up. 15
MINOCA: New Chapter!
Not focused into specific treatments,
rather encouraging pursuing etiology!
Aligned with dedicated ESC position papers
Quality indicators: New Chapter!
There is a wide practice gap between optimal and actual care
for patients with STEMI across the world.
Quality indicators
• Structural measures
• Performance measures
- for reperfusion therapy
- for risk assessment
- for antithrombotic treatment
- for discharge medication and counseling
• Patient-related outcomes
• Outcome measures
• Opportunity-based composite QIs
17
Full 90 min session on
2017 STEMI Guidelines
DREAM STEAMI
PART I
2017 ESC Guidelines on the Diagnosis

and Treatment of Peripheral Arterial
Diseases, in collaboration with the
European Society for Vascular Surgery
(ESVS)
Victor Aboyans, MD, PhD, FESC
Department of Cardiology
Dupuytren University, Limoges, France
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with ESVS 2
(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095)
Presentations of Peripheral Arterial Diseases (PADs)
PADs
Territories Presentations
Aorta
Cerebrovascular diseases: Stroke, Transient Ischaemic
disease - Carotid artery disease Attack ( TIA), acute
- Vertebral artery disease monocular blindness
Atherosclerosis
Coronary Artery Subclavian steal syndrome,

Disease (CAD) Upper-Extremity pain on exertion, digital
Artery Disease (UEAD)
symptoms, acute ischaemia
Chronic Mesenteric
Mesenteric artery Ischaemia (CMI)
disease Acute Mesenteric
Ischaemia (AMI)
Peripheral Renal Artery Disease Hypertension,
Arterial (RAD) renal failure
Diseases NEW!
(PADs) Typical claudication,
Lower-Extremity
Artery Disease
atypical symptoms,
Chronic Limb-Threatening
Cardiac
(LEAD) Ischaemia (CLTI),
Acute Limb Ischaemia (ALI) Conditions
General Aspects
General prevention
PADs patients
management
Address general CV risk Address related symptoms

and prevention at the specific localization
In healthcare centres, it is recommended to set up a

multi-disciplinary Vascular Team to make decisions for I C
the management of patients with PADs.
www.escardio.org/guidelines 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with ESVS
General CV prevention
• Smoking cessation
Non • Healthy diet
pharmacological
therapy • Weight loss
• Regular physical exercise
Best
Medical
Therapy
• Anti-HTN drugs
• Statins
Pharmacological
measures • Optimal glucose control
in diabetic pts
• Antithrombotic drugs
Lower extremities artery disease
(LEAD)
Clinical stages of LEAD (I)
Fontaine classification Rutherford classification

Concept of
« Masked LEAD » Stage Symptoms Grade Category Symptoms
in
• Ageing I Asymptomatic  0 0 Asymptomatic
• Frailty
I 1 Mild claudication
• Neuropathy Non-disabling
IIa
• Joint disease intermittent claudication I 2 Moderate claudication
• Heart failure II 
• COPD Disabling intermittent
…. with limited/no IIb I 3 Severe claudication
claudication
walking
III Ischaemic rest pain  II 4 Ischaemic rest pain
III 5 Minor tissue loss
IV Ulceration or gangrene 
III 6 Major tissue loss
The Ankle-Brachial Index
Who should have an ABI measurement in clinical practice?
• Patients with clinical suspicion for LEAD:
‒ lower extremities pulse abolition and/or arterial bruit,
‒ typical intermittent claudication or symptoms suggestive for LEAD,
‒ non-healing lower extremity wound.
• Patients at risk for LEAD because of the following clinical conditions:
‒ atherosclerotic diseases: CAD, any PADs,
‒ other conditions: AAA, CKD, heart failure.
• Asymptomatic individuals clinically-free but at-risk for LEAD:
‒ men and women aged >65 years,
‒ men and women aged <65 years classified at high CV risk according the
ESC Guidelines,
‒ men and women aged >50 years with family history for LEAD.
Clinical stages of LEAD (II)

Modern
Management of Stage Symptoms Grade Category Symptoms
Claudication:
CVD prevention I Asymptomatic  0 0 Asymptomatic
Exercise therapy I 1 Mild claudication
Non-disabling
IIa
intermittent claudication I 2 Moderate claudication
+ Revascularization
II 
Vasoactive drugs= no proof in
Disabling intermittent
the modern management IIb I 3 Severe claudication
claudication

Clinical stages of LEAD

Chronic Limb
Threatening Stage Symptoms Grade Category Symptoms
Ischaemia
(CLTI) I Asymptomatic  0 0 Asymptomatic
Early referral to a I 1 Mild claudication

Non-disabling
vascular team for IIa
intermittent claudication I 2 Moderate claudication
risk stratification II 
and management Disabling intermittent
IIb I 3 Severe claudication
claudication

Risk of amputation : : the WIFI classification
Interpretation of the WIFI classification
Estimate risk of amputation at 1 year for each combination

Ischaemia - 0 Ischaemia - 1 Ischaemia - 2 Ischaemia - 3
W-0 VL VL L M VL L M H L L M M L M M H
W-1 VL VL L M VL L M H L M H H M M H H
W-2 L L M H M M H H M H H H H H H H
W-3 M M H H H H H H H H H H H H H H
fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3 fl-0 fl-1 fl-2 fl-3
fI = foot infection; H = high-risk; L = low-risk; M = moderate risk; VL = very low risk; W = wound.
Management of Chronic Limb-Threatening
Ischaemia (CLTI)
Early recognition of tissue loss and/or infection and referral to the
vascular team is mandatory to improve limb salvage. I C
In patients with CLTI, assessment of the risk of amputation is
indicated. I C
In patients with CLTI and diabetes, optimal glycaemic control
isrecommended. I C
For limb salvage, revascularization is indicated whenever feasible. I B
In CLTI patients with below-the-knee lesions, angiography including

foot runoff should be considered prior to revascularization. IIa C
Antiplatelet therapy in patients
with lower extremity artery disease
Management of antiplatelet therapy in patients with LEAD
not requiring anticoagulation
Asymptomatic Symptomatic Revascularization
Percutaneous Surgery
A
0
DAPT SAPT Aspirin
A+C
No SAPT SAPT Class IIa C A or C 75-100 mg/day
1 mo.
Class IIb B
Time delay
A or C SAPT C
Clopidogrel
Class III A Class I A
A or C VKA 75 mg/day
O
Class IIa C
Class IIb B O
1 year
Oral
Long term Anticoagulation
Multisite Artery Disease
Screening of associated atherosclerotic
disease in additional vascular territories
Screened disease CAD LEAD Carotid Renal

Leading disease
CAD
Scheduled for CABG IIa I IIb U
Not scheduled for CABG IIb NR U
LEAD
Scheduled for surgery I NR U
Not scheduled for surgery NR NR U
Carotid stenosis
Scheduled for CEA/CAS IIb NR U
Not scheduled for CEA/CAS NR NR U
PADs associated with other
cardiac conditions
• Heart Failure
• Atrial Fibrillation
Interrelations between heart failure and
lower extremity artery disease
Smoking
Inflammation
Atherosclerosis
Dyslipidaemia
CAD Aorta
Diabetes stiffness
Heart LEAD
failure
Hypertension Ageing
Physical impairment
and deconditioning
Management of HF associated with PADs

Full vascular assessment is indicated in all patients considered
I C
for heart transplantation or cardiac assist device implantation.
In patients with symptomatic PADs, screening for heart failure
with TTE and/or natriuretic peptides assessment should be IIa C
considered.
Screening for LEAD may be considered in patients with heart
IIb C
failure.
Management of AF associated with PADs

In patients with LEAD and atrial fibrillation, oral anticoagulation:
• is recommended when CHA2DS2-VASc score ≥2, I A
• should be considered in all other patients. IIa B
Antithrombotic therapy in patients
with LEAD requiring oral anticoagulation
LEAD in patients requiring long-term oral anticoagulation
(A)symptomatic Surgery Percutaneous

intervention
Bleeding risk low Bleeding risk high
0 DAT A
O A or C
OAC Class IIa OAC Aspirin
1 mo. Monotherapy Monotherapy 75-100 mg/day
Time delay
DAT
O
O A+C O C
Class IIb O Clopidogrel
Class I Class IIa 75 mg/day
OAC
Monotherapy
Class IIb
1 year O
Long term Oral
Anticoagulation
PART II
2017 ESC Guidelines on the Diagnosis

and Treatment of Peripheral Arterial
Diseases, in collaboration with the
European Society for Vascular Surgery
(ESVS)
Jean-Baptiste RICCO
Vascular Surgery Department
University of Poitiers, Medical School, France
RENAL ARTERY DISEASE
Why RAD is important?
• RAD is a strong independent predictor
of mortality and increasing severity of
RAD has an incremental effect on
survival probability
Conlon et al. JASN 1998

Conlon et al. Kidney Int 2001
RAD: MEDICAL THERAPY

Medical therapy
ACEIs/ARBs are recommended for treatment of hypertension I B
associated with unilateral RAS.
Calcium channel blockers, beta-blockers and diuretics are

recommended for treatment of hypertension associated with renal I C
artery disease.
ACEIs/ARBs may be considered in bilateral severe RAS and in the

case of stenosis in a single functioning kidney, if well tolerated and IIb B
under close monitoring.
ACEIs: Angiotensin-converting enzyme inhibitor, ARBs: Angiotensin-receptor blockers

(European Heart Journal 2017; doi:10.1093/eurheartj/ehx095) 5
RAD: Revascularization
Meta-analysis of studies
CORAL trial
Riaz et al. Am J Cardiol 2014
3 RCT’s have shown no benefit of

stenting with respect to the composite
primary end point or any of its
individual components: Kidney ischemia
and impaired renal function
STAR, Ann Intern Med 2009 ASTRAL, NEJM 2009
CORAL, NEJM 2014
RAD: Revascularization
Revascularization
Routine revascularization is not recommended in RAS secondary to
III A
atherosclerosis.
Balloon angioplasty, with or without stenting, may be considered in
selected patients with RAS and unexplained recurrent congestive IIb C
heart failure or sudden pulmonary oedema.
In cases of hypertension and/or signs of renal impairment related to
renal arterial fibromuscular dysplasia, balloon angioplasty with IIa B
bailout stenting should be considered.
In the case of an indication for revascularization, surgical
revascularization should be considered for patients with complex
IIa B
anatomy of the renal arteries, after a failed endovascular procedure,
or during open aortic surgery. (European Heart Journal 2017; doi:10.1093/eurheartj/ehx095) 7
EXTRACRANIAL CAROTID DISEASES
OPTIMAL MEDICAL TREATMENT REDUCES THE
RISK OF STROKE IN ASYMPTOMATIC PATIENTS
The rate of ipsilateral stroke was 2.3% in studies before 2000 and decreases to less than 1% Abbott AL et al. Int J Stroke 2007
in studies completing recruitment between 2000 and 2010 Naylor A R Semin Vasc Surg 2008
Clinical/imaging features associated with increased risk of stroke
in patients with asymptomatic carotid stenosis treated medically
Clinical • Contralateral TIA/stroke
Cerebral imaging • Ipsilateral silent infarction
Ultrasound • Stenosis progression (> 20%)
T
M
B
imaging • Spontaneous embolization on transcranial Doppler (HITS)
TE
PI
ES
• Impaired cerebral vascular reserve

K E D
RO
• Large plaques
ST
R
• Echolucent plaques
FO
ISK
• Increased juxta-luminal black (hypoechogenic) area

T R
A
ILL
ST
MRA • Intraplaque haemorrhage

• Lipid-rich necrotic core
TIA: Transient attack, HITS: High intensity transient signal, MRA: Magnetic resonance angiography
MANAGEMENT OF EXTRACRANIAL CAROTID ARTERY DISEASE
ASYMPTOMATIC
Carotid Carotid Occlusion

stenosis stenosis or near
60-99% <60% occlusion
Life expectancy >5 yrs?
BMT
No
Favourable anatomy?
Class I A
≥1 feature suggesting
higher stroke risk on BMT?
CEA + BMT
should be considered
Class IIa B
CAS + BMT
may be considered
Class IIb B
MANAGEMENT OF ASYMPTOMATIC CAROTID DISEASE
In “average surgical risk” patients with an asymptomatic 60-99%
stenosis in the presence of clinical and/or imaging characteristics d
that may be associated with an increased risk of late ipsilateral
IIb B
stroke, CAS may be an alternative to CEA provided documented
perioperative stroke/death rates are <3% and the patient’s life
expectancy is >5 years.
REVASCULARIZATION IN PATIENTS WITH
SYMPTOMATIC CAROTID DISEASE
CEA is recommended in symptomatic patients with 70-99% carotid
I A
stenoses, provided the documented procedural death/stroke rate is <6%.
CEA should be considered in symptomatic patients with 50-69% carotid

IIa A
stenoses, provided the documented procedural death/stroke rate is <6%.
In recently symptomatic patients with a 50–99% stenosis who present
with adverse anatomical features or medical comorbidities that are
IIa B
considered to make them “high-risk for CEA”, CAS should be considered,
provided the documented procedural death/stroke rate is <6%.
When revascularization is indicated in “average surgical risk”

patients with symptomatic carotid disease, CAS may be considered
IIb B
as an alternative to surgery, provided the documented procedural
death/ stroke rate is <6%.
Revascularization is not recommended in patients with a <50%

III A
carotid stenosis.
Meta-analyses from RCT’s have shown that patients over 70 yrs should receive CEA rather than CAS
Timing of interventions after onset of symptoms
Recommendations
When decided, it is recommended to
perform revascularization of
symptomatic 50–99% carotid stenoses I A
as soon as possible, preferably within 14
days of symptom onset.
Meta-analyses from RCT’s have shown that patients
revascularized within 2 weeks do better with CEA rather than
with CAS
MANAGEMENT OF EXTRACRANIAL CAROTID ARTERY DISEASE
SYMPTOMATIC
Occlusion Carotid Carotid Carotid
or near stenosis stenosis stenosis
occlusion <50% 50-69% 70-99%
CEA + BMT CEA + BMT
BMT recommended
should be
Class I A considered
Class I A
Class IIa B
CAS + BMT
should be
CAS + BMT considered if
may be “high-risk” for
considered CEA
Class IIa B
Class IIb B
otherwise
may be
considered
Algorithm of management strategies Class IIb B
In patients with symptomatic carotid stenosis
Management of antithrombotic treatment in patients
with carotid stenosis
Management of antiplatelet therapy in carotid artery stenosis
Asymptomatic Carotid Artery Stenting Carotid Surgery
0
DAPT
A + C
SAPT Class I A SAPT
1 mo.
Time delay
A or C A or C A
SAPT
Aspirin
A or C Class I A
Class IIa C 75-100 mg/day
Class I A
C
1 year Clopidogrel
75 mg/day
Long term
SAPT: single antiplatelet therapy, DAPT: dual antiplatelet therapy
Should we screen for CAD, patients undergoing
carotid revascularization?
Recommendations
In patients undergoing elective
CEA, preoperative CAD screening,
P=0.01 IIb B
including coronary angiography,
may be considered.
Preoperative CAD screening followed, if needed, by coronary

revascularization decreases the risk of MI and improves late survival
(Illuminati et al)
Should we screen for carotid disease, patients
undergoing CABG?
In patients undergoing CABG, DUS is recommended in
I B
patients with a recent (<6 months) history of TIA/stroke.
In patients with no recent (< 6 months) history of
TIA/stroke, DUS may be considered in the following cases:
IIb B
age ≥70 years, multivessel coronary artery disease,
concomitant LEAD, or carotid bruit.
Screening for carotid stenosis is not indicated in patients
III C
requiring urgent CABG with no recent stroke/TIA.
How to deal with a symptomatic carotid stenosis
in a patient undergoing CABG?
It is recommended that the indication (and if so the method and
timing) for carotid revascularization be individualized after I C
discussion within a multidisciplinary team, including a neurologist.
In patients scheduled for CABG, with recent (<6 months) history of TIA/stroke:
• Carotid revascularization should be considered in patients with 50
IIa B
–99% carotid stenosis,
• Carotid revascularization with CEA should be considered as first
IIa B
choice in patients with 50–99% carotid stenosis,
• Carotid revascularization is not recommended in patients with
III C
carotid stenosis <50%.
How to deal with an asymptomatic carotid
stenosis in a patient undergoing CABG?
In neurologically asymptomatic patients scheduled for CABG:
• Routine prophylactic carotid revascularization in patients with a 70-
III B
99% carotid stenosis is not recommended.
• Carotid revascularization may be considered in patients with
bilateral 70-99% carotid stenoses or 70-99% carotid stenosis + IIb B
contralateral occlusion.
• Carotid revascularization may be considered in patients with a 70–
99% carotid stenosis, in the presence of one or more characteristics
IIb C
that may be associated with an increased risk of ipsilateral stroke,
in order to reduce stroke risk beyond the perioperative period.
Want more details?
2017 ESC Focused Update on Dual
Antiplatelet Therapy in Coronary Artery
Disease developed in collaboration with
the EACTS*
*: European Association for Cardio-Thoracic Surgery

Marco Valgimigli declares Speaker fees, Honoraria, Consultancy, Advisory Board fees, Investigator,
Committee Member from Abbott Vascular, Terumo, Bayer, Astra Zeneca, Sinomed, Daichi Sankyo
and research grants from Terumo, Astra Zeneca, Medicure, Abbott Vascuar
2017 ESC Focused Update on Dual Antiplatelet
Therapy in Coronary Artery Disease developed
in collaboration with EACTS
The Task Force for the Management of Dual Antiplatelet Therapy in Coronary
Artery Disease of the European Society of Cardiology (ESC) and of the European
Association for Cardio-Thoracic Surgery (EACTS)
ESC Chairperson: Marco Valgimigli (Switzerland).
Authors/Task Force Members: Héctor Bueno (Spain), Robert Byrne (Germany),
Jean-Philippe Collet (France), Francesco Costa (Italy), Anders Jeppsson (Sweden),
Peter Jüni (Canada), Adnan Kastrati (Germany), Philippe Kolh (Belgium),
Laura Mauri (USA), Gilles Montalescot (France), Franz-Josef Neumann (Germany),
Mate Petricevic (Croatia), Marco Roffi (Switzerland), Philippe Gabriel Steg (France),
Stephan Windecker (Switzerland), Jose Luis Zamorano (Spain).
Additional Contributor: Glenn Levine (USA).
www.escardio.org/guidelines 2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS 2
(European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
History of dual antiplatelet therapy (DAPT) in patients
with coronary artery disease
ASPIRIN
TICLOPIDINE
CLOPIDOGREL
PRASUGREL
TICAGRELOR
<1 m STARMATTIS ACCOAST ATLANTIC
(1998) (1998) (2013) ISAR PRAGUE
CURRENT (2014) TRIPLE
OASIS 7 (2016)
Investigated DAPT Duration
1 m (2010) RESET (2015)

ISAR CLASSIC (2012)
(1996) (2000) COMMIT
3 m FANTASTIC (2005) GRAVITAS SECURITY I-LOVE-IT 2
PLATO
(1998) (2009) (2011) EXCELLENT OPTIMIZE (2014) ISAR SAFE (2016)
(2012) (2013) (2015)
6 m TRITON
CURE (2007) IVUS XPL
(2001) ARTIC INT ITALIC (2016)
12 m CREDO (2015)
(2002) (2014)
ARTIC WOEST ANTARTIC
(2012) TRILOGY (2013) (2016)
30 m PRODIGY NIPPON
(2012) ACS OPTIDUAL (2016)
(2013) (2015)
36 m CHARISMA REAL-LATE DAPT
(2006) ZEST-LATE (2014)
(2010) DES-LATE PEGASUS
(2014) (2015)
1996 2017
Size of the circles denotes sample size Perimeter of the circles denotes type of investigated population
‒ Mixed clinical presentation at the time of -- DAPT initiated in patients with prior
2 5 10 20 K pts stent implantation myocardia infarction
‒ Acute coronary syndrome at presentation ‒ DAPT for primary prevention 3
www.escardio.org/guidelines 2017 ESC Focused Update on DAPT in Coronary Artery Disease, developed in collaboration with EACTS (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx419)
What is new in the 2017 ESC focussed update
on DAPT?
Use of risk scores as guidance for the
duration of dual antiplatelet therapy
The use of risk scores designed to evaluate the benefits and
IIb A
risks of different DAPT durations may be considered.
Risk scores validated for dual antiplatelet
therapy duration decision-making
PRECISE-DAPT score DAPT score
Time of use At the time of coronary stenting After 12 months of uneventful DAPT
DAPT duration Short DAPT (3–6 months) vs. Standard DAPT (12 months) vs.
strategies assessed Standard/long DAPT (12–24 months) Long DAPT (30 months)
Score calculation HB ≥2 11-5 11 10-5 ≤10 Age
≥75 –2 pt
WBC ≤5 8 1012141618 ≥20 65 to <75 –1 pt
<65 0 pt
Age ≤50 60 70 80 ≥90 Cigarette smoking +1 pt
Diabetes mellitus +1 pt
CrCI ≥100 80 60 40 20 0
MI at presentation +1 pt
Prior PCI or prior MI +1 pt
Prior No Yes
Paclitaxel-eluting stent +1 pt
Bleeding
Stent diameter <3 mm +1 pt
Score 0 2 4 6 8 1012141618202224262830 CHF or LVEF <30% +2 pt
Points
Vein graft stent +2 pt
Score range 0 to 100 points –2 to 10 points
Decision making Score ≥25 � Short DAPT Score ≥2 � Long DAPT
cut-off suggested Score <25 � Standard/long DAPT Score <2 � Standard DAPT
Calculator www.precisedaptscore.com www.daptstudy.org
Algorithm for dual
antiplatelet therapy (DAPT)
in patients treated with
percutaneous coronary
intervention
Dual antiplatelet therapy duration in high bleeding
risk patients with stable coronary artery disease
treated with percutaneous coronary intervention
In patients with stable CAD considered at high bleeding risk
(e.g. PRECISE-DAPT ≥25), DAPT for 3 months should be IIa B
considered1.
In patients with stable CAD in whom 3-month DAPT poses
IIb C
safety concerns, DAPT for 1 month may be considered2.
1:Theevidence supporting this recommendation comes from two studies where zotarolimus-eluting
Endeavour sprint stent has been investigated in conjunction with a 3-month DAPT regimen.
2:1-month DAPT after implantation of zotarolimus-eluting Endeavour sprint stent or drug coated
Biofreedom stent reduced risks of reintervention, myocardial infarction and inconsistently of stent
thrombosis compared to bare-metal stent under similar DAPT duration.
It is unclear if this evidence applies to other contemporary DES.
Algorithm for dual
antiplatelet therapy
(DAPT) in patients
with acute coronary
syndrome undergoing
coronary artery bypass
grafting
No indication
for DAPT in
stable CAD
pts unless
concomitant
or prior
indication
overrides
Algorithm for dual
(DAPT) in patients with
acute coronary
syndrome undergoing
medical management
No indication
for DAPT in
stable CAD
pts unless
concomitant
or prior
indication
overrides
Algorithm for switching between oral P2Y12 inhibitors
in the acute setting
CLOPIDOGREL
Ti spe tim
l
in id )
irr
re
os p g
ca cti in
d Clo m
g og
gr ve g a
d g)
Cl h a
nd ior 60
el of nd
el m
e
24
op fte
g a pr (
os
or pr d
gr 0
in of LD
id r la
LD ior si
su 0
og st
ra (6
tim ive rel
(1 Clo ng
re Ti
t P D
ec ug
as l L
80 pid
l L cag
p s
r l e
a
D re
m ogr
o
t
r
ACUTE
Pr
te g
(6 lo
g) el
af o
es
h id
00 r d
SETTING
irr
24 op
m ose
Cl
g)
ALWAYS RELOAD
Ticagrelor LD (180 mg)
24h after last Prasugrel dose
PRASUGREL TICAGRELOR
Prasugrel LD (60 mg)
24h after last Ticagrelor dose
Algorithm for switching between oral P2Y12 inhibitors in
the chronic setting
CLOPIDOGREL
os .)
Ti h
d d
ca af
el .
e
gr g q
24
gr te
os .)
d .d
Cl h a
el r la
pi m
24
el q
or st
op fte
lo 10
gr g
M Cl
do
su m
id r la
t C D (
D pi
og st
ra 75
M
(9 do
re Ti
t P (
0 gr
as D
o
l
l L cag
as
re
r l l M
m el
r l
D re
ug
g b do
CHRONIC
fte
fte re
(6 lo
as
.i. se
a g
a
00 r d
o
Pr
d.
h
SETTING
4h id
24
m ose
)
2 op
g)
Cl
Ticagrelor MD (90 mg b.i.d.)
24h after last Clopidogrel dose
PRASUGREL TICAGRELOR
Prasugrel LD (60 mg)
24h after last Ticagrelor dose
Algorithm for dual
(DAPT) in patients
with an indication for
oral anticoagulation
undergoing
percutaneous
coronary
intervention (PCI)
Clopidogrel is
the only
option to
establish a
DAPT
regimen
Timing for elective non-cardiac surgery in patients treated
with dual antiplatelet therapy (DAPT) after percutaneous
coronary intervention (PCI)
P2Y12 inhibitor interruption after PCI for elective non-cardiac surgery
ASA continued throughout the perioperative period
ACS at index PCI or other high ischaemic risk features?
Time from DAPT No Yes
initiation
Class III B Class III B
1 mo.
Class IIa B Class IIb C
6 mo.
Class I B Class I B
Dual antiplatelet therapy in patients
undergoing elective non-cardiac surgery
(continued)

If both oral antiplatelet agents have to be discontinued
perioperatively, a bridging strategy with intravenous
IIb C
antiplatelet agents may be considered, especially if surgery
has to be performed within 1 month after stent implantation.
Minimal discontinuation and re-implementation time
frames of dual antiplatelet therapy (DAPT) for patients
undergoing elective surgery
PRASUGREL STOP PRASUGREL2
CLOPIDOGREL STOP CLOPIDOGREL
TICAGRELOR STOP TICAGRELOR2
ASPIRIN1
//….9…….8….…7…….6….…5…….4….…..3……..2…… ….0……………………………… 1-4
Minimal delay for P2Y12 interruption Days after surgery
= Expected average platelet function recovery
1 Decision to stop aspirin throughout surgery should be made on a single case basis taking into
account the surgical bleeding risk.
2 In patients not requiring OAC.
Gender considerations and those for special
populations
Similar type and duration of DAPT are recommended in male
and female patients. I A
It is recommended to reassess the type, dose and duration of
DAPT in patients with actionable bleeding complication while I C
on treatment.
Similar type and duration of DAPT should be considered in
patients with and without diabetes mellitus. IIa B
Prolonged (i.e. >12 months) DAPT duration should be
considered in patients with prior stent thrombosis, especially IIa C
in the absence of correctable causes (e.g. lack of adherence or
correctable mechanical stent-related issues).
Gender considerations and those for special
Populations (continued)
Prolonged (i.e. >12 months) DAPT duration may be considered IIb B
in CAD patients with LEAD.
Prolonged (i.e. >6 months) DAPT duration may be considered IIb B
in patients who underwent complex PCI.
Bleeding during treatment with dual antiplatelet therapy ± OAC
• Continue DAPT.
TRIVIAL BLEEDING
Any bleeding not requiring medical • Consider OAC continuation or skip one single next pill.
intervention or further evaluation
• Reassure the patient.
e.g. skin bruising or ecchimosis, • Identify and discuss with the patient possible preventive
self-resolving epistaxis, minimal strategies.
conjunctival bleeding
• Counsel patient on the importance of drug-adherence.
Legend
DAPT management
OAC management
General recommendations
20
MILD BLEEDING • Continue DAPT.
Any bleeding that requires medical • Consider shortening DAPT duration or switching to less potent
attention without requiring P2Y12 inhibitor (i.e.from ticagrelor/ prasugrel to clopidogrel),
hospitalization especially if recurrent bleeding occurs.
e.g. not self resolving epistaxis, • In case of triple therapy consider downgrading to dual
moderate conjunctival bleeding, therapy, preferably with clopidogrel and OAC.
genitourinary or upper/lower
gastrointestinal bleeding without • Identify and possibly treat concomitant conditions associated
significant blood loss, with bleeding (e.g. peptic ulcer, haemorrhoidal plexus,
mild haemoptysis neoplasm).
• Add PPI if not previously implemented.
Legend • Counsel patient on the importance of drug-adherence.
DAPT management
OAC management
21
• SAPT, preferably with the P2Y12 inhibitor especially in case of upper GI
MODERATE BLEEDING bleeding.
Any bleeding associated with • Reinitiate DAPT as soon as deemed safe.
blood loss (>3 g/dL HB) and/or • Consider shortening DAPT duration or switching to less potent P2Y12,
requiring hospitalization, which especially if recurrence occurs.
is haemodynamically stable • Consider OAC dis. or reversal until bleeding is controlled, unless very high
and not rapidly evolving thrombotic risk
• Reinitiate treatment within one week if clinically indicated. For VKA
e.g. genitourinary, target INR of 2.0–2.5 unless overriding indication (i.e. mechanical heart
respiratory or upper/lower gastro- valves or cardiac assist device) for NOAC consider the lowest effective
intestinal bleeding with significant dose.
blood loss or requiring transfusion • In case of triple therapy consider downgrading to dual therapy,
Legend preferably with clopidogrel and OAC.
• If patients on dual therapy, consider stopping antiplatelet Tx.
DAPT management
• Consider i.v. PPI if GI bleeding occurred.
OAC management • Identify and possibly treat concomitant conditions associated with
General recommendations bleeding (e.g. peptic ulcer, haemorrhoidal plexus, neoplasm).
• Counsel patient on the importance of drug-adherence. 22
• Consider stopping DAPT and continue with SAPT, preferably with the P2Y 12 inhibitor
SEVERE BLEEDING especially in case of upper GI bleeding.
Any bleeding requiring • If bleeding persists despite treatment or treatment is not possible, consider stopping
hospitalisation, associated with a all antithrombotic medications.
• Once bleeding has ceased, re-evaluate the need for DAPT or SAPT, preferably with the
severe blood loss P2Y12 inhibitor especially in case of upper GI bleeding.
(>5 g/dL HB) which is haemo- • If DAPT is re-started, consider shortening DAPT duration or switching to less potent
dynamically stable and not rapidly P2Y12 inhibitor (i.e. from ticagrelor/prasugrel to clopidogrel), especially if recurrent
evolving bleeding occurs.
e.g. severe genitourinary, • Consider stopping and reversing OAC until bleeding is controlled unless prohibitive
respiratory thrombotic risk (i.e. mechanical heart valve in mitral position, cardiac assist device).
or upper/lower • Reinitiate treatment within one week if clinically indicated. For vitamin-K antagonists
gastrointestinal bleeding consider a target INR of 2.0-2.5 unless overriding indication (i.e. mechanical heart
valves or cardiac assist device) for NOAC consider the lowest effective dose.
Legend • If patient on triple therapy consider downgrading to dual therapy with clopidogrel and
OAC. If patients on dual therapy, consider stopping antiplatelet therapy if deemed
DAPT management safe.
• Consider i.v. PPI if GI bleeding occurred.
OAC management • RBC transfusion if HB <7-8 g/Dl.
• Consider platelet transfusion.
General recommendations • Urgent surgical or endoscopic treatment of bleeding source if deemed possible.. 23
LIFE-THREATENING BLEEDING • Immediately discontinue all antithrombotic medications.
Any severe active bleeding putting • Once bleeding has ceased, re-evaluate the need for DAPT
patient’s life immediately at risk
or SAPT, preferably with the P2Y12 inhibitor especially in
e.g. massive overt genitourinary, case of upper GI bleeding.
respiratory or upper/lower
gastrointestinal bleeding,
active intracranial, • Stop and reverse OAC.
spinal or intraocular haemorrhage,
or any bleeding causing • Fluid replacement if hypotension.
haemodynamic instability.
• Consider RBC transfusion irrespective of HB values.
Legend • Platelet transfusion.
DAPT management • Consider i.v. PPI if GI bleeding occurred.
OAC management
• Urgent surgical or endoscopic treatment of bleeding
source if deemed possible.
24
Guidelines team - Names and roles
Veronica Dean Head of Guidelines Department
Scientific Research Analyst & Senior Project Manager,
Catherine Despres
responsible for Quality Assurance
Nathalie Cameron Senior Guidelines Development Coordinator
Laetitia Flouret Guidelines Development Officer
Maike Binet Guidelines Development Officer
Veronica Catherine Nathalie Laetitia Maike

Dean Despres Cameron Flouret Binet
…and some other hidden heroes
Myocardial Infarction with Non-Obstructive
Coronary Arteries
MINOCA
Professor Stefan Agewall MD PhD

Oslo University Hospital Ullevål, Oslo
University of Oslo, Norway
1
2
Reperfusion therapy

Reperfusion therapy is indicated in all patients with symptoms of
I A
ischaemia of ≤12 hours duration and persistent ST-segment elevation.
A primary PCI strategy is recommended over fibrinolysis within
I A
indicated time frames.
If primary PCI cannot be performed timely after STEMI diagnosis,
fibrinolytic therapy is recommended within 12 hours of symptom I A
onset in patients without contra-indications.
3
No stenosis ???
4
5
Diagnostic criteria for myocardial infarction
with non-obstructive coronary arteries
The diagnosis of MINOCA is made immediately upon coronary
angiography in a patient presenting with features consistent with an
AMI, as detailed by the following criteria:
(1) Universal AMI criteria.
(2) Non-obstructive coronary arteries on angiography, defined as no
coronary artery stenosis ≥50% in any potential IRA.
(3) No clinically overt specific cause for the acute presentation.
6
Flow-chart
nEur Heart J. 2017;38:143-153.

7
Cardiac magnetic resonance imaging
(within 6 weeks after the event)
Pasupathy et al Circulation 2015

Myocarditis should be considered!
• Similar pain history

• Troponin increased
• ECG changes
• No reliable biochem
• Biopsy risky
• MRI new gold stand
MINOCA
• Prevalence of 1–13% of all AMI patients
• Heterogeneous, with several potential aetiologies diagnosis
• Working diagnosis
• A routine examination with CMR imaging recommended
Eur Heart J. 2017;38:143-153.
10
MINOCA
Failure to identify the underlying cause may result in no

adequate therapy or inappropriate therapy in these
patients.
Eur Heart J. 2017;38:143-153.

11
Possibly Causes
1) Secondary to epicardial coronary artery disorders (e.g.

atherosclerotic plaque rupture, ulceration, fissuring,
erosion, or coronary dissection with non-obstructive or no
CAD) (MI type 1)
2) Imbalance between oxygen supply and demand

(MI type 2)
12
Possibly Causes
3) Coronary endothelial dysfunction

(e.g. microvascular spasm)
4) Secondary to myocardial disorders without

obvious involvement of the coronary arteries
(e.g. myocarditis or Takotsubo)
13
Quantitative
assessment of 28
publications.
The prevalence of
MINOCA was 6%

STEMI

All-cause mortality at 12 months was lower in MINOCA (4.7%; 95%
confidence interval, 2.6%–6.9%) compared with myocardial infarction
associated with obstructive coronary artery disease (6.7%, 95%
confidence interval, 4.3%–9.0%).

Diagnostic test
flow chart
in MINOCA
18
Diagnostic test flow chart in MINOCA
SUSPECTED STEMI
ACUTE INVESTIGATION
No Coronary stenosis
Coronary stenosis ≥50% Urgent angiography ≥50% + Fulfilment
universal AMI criteria
Treat as STEMI
MINOCA
Acute LV wall motion assessment (angiogram/echo)
19
Diagnostic test flow chart in MINOCA (continued)
SUSPECTED DIAGNOSIS AND FURTHER

DIAGNOSTIC TESTS
Non-invasive Invasive
TTE Echo Endomyocardial biopsy

(Pericardial effusion) (myocarditis)
Myocarditis
CMR
(Myocarditis, pericarditis)
TTE Echo (Regional wall motion IVUS/OCT

abnormalities, embolic source) (Plaque disruption/dissection)
Coronary
(epicardial/ CMR (small infarction) Ergonovine/Ach test
TOE/Bubble Contrast Echo (Spasm)
microvascular)
(Patent foramen ovale, atrial septal Pressure/Doppler wire
defect) (Microvascular dysfunction)
20
Diagnostic test flow chart in MINOCA (continued)
SUSPECTED DIAGNOSIS AND FURTHER

DIAGNOSTIC TESTS
Non-invasive Invasive
TTE Echo
Myocardial
CMR
disease
(Takotsubo, others)
D-dimer(Pulmonary embolism)
Pulmonary
CT scan (Pulmonary embolism)
Embolism
Thrombophilia screen
Oxygen supply/ Blood test,

demand imbalance-
Type 2 MI Extracardiac investigation
21
Conclusion I
• MINOCA fulfills the AMI criteria
• MINOCA is common (6% of AMI)
• The MINOCA syndrome is heterogeneous and as

such there is not one common physiopathological
mechanism.
Conclusion II
MINOCA is a working diagnosis and should lead the
treating physician to investigate underlying causes.
Failure to identify the underlying cause may result in no

adequate therapy or inappropriate therapy in these
patients.
MRI might be considered a standard examination when

the underlying cause is not identified.
•
Thank you for the attention
Quality indicators in STEMI:
measure to improve.
Héctor Bueno, MD, PhD, FESC
Centro Nacional de Investigaciones Cardiovasculares (CNIC)
Cardiology Department. Hospital Universitario 12 de Octubre, Madrid, Spain
Aug 28, 2017
Disclosure
Dr. Bueno receives research funding from the Instituto de Salud

Carlos III (PIE16/00021), Astra-Zeneca, BMS, Janssen and Novartis;
and consulting fees, speaking fees or support for attending scientific
meetings from
Abbott, Astra-Zeneca, Bayer, BMS-Pfizer, Ferrer, Novartis; Servier
and MEDSCAPE-the heart.og.
symptoms.
3
New quality indicators for STEMI management
2012 2017
Performance measures Quality indicators
• Structural measures
• Performance measures
- for reperfusion therapy
- for risk assessment
- for antithrombotic treatment
- for discharge medication and counseling
• Patient-related outcomes
• Outcome measures
• Opportunity-based composite QIs
Rationale: Why new quality indicators?
Dimensions Focus of the analysis Point of view
Technical competence
Security & personal relations
Structure Community
Effectiveness
Type of problem Patient
Patient-centered Process
HC Providers
Timeliness
Results HC system
Uderuse of Overuse of
Efficiency
approriate services
unncessary services Administration
Equity
Financier
Rationale: Why new quality indicators?
Focus of the analysis
Human
Material Resources Structure Structural conditions
Financial
Interaction HC Process Adequacy with standards
professionals - patients
Health outcomes Results Outcome improvement
Definition of Quality indicators
Schiele F, et al. Eur Heart J Acute Cardiovasc Care 2017



FMC: EMS
<10’
strategy
STEMI
diagnosis Time
to PCI?
<10’
>120 min Fibrinolysis <10’ Reperfusion
Non-PCI centre

PCI (Wire crossing)
STEMI strategy
11
Quality indicators
Type of indicator Quality indicator
and process
Structural measures 1) The centre should be part of a network specifically developed
(organization) for the rapid and efficient management of STEMI patients with
written protocols covering the following points:
• Single emergency telephone number for patients to contact the
emergency services
• Prehospital interpretation of the ECG for diagnosis and strategy
decision
• Prehospital activation of the catheterization laboratory,
• Transportation (ambulance-helicopter) equipped with ECG
defibrillators
2) Key times to reperfusion are systematically recorded and periodically
reviewed for quality assessments by the centre or network participants.
12
“Do not forget”
interventions in STEMI
patients undergoing a
primary PCI strategy
13
Quality indicators (continued)
and process
Performance 1) Proportion of STEMI patients arriving in the first 12 h receiving reperfusion
measures therapy
for reperfusion 2) Proportion of patients with timely reperfusion therapy, defined as:
therapy • For patients attended to in the pre-hospital setting:
‒ 90 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI,
‒ <10 min from STEMI diagnosis to lytic bolus for reperfusion with fibrinolysis
• For patients admitted to PCI centres:
‒ <60 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI,
• For transferred patients:
‒ <120 min from STEMI diagnosis to IRA wire crossing for reperfusion with PCI
‒ <30 min door-in-door-out for patients presenting in a non-PCI centre (en
route to a PCI centre)
14
and process
Performance 1) Proportion of patients having LVEF assessed before discharge.
measures for risk
assessment in
hospital
Performance 1) Proportion of patients without a clear and documented contra-indication for
measures for aspirin and/or a P2Y12 inhibitor, discharged on DAPT.
antithrombotic
treatment in
hospital
15
and process
Performance 1) Proportion of patients without contra-indications with a statin (high-
measures for intensity) prescribed at discharge.
discharge 2) Proportion of patients with LVEF ≤40% or clinical evidence of heart failure
medication and without contra-indications with a beta-blocker prescribed at
and counseling discharge.
3) Proportion of patients with LVEF ≤40% or clinical evidence of heart failure
without contra-indications with an ACE inhibitor(or ARB if not tolerated)
prescribed at discharge.
4) Proportion of patients with smoking cessation advice/counsellng at
discharge.
5) Proportion of patients without contra-indications enrolled in a secondary
prevention/cardiac rehabilitation programme at discharge.
16
Validity of the Quality Indicators
Distribution of hospitals’ performance Distribution of the opportunity-based
in the ACCA QIs for AMI ACCA composite QI for AMI
(MINAP –UK) (FAST-MI – France, 2005 & 2010)
Bebb O, et al. Eur Heart J 2017 Schiele F, et al. Circ Cardiovasc Qual Outcomes. 2017
Scatter correlation matrix of ACCA QIs for AMI (MINAP –UK)
Bebb O, et al. Eur Heart J 2017

UK hospital rank of unadjusted vs GRACE score-adjusted 30-day mortality rates
Bebb O, et al. Eur Heart J 2017

and process
Outcome 1) 30-day adjusted mortality (e.g. GRACE risk score-adjusted).
measures 2) 30-day adjusted readmission rates.
Opportunity- • Proportion of patients with LVEF >40% and no evidence of heart failure
based receiving at discharge low-dose aspirin and a P2Y12 inhibitor and high-
composite quality intensity statins.
indicators • Proportion of patients with LVEF ≤40% and/or heart failure receiving at
discharge low-dose aspirin, a P2Y12 inhibitor, high-intensity statins, an ACE
inhibitor (or ARB), and a beta-blocker.
20
Association between ACCA QIs for AMI and Association between ACCA QIs for AMI
crude 30-day mortality (MINAP –UK) and 3-year adjusted survival (FAST-MI – FR)
Bebb O, et al. Eur Heart J 2017 Schiele F, et al. Circ Cardiovasc Qual Outcomes. 2017
Survival according to quartiles of the opportunity- 3-Year adjusted* mortality risk for each category of
based composite QI (FAST-MI - France) the ACCA composite QI (FAST-MI – France)
* Adjusted for deciles of GRACE risk score, DM, prior HF, prior stroke, prior
COPD, type of MI, cohort (2005 vs 2010), glycemia, and Hb at admission
Schiele F, et al. Circ Cardiovasc Qual Outcomes. 2017;10:e003336.

and process
Patient-reported • Availability of a program to obtain feedback regarding the patient’s
outcomes experience and quality of information received, including the following
points:
‒ Angina control,
‒ Explanations provided by doctors and nurses (about the disease,
benefit/risk of discharge treatments, and medical follow-up),
‒ Discharge information regarding what to do in case of recurrence of
symptoms and recommendation to attend a rehabilitation programme
(including smoking cession and diet counselling).
23
Quality indicators in STEMI:
measure to improve.
Héctor Bueno, MD, PhD, FESC
Centro Nacional de Investigaciones Cardiovasculares (CNIC)
Cardiology Department. Hospital Universitario 12 de Octubre, Madrid, Spain
Aug 28, 2017
2017 ESC/EACTS Guidelines
for the management of
valvular heart disease
AORTIC VALVE DISEASE

2
2017 ESC/EACTS Valvular Heart Disease GL
AORTIC STENOSIS
NEWS / CHANGES COMPARED TO 2012 VERSION
Assessment of aortic stenosis severity
(low gradient)
Indications for intervention
(low gradient AS, asymptomatic AS)
Choice of intervention modality
(SAVR vs. TAVI vs. BAV)
www.escardio.org/guidelines 2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease 3
AORTIC STENOSIS
ASSESSMENT OF AS SEVERITY
Classification by
Gradient (high/low) Severe AS: Vpeak ≥ 4m/s / ∆Pmean ≥ 40mmHg
EF (normal/low) and/or
Flow (normal/low) AVA < 1.0cm2
LOW GRADIENT
AS
∆Pm < 40 mmHg
AVA < 1.0 cm2
AORTIC STENOSIS
LOW GRADIENT AS
Heterogenous population including patients with severe as
well as moderate AS
Measurement errors, small patient stature and
inconsistency of AVA and gradient cut-offs remain major
sources of misclassification of moderate as severe AS
raising concerns of overtreatment
Assessment of severe AS remains challenging
Stepwise integrated approach for the assessment of aortic
stenosis severity (Modified from Baumgartner et al. Eur Heart J CVI
2017;18:254)
Stepwise integrated approach for the assessment of aortic
stenosis severity (Modified from Baumgartner et al. Eur Heart J CVI
2017;18:254)
aHigh flow may be reversible in settings such

as anaemia, hyperthyroidism,
arteriovenousshunts
bPseudosevere AS is defined by an increase

b
to an AVA >1.0 cm2with flow normalization
Criteria that increase the likelihood of severe
aortic stenosis in patients with AVA <1.0 cm2,
mean gradient < 40 mmHg and preserved EF
(Baumgartner et al)
Criteria
Clinical criteria • Typical symptoms without other explanation.
• Elderly patient (>70 years).
Qualitative imaging data • LV hypertrophy (additional history of
hypertensionto beconsidered).
• Reduced LV longitudinal function without other
explanation.
Quantitative imaging data • Mean gradient 30−40 mmHg.
• AVA ≤0.8 cm2.
Criteria that increase the likelihood of severe
aortic stenosis in patients with AVA <1.0 cm2,
mean gradient < 40 mmHg and preserved EF
(Baumgartner et al)
Criteria(continued)
Quantitative imaging • Low flow (SVi <35 mL/m2) confirmed by techniques
data (continued) other than standard Doppler technique (LVOT
measurement by 3D TOE or MSCT; CMR, invasive data).
• Calcium score by MSCT:
‒ Severe aortic stenosis very likely:
men ≥3000; women ≥1600,
‒ Severe aortic stenosis likely:
men ≥2000; women ≥1200,
‒ Severe aortic stenosis unlikely:
men <1600; women<800.
AORTIC STENOSIS
Changes in recommendations
2012 2017
Indications for intervention in symptomatic aortic stenosis
IIb C IIa C
Intervention may be considered in Intervention should be considered in
symptomatic patients with low-flow, low- symptomatic patients with low-flow, low-
gradient aortic stenosis and reduced ejection gradient aortic stenosis and reduced ejection
fraction without flow (contractile) reserve. fraction without flow (contractile) reserve,
particularly when CT calcium scoring
confirms severe aortic stenosis.
Indications for intervention in aortic
stenosis and recommendations for the
choice of intervention mode
a) Symptomatic aortic stenosis
Intervention is indicated in symptomatic patients with severe, high-
gradient aortic stenosis (mean gradient ≥40 mmHg or peak velocity I B
≥4.0 m/s).
Intervention is indicated in symptomatic patients with severe low-
flow,
low-gradient (<40 mmHg) aortic stenosis with reduced ejection I C
fraction, and evidence of flow (contractile) reserve excluding pseudo-
severe aortic stenosis.
Intervention should be considered in symptomatic patients with low
flow, low-gradient (<40 mmHg) aortic stenosis with normal ejection IIa C
fraction after careful confirmation of severe aortic stenosis.
choice of intervention mode (continued)
Intervention should be considered in symptomatic patients with low-
flow, low-gradient aortic stenosis and reduced ejection fraction
IIa C
without flow (contractile) reserve, particularly when CT calcium
scoring confirms severe aortic stenosis.
Intervention should not be performed in patients with severe
comorbidities when the intervention is unlikely to improve quality of III C
life or survival.
b) Choice of intervention in symptomatic aortic stenosis
AORTIC STENOSIS
Indications for surgery in asymptomatic aortic stenosis
2012 2017
IIb C IIa C
Markedly elevated BNP levels. Markedly elevated BNP levels (>threefold
age- and sex-corrected normal range)
confirmed by repeated measurements
without other explanations.
IIb C
Increase of mean pressure gradient with Taken out
exercise by >20 mmHg.
IIb C
Excessive LV hypertrophy in the absence of Taken out
hypertension.
2017 New recommendation

New IIa C recommendation:
Severe pulmonary hypertension (systolic pulmonary artery pressure at rest >60 mmHg
confirmed by invasive measurement) without other explanation.
www.escardio.org/guidelines 2017 ESC/EACTS Guidelines for the Management of Valvular Heart Disease
13
AORTIC STENOSIS
EXERCISE ECHOCARDIOGRAPHY IN ASYMPT. AS
112 pts., mean FU 14 months 51 pts., mean FU 21 months
30 events, 25 AVR, no deaths 20 events, all AVR, no deaths
Goublaire C et al JACC-Img 2017;epub Domanski O et al Int J Cardiol 2017;227:908-914

AORTIC STENOSIS
B-TYPE NATRIURETIC PEPTICDE IN AORTIC STENOSIS
1953 pts. with at least mod. AS 40% asymptomatic
ALL PATIENTS ASYMPTOMATIC PATIENTS
Clavel A et al J Am Coll Cardiol 2014;63:2016-25

AORTIC STENOSIS
PULMONARY HYPERTENSION IN AORTIC STENOSIS
Zuern CS et al. Prognostic value of mild to moderate pulmonary hypertension in patients with severe aortic
valve stenosis undergoing aortic valve replacement. Clin Res Cardiol 2012;101:81– 8.
Lancellotti P et al. Determinants and prognostic significance of exercise pulmonary hypertension in
asymptomatic severe aortic stenosis. Circulation 2012;126:851– 9.
Mutlak D et al. Frequency, determinants and outcome of pulmonary hypertension in patients with aortic
valve stenosis. Am J Med Sci 2012;343:397– 401.
Zlotnick DM et al; Northern New England Cardiovascular Disease Study Group. Effect of preoperative
pulmonary hypertension on outcomes in patients with severe aortic stenosis following surgical aortic valve
replacement. Am J Cardiol 2013;112:1635– 40.
Miceli A et al. Impact of pulmonary hypertension on mortality after operation for isolated aortic valve
stenosis. Int J Cardiol 2013;168:3556– 9.
Melby SJ et al. Impact of pulmonary hypertension on outcomes after aortic valve replacement for aortic
valve stenosis. J Thorac Cardiovasc Surg 2011;141:1424-30.
AORTIC STENOSIS
PULMONARY HYPERTENSION IN AORTIC STENOSIS
Miceli A et al Int J Cardiol 2013;168:3556– 9 Zlotnick DM et al Am J Cardiol 2013;112:1635–

40
c) Asymptomatic patients with severe aortic stenosis (refers only to patients
eligible for surgical valve replacement)
SAVR is indicated in asymptomatic patients with severe aortic stenosis I C
and systolic LV dysfunction (LVEF <50%) not due to another cause.
SAVR is indicated in asymptomatic patients with severe aortic stenosis
and abnormal exercise test showing symptoms on exercise clearly I C
related to aortic stenosis.
SAVR should be considered in asymptomatic patients with severe aortic
stenosis and abnormal exercise test showing fall in blood pressure below IIa C
baseline.
SAVR should be considered in asymptomatic patients with normal ejection
fraction and none of the above-mentioned exercise test abnormalities if
the surgical risk is low and one of the following findings is present:
‒ very severe aortic stenosis defined by a Vmax>5.5 m/s,
‒ severe valve calcification and a rate of Vmax progression ≥0.3m/s/year,
‒ markedly elevated BNP levels (>threefold age- and sex-corrected IIa C
normalrange) confirmed by repeated measurements without other
explanations,
‒ severe pulmonary hypertension (systolic pulmonary artery pressure at
rest >60 mmHg confirmed by invasive measurement) without other
explanation.
d) Concomitant aortic valve surgery at the time of other cardiac/ascending aorta
surgery
SAVR is indicated in patients with severe aortic stenosis undergoing
I C
CABG, or surgery of the ascending aorta or of another valve.
SAVR should be considered in patients with moderate aortic stenosis*
undergoing CABG, or surgery of the ascending aorta or of another IIa C
valve after Heart Team decision.
* Moderate aortic stenosis is defined by a valve area of 1.0-1.5 cm2 or a mean gradient of 25-40 mmHg
in the presence of normal flow conditions. However, clinical judgement is required.
AORTIC STENOSIS: TAVI vs. SAVR
5 randomized trials
1 meta-analysis
Large registries
Vahl T et al J Am Coll Cardiol 2016;67:1472-87
High risk
High/Interm. risk
Intermediate risk
Intermediate risk
Siontis GCM et al Eur Heart J 2016;37:3503-3512





PARTNER 2A SURTAVI
Age (years) 81.6 ± 6.7 79.8 ± 6.2
STS Score 5.8 ± 2.0 4.5 ± 1.6
Frail (%) 44.4 52.3
PARTNER PARTNER SURTAVI SURTAVI
Surgery TAVI Surgery TAVI
30-day mortality (%) 4.1 3.9 1.7 2.2
2-year mortality (%) 18.0 16.7 11.6 11.4
Stroke 30-day (%) 6.1 5.5 5.6 3.4
Moderate/severe AR 3.7 0.6 5.3
(%)
New PM (%) 6.9 8.5 6.6 25.9
Reardon MJ et al New Engl J Med 2017 (epub March 17)
Consideration of TAVI as an alternative to SAVR in a wide range of patients with
increased surgical risk („intermediate“ or „high risk“)
Risk scores alone are insufficient to guide decision between TAVI and SAVR
Avaliable data for TAVI mostly in population > 75 years !
- Bicuspid valves more frequent in younger patients (few experience,
worse results?)
- Missing longterm durability data
- Higher PM and PVL rates become more relevant in younger patients
When patients are theoretically eligible for both, TAVI and surgery, a number
of patient characteristics affect the individual risk / benefit ratio for both
modalities (complex decision process)
Local outcome data for both modalities require consideration
Aspects to be considered by the Heart Team
for the decision between SAVR and TAVI
in patients at increased surgical risk
Favours Favours
TAVI SAVR
Clinical characteristics
STS/EuroSCORE II <4% (logistic EuroSCORE I<10%) +
STS/EuroSCORE II ≥4% (logistic EuroSCORE I ≥10%) +
Presence of severe comorbidity (not adequately reflected by
scores)
+
Age <75 years +
Age ≥75 years +
Previous cardiac surgery +
in patients at increased surgical risk (continued)
Favours Favours
TAVI SAVR
Clinical characteristics (continued)
Frailty +
Restricted mobility and conditions that may affect the
rehabilitation process after the procedure
+
Suspicion of endocarditis +
Anatomical and technical aspects
Favourable access for transfemoral TAVI +
Unfavourable access (any) for TAVI +
Favours Favours
TAVI SAVR
Anatomical and technical aspects (continued)

Sequelae of chest radiation +
Porcelain aorta +
Presence of intact coronary bypass grafts at risk when
sternotomy is performed
+
Expected patient–prosthesis mismatch +
Severe chest deformation or scoliosis +
Short distance between coronary ostia and aortic valve
annulus
+
Favours Favours
TAVI SAVR
Anatomical and technical aspects (continued)

Size of aortic valve annulus out of range for TAVI +
Aortic root morphology unfavourable for TAVI +
Valve morphology (bicuspid, degree of calcification,
calcification pattern) unfavourable for TAVI
+
Presence of thrombi in aorta or LV +
Cardiac conditions in addition to aortic stenosis that require consideration for
concomitant intervention
Severe CAD requiring revascularization by CABG +
Favours Favours
TAVI SAVR
Cardiac conditions in addition to aortic stenosis that require consideration for
concomitant intervention (continued)
Severe primary mitral valve disease, which could be treated
surgically
+
Severe tricuspid valve disease +
Aneurysm of the ascending aorta +
Septal hypertrophy requiring myectomy +
b) Choice of intervention in symptomatic aortic stenosis
Aortic valve interventions should only be performed in centres with
both departments of cardiology and cardiac surgery on-site, and with
I C
structured collaboration between the two, including a Heart Team
(heart valve centres).
The choice for intervention must be based on careful individual evalu-
ation of technical suitability and weighing of risks and benefits of each
modality (aspects to be considered are listed in the according table). I C
In addition, the local expertise and outcomes data for the given
intervention must be taken into account.
SAVR is recommended in patients at low surgical risk (STS or
EuroSCORE II <4% or logistic EuroSCORE I <10% and no other risk
I B
factors not included in these scores, such as frailty, porcelain aorta,
sequelae of chest radiation).
TAVI is recommended in patients who are not suitable for SAVR as
I B
assessed by the Heart Team.
In patients who are at increased surgical risk (STS or EuroSCORE II ≥4%
or logistic EuroSCORE I ≥10% or other risk factors not included in
these scores such as frailty, porcelain aorta, sequelae of chest
radiation), the decision between SAVR and TAVI should be made by I B
the Heart Team according to the individual patient characteristics (see
according table), with TAVI being favoured in elderly patients suitable
for transfemoral access.
Balloon aortic valvotomy may be considered as a bridge to SAVR or
TAVI in haemodynamically unstable patients or in patients with
IIb C
symptomatic severe aortic stenosis who require urgent major non-
cardiac surgery.
Balloon aortic valvotomy may be considered as a diagnostic means
in patients with severe aortic stenosis and other potential cause for
symptoms (i.e. lung disease) and in patients with severe myocardial IIb C
dysfunction, pre-renal insufficiency or other organ dysfunction that
maybe reversible with balloon aortic valvotomy when performed in
centres that can escalate to TAVI.
Management of aortic regurgitation
Significant enlargement of ascending aortaa
No Yes
Severe aortic regurgitation
No Yes
Symptoms
No Yes
LVEF ≤50% or LVEDD >70 mm
or LVESD >50 mm (or >25 mm/m2 BSA)
No Yes
Follow-up Surgeryb
a See table of recommendations for definitions of aortic diameter
b Surgery should also be considered if significant changes in LV and aortic size occur during FU (see table)
AORTIC REGURGITATION
EVALUATION
AORTIC REGURGITATION
EVALUATION
What is new in the 2017 Valvular Heart
Disease Guidelines?
2017 New recommendations
Indications for surgery in severe aortic regurgitation and aortic root disease
New I C recommendations:
* Patients with pliable non-calcified tricuspid or bicuspid valves who have a type I (enlargement
• Heart Team discussion is recommended in selected patients in whom aortic valve repair
of the aortic root with normal cusp motion) or type II (cusp prolapse) mechanism of AR.
may be a feasible alternative to valve replacement.
• Aortic valve repair, using the reimplantation or remodelling with aortic annuloplasty
technique, is recommended in young patients with aortic root dilationand tricuspid
aortic valves, when performed by experienced surgeons.
New IIa C recommendation:
Surgery should be considered in patients who have aortic root disease with maximal
ascending aortic diameter: ≥45 mmin patients with a TGFBR1 orTGFBR2 mutation
(including Loeys-Dietz syndrome)*.
* A lower threshold of 40 mm may be considered in women with low BSA, in patients with a TGFBR2
mutation, or in patients with severe extra-aortic features.
Full Text and ESC Textbook chapter VHD
www.escardio.org/guidelines
Mitral Valve Disease
Raphael Rosenhek
Medical University of Vienna
2
Experience and Outcome of Mitral
Surgery in Mitral Regurgitation
Proportion repaired
Bolling S et al.
Ann Thorac Surg 2010;90:1904-11
# of isolated mitral cases per surgeon and year
Concept of Heart Valve Centres
• Multidisciplinary Teams
Heart • Volume
Interventional
Cardiology Surgery • Quality Assessment (robust audit)
• Excellence in
Imaging
Intervention
PAT Surgery
Non-interventional
Cardiology
Imaging
Modified from Chambers J et al. Eur Heart J 2017;38:2177-2183.

Indications for intervention in severe
primary mitral regurgitation
100
NYHA I-II
Survival (%) 80
60
40 NYHA III-IV
20
0
0 1 2 3 4 5 6 7 8 9 10
Years
Tribouilloy C et al. Circulation 1999;99:400
100
Survival (%) 80 EF ≥ 60%
60 EF 50-60%
40
20
EF <50%
0
0 2 4 6 8 10
Enriquez-Sarano et al. Circulation 1994;90:830-837.
Atrial Fibrillation & Pulmonary Hypertension
Postoperative survival
Survival (%)
Years
Badhwar et al. Ann Thor Surg 2012;94:1870-1877 Le Tourneau et al. Heart 2010;96:1311-1317
Mitral valve repair should be the preferred technique when the results
I C
are expected to be durable.
Surgery is indicated in symptomatic patients with LVEF >30%. I B
Surgery is indicated in asymptomatic patients with LV dysfunction
I B
(LVESD ≥45 mm* and/or LVEF ≤60%).
Surgery should be considered in asymptomatic patients with
preserved LV function (LVESD <45 mm and LVEF >60%) and atrial
IIa B
fibrillation secondary to mitral regurgitation or pulmonary hyper-
tension (systolic pulmonary pressure at rest >50 mmHg**).
* Cut-offs refer to average-size adults and may require adaptation in patients with unusually small or large stature
** If an elevated SPAP is the only indication for surgery, the value should be confirmed by invasive
measurement
primary mitral regurgitation (continued)
Left Ventricular and Left Atrial Size
In patients with flail leaflets
Tribouilloy C et al.
Le Tourneau T. et al.
J Am Coll Cardiol 2009;54:1961-1968
J Am Coll Cardiol 2010;56:570-8
Surgery should be considered in asymptomatic patients with
preserved LVEF (>60%) and LVESD 40–44 mm* when a durable repair
is likely, surgical risk is low, the repair is performed in heart valve
centres, and at least one of the following findings is present: IIa C
- flail leaflet or,
- presence of significant LA dilatation (volume index ≥60 mL/m²
BSA) in sinus rhythm.
Mitral valve repair should be considered in symptomatic patients with
severe LV dysfunction (LVEF <30% and/or LVESD >55 mm) refractory
IIa C
to medical therapy when likelihood of successful repair is high and
comorbidity low.
* Cut-offs refer to average-size adults and may require adaptation in patients with unusually small or large stature
Disease Guidelines?
2012 2017
Indications for intervention in asymptomatic severe primary mitral regurgitation
Pulmonary hypertension on exercise (SPAP
Taken out
≥60 mmHg at exercise).

Mitral valve replacement may be considered in symptomatic patients
with severe LV dysfunction (LVEF <30% and/or LVESD >55 mm)
IIb C
refractory to medical therapy when likelihood of successful repair is
low and comorbidity low.
Percutaneous edge-to-edge procedure may be considered in patients
with symptomatic severe primary mitral regurgitation who fulfill the
IIb C
echocardiographic criteria of eligibility and are judged inoperable or at
high surgical risk by the Heart Team, avoiding futility.
Management of severe chronic primary mitral regurgitation
Symptoms
No Yes
LVEF ≤60% or LVESD ≥45 mm LVEF >30%
No Yes No Yes
New onset of AF or Refractory to medical therapy
SPAP >50 mmHg
No Yes No Yes
High likelihood of durable Medical therapy
repair, low surgical risk, and Durable valve repair is likely
presence of risk factorsa and low comorbidity
No Yes No Yes
Extended HF
Follow-up treatment/percutaneous
edge-to-edge repair
Surgery (repair whenever possible)
a LVESD ≥40 mm and one of the following present: flail leaflet or LA volume ≥60 mL/m² BSA at sinus rhythm
Echocardiographic criteria for the
definition of severe valve regurgitation:
an integrative approach (continued)
(Adapted from Lancellotti et al.)
Mitral regurgitation
Quantitative Primary Secondary
EROA (mm²) ≥40 ≥20
Regurgitant volume
≥60 ≥30
(mL/beat)
+ enlargement of cardiac LV, LA
chambers/vessels
Disease Guidelines?
2012 2017
Indications for mitral valve intervention in secondary mitral regurgitation (continued)
Additional statement:
The lower thresholds defining severe MR
compared to primary MR are based on their
association with prognosis. However, it is
unclear if prognosis is independently
affected by MR compared to LV dysfunction.
For isolated mitral valve treatment in
secondary MR, thresholds of severity of MR
for intervention still need to be validated in
clinical trials. So far, no survival benefit has
been confirmed for reduction of secondary
MR.
Indications for mitral valve
intervention in chronic secondary
mitral regurgitation
Surgery is indicated in patients with severe secondary mitral
I C
regurgitation undergoing CABG and LVEF >30%.
Surgery should be considered in symptomatic patients with severe
secondary mitral regurgitation, LVEF <30% but with an option for IIa C
revascularization, and evidence of myocardial viability.
Disease Guidelines?
2012 2017
Indications for mitral valve intervention in secondary mitral regurgitation
IIa C
Surgery should be considered in patients
with moderate secondary mitral Taken out
regurgitation undergoing CABG
Indications for mitral valve intervention
in chronic secondary mitral regurgitation
(continued)
When revascularization is not indicated, surgery may be considered in
patients with severe secondary mitral regurgitation and LVEF >30%,
IIb C
who remain symptomatic despite optimal medical management
(including CRT if indicated) and have a low surgical risk.
In patients with severe secondary mitral regurgitation and LVEF <30%
who remain symptomatic despite optimal medical management
(including CRT if indicated) and who have no option for revascularis-
ation, the Heart Team may consider percutaneous edge-to-edge IIb c
procedure or valve surgery after careful evaluation for ventricular
assist device or heart transplant according to individual patient
characteristics.
Indications for PMC and mitral valve
Surgery in clinically significant mitral
stenosis (≤1.5cm2)
PMC is indicated in symptomatic patients without unfavourable
I B
characteristics for PMC.
PMC is indicated in any symptomatic patients with a contra-
I C
indication or at high-risk for surgery.
Mitral valve surgery is indicated in symptomatic patients who
I C
are not suitable for PMC.
PMC should be considered as initial treatment in symptomatic
patients with suboptimal anatomy but no unfavourable clinical IIa C
characteristics* for PMC.
* Several of the following: old age, history of commissurotomy, NYHA class IV, Afib., pulm. hypertension
Indications for PMC and mitral valve
surgery (continued)
PMC should be considered in asymptomatic patients without
unfavourable clinical and anatomical characteristics for PMC
and
• high thromboembolic risk (history of systemic embolism,
dense spontaneous contrast in the LA, new-onset or IIa C
paroxysmal atrial fibrillation); and/or
• high-risk of haemodynamic decompensation (systolic
pulmonary pressure >50 mmHg at rest, need for major non
-cardiac surgery, desire for pregnancy).
Contra-indications for percutaneous
mitral commissurotomy (PMC)
Contra-indications
Mitral valve area >1.5 cm²
Left atrial thrombus
More than mild mitral regurgitation
Severe or bi-commissural calcification
Absence of commissural fusion
Severe concomitant aortic valve disease, or severe combined tricuspid
stenosis andregurgitation requiring surgery
Concomitant CAD requiring bypass surgery
Echo scores: Wilkins score, Cormier
score, and Echo Score “Revisited” for
immediate outcome prediction
Assessment of mitral valve anatomy according to the Wilkins score
Grade Mobility Thickening
Highly mobile valve with only Leaflets near normal in
1
leaflettips restricted thickness(4−5 mm)
Leaflet mid and base portions Mid leaflets normal, considerable
2
havenormal mobility thickeningof margins (5−8 mm)
Valve continues to move forward Thickening extending through the
3
indiastole, mainly from the base entireleaflet(5−8 mm)
No or minimalforwardmovementof Considerable thickening of all leaflet
4
the leaflets in diastole tissue(>8−10 mm)
The total score is the sum of the four items and ranges between 4 and 16
Echo scores: Wilkins score, Cormier score,
and Echo Score “Revisited” for immediate
outcome prediction (continued)
Assessment of mitral valve anatomy according to the Wilkins score
Grade Calcification Subvalvular thickening
A single area of increased Minimal thickening just below the mitral
1
echobrightness leaflets
Scattered areas of brightness Thickening of chordal structures extending
2
confined to leaflet margins to one thirdof the chordal length
Brightness extending into the Thickening extended to distal third of the
3
midportions of the leaflets chords
Extensive brightness through- Extensive thickening and shortening of all
4 outmuch of the leaflet tissue chordalstructures extending down to the
papillary muscles
Unfavourable anatomy: score >8
Echo scores: Wilkins score, Cormier score,
and Echo Score “Revisited” for immediate
outcome prediction (continued)
Assessment of mitral valve anatomy according to the Cormier score
Echocardiographic group Mitral valve anatomy
Pliable non-calcified anterior mitral leaflet and
Group1 mild subvalvular disease (i.e., thin chordae
≥10 mm long)
Pliable non-calcified anterior mitral leaflet and
Group 2 severe subvalvular disease (i.e., thickened
chordae <10 mm long)
Calcification of mitral valve of any extent, as
Group 3 assessed by fluoroscopy, whatever the state
ofsubvalvular apparatus
Management of clinically significant mitral stenosis (MVA <1.5 cm 2)
Symptoms
No Yes
High-risk of embolism or haemodynamic decompensation CI to PMC
No Yes No Yes
Exercice testing CI or high-risk for surgery Surgery
No Yes
Symptoms
No Yes PMC
Follow-up CI to or unfavourable Favourable anatomical
characteristics for PMC characteristics
No Yes No Yes
Favourable clinical
characteristics*
No Yes
PMC Surgery* Surgery PMC

See table of recommendations *If symptoms occur for a low level of exercise and operative risk is low
Tricuspid valve disease
De Bonis Michele, MD, FESC, FAHA
Vita-Salute San Raffaele University
Department of Cardiac Surgery,
San Raffaele University Hospital, Milan, Italy
Declaration of interest
• No disclosures
What is new in the 2017 Valvular
Heart Disease Guidelines?
Tricuspid valve
disease
Disease Guidelines?
2017 NEW/REVISED CONCEPTS

New concept
• Condense guideline document linked to ESC Textbook for more background information.
• Key points and gaps in evidence after each section.
Heart valve centres and heart team
New concept!
• See new Table “Recommended requirements of a heart valve centre”, see Section 3.6
Class I Class IIa Class IIb Class III
)
Disease Guidelines?
2017 NEW/REVISED CONCEPTS

New concept
• Condense guideline document linked to ESC Textbook for more background information.
• Key points and gaps in evidence after each section.
Heart valve centres and heart team
New concept!
• See new Table “Recommended requirements of a heart valve centre”, see Section 3.6
Class I Class IIa Class IIb Class III
)
Requirements of a heart valve centre
(Modified from Chambers et al.)
Requirements
Multidisciplinary teams with competencies in valve replacement, aortic
root surgery, mitral, tricuspid and aortic valve repair, as well as trans-
catheter aortic and mitral valve techniques including reoperations and
reinterventions. The Heart Teams must meet on a regular basis and work
with standard operating procedures.
Imaging, including 3D and stress echocardiographic techniques, peri-
operative TOE,cardiac CT, MRI, and positron emission tomography-CT.
Regular consultation with community, other hospitals, and extracardiac
departments,and between non-invasive cardiologists and surgeons and
interventional cardiologists.
)
Patient evaluation
Essential questions in the evaluation of
patients for valvular intervention
Questions
• How severe is VHD?
• What is the aetiology of VHD?
• Does the patient have symptoms?
• Are symptoms related to valvular disease?
• Are any signs present in asymptomatic patients that indicate a worse
outcome if the intervention is delayed?
• What are the patient’s life expectancy and expected quality of life?
)
(continued)
Questions (continued)
• Do the expected benefits of intervention (versus spontaneous
outcome)outweigh its risks?
• What is the optimal treatment modality? Surgical valve replacement
(mechanicalor biological), surgical valve repair, or catheter intervention?
• Are local resources (local experience and outcome data for a given
intervention)optimal for the planned intervention?
• What are the patient’s wishes?
)
Questions
• How severe is VHD?
• What is the aetiology of VHD?
• Does the patient have symptoms?
• Are symptoms related to valvular disease?
• Are any signs present in asymptomatic patients that indicate a worse
outcome if the intervention is delayed?
• What are the patient’s life expectancy and expected quality of life?
)
(continued)
Questions (continued)
• Do the expected benefits of intervention (versus spontaneous outcome)
outweigh its risks?
• What is the optimal treatment modality? Surgical valve replacement
(mechanical or biological), surgical valve repair, or catheter
intervention?
• Are local resources (local experience and outcome data for a given
intervention) optimal for the planned intervention?
• What are the patient’s wishes?
)
Tricuspid regurgitation
Etiology
• Secondary TR
– RV dysfunction following pressure and/or volume overload
– structurally normal leaflets
• Primary TR
– infective endocarditis (especially in intravenous drug addicts)
– rheumatic heart disease
– carcinoid syndrome
– myxomatous disease
– endomyocardial fibrosis
– Ebstein’s anomaly
– congenitally dysplastic valves
– drug-induced valve diseases
– thoracic trauma
– iatrogenic valve damage
Evaluation
• Echocardiography
– abnormalities of the valve structure (primary TR)
– degree of dilatation of the annulus/degree of TV deformation (secondary TR)
– RV dimension and function
– TR severity (integration of multiple qualitative and quantitative parameters) and pulmonary
systolic pressure
– associated valve lesions (particularly on the left side) and LV function
– In experienced laboratories, 3D measurements of RV volumes can be considered
• CMR
– gold standard for assessing RV volumes and function
• Cardiac catheterization
– to evaluate haemodynamics (in particular pulmonary vascular resistance) in patients in whom
isolated tricuspid valve surgery is contemplated for secondary tricuspid regurgitation
TR severity (integration of multiple qualitative and
quantitative parameters)
Qualitative
Valve morphology Abnormal/flail/large coaptation defect
Colour flow regurgitant jet Very large central jet or eccentric wall
impinging jet
Dense/triangular with early peaking
CW signal of regurgitant jet
(peak <2 m/s in massive TR)
Other –
)
Semiquantitative
Vena contracta width (mm) ≥7
Upstream vein flow Systolic hepatic vein flow reversal
Inflow E-wave dominant ≥1 m/s
Other PISA radius >9 mm
)
Quantitative Primary
EROA (mm²) ≥40
Regurgitant volume ≥45
(mL/beat)
+ enlargement of cardiac RV, RA, inferior vena cava
chambers/vessels
)
Indications for Tricuspid Valve Surgery
Timing
– controversial (limited/heterogeneous data available)
– surgery should be carried out sufficiently early to avoid
irreversible RV dysfunction.
Indications for tricuspid valve surgery
Primary tricuspid regurgitation
Surgery is indicated in patients with severe primary tricuspid
I C
regurgitation undergoing left-sided valve surgery.
Surgery is indicated in symptomatic patients with severe isolated
primary tricuspid regurgitation without severe right-ventricular I C
dysfunction.
Surgery should be considered in patients with moderate primary IIa C
tricuspid regurgitation undergoing left-sided valve surgery.
Surgery should be considered in asymptomatic or mildly symptomatic
patients with severe isolated primary tricuspid regurgitation and IIa C
progressive right-ventricular dilatation or deterioration of right
ventricular function.
)
I C
dysfunction.
)
I C
dysfunction.
)
I C
dysfunction.
)
I C
)
I C
)
I C
)
dysfunction.
)
dysfunction.
)
dysfunction.
)
dysfunction.

)
dysfunction.

)
dysfunction.

Though these patients respond well to diuretic therapy, delaying surgery is likely to result in
irreversible RV damage, organ failure, and poor results of late surgical intervention.
)
Secondary tricuspid regurgitation
Surgery is indicated in patients with severe secondary tricuspid I C
Surgery should be considered in patients with mild or moderate
secondary tricuspid regurgitation with dilated annulus (≥40 mm or IIa C
>21 mm/m² by 2D echocardiography) undergoing left-sided valve surgery.
Surgery may be considered in patients undergoing left-sided valve
surgery with mild or moderate secondary tricuspid regurgitation IIb C
even in the absence of annular dilatation when previous recent right heart failure has
been documented.
After previous left-sided valve surgery and in the absence of recurrent left-sided
valve dysfunction, surgery should be considered in patients with severe tricuspid
regurgitation who are symptomatic or have progressive right-ventricular IIa C
dilatation/dysfunction, in the absence of severe right or LV dysfunction,and severe
34
pulmonary vascular disease/hypertension.
)
been documented.
After previous left-sided valve surgery and in theabsence of recurrent left-sided valve
dysfunction, surgery should be considered in patients with severe tricuspid
35
)

been documented.
After previous left-sided valve surgery and in theabsence of recurrent left-sided valve
dysfunction, surgery should be considered in patients with severe tricuspid
36
)
been documented.

37
)

even in the absence of annular dilatation when previous recent right heart failure
has been documented.
)
Indications for surgery in secondary TR
during left sided valve surgery
• Tricuspid repair during left-sided surgery should be
performed liberally when annulus dilatation is present
because:
– It does not increase operative risk
– It provides RV reverse remodeling
– It improves the functional status

)

)

)

dilatation/dysfunction, in the absence of severe right or LV dysfunction, and severe
)

)
Indications for surgery in secondary TR after
previous left sided valve surgery
• Reoperation in late TR following mitral valve surgery carries a
high risk, mostly due to the late referral and the consequently
poor clinical condition of the patients.
• To improve the prognosis of these patients surgery should be
considered earlier, even in asymptomatic patients, if there are
signs of progressive RV dilatation or decline in RV function.
Surgical timing
- a key issue -
The problem of late surgical referral is emphasized in
the 2014 AHA Guidelines :

Tricuspid Regurgitation: Intervention
Recommendations COR LOE
Reoperation for isolated tricuspid valve repair or
replacement may be considered for persistent
symptoms due to severe TR (stage D) in patients
who have undergone previous left-sided valve IIb C
surgery and who do not have severe pulmonary
hypertension or significant RV systolic dysfunction
….waiting for persistent
symptoms, as recommended,
is not going to make it any
better!
According to the 2012
ESC/EACTS VHD guidelines
Since severe TR will certainly lead to RV
failure, progressive RV dilatation/initial
dysfunction should trigger TV surgery
regardless of symptoms
Indications for tricuspid valve surgery in
ESC/EACTS VHD Guidelines
)
)
)
Contra-indications for tricuspid valve surgery in
isolated secondary TR after previous left-sided
valve surgery
)
Type of intervention in TR
• Valve repair is preferable to valve replacement (ring annuloplasty)
• Valve replacement should be considered if:
– leaflets are significantly tethered
– annulus is severely dilated
• Percutaneous repair techniques must be further evaluated before
any recommendations can be made.
Management of tricuspid regurgitation (TR)
Need for left-sided valve surgery?
No Yes
Kind of tricuspid regurgitation Kind of tricuspid regurgitation
Severe secondary TR Severe primary TR Mild to moderate Severe primary or
secondary TR secondary TR
Absence of severe RV or LV TA dilatation* or recent signs of
dysfunction and of severe right-heart failure?
pulmonary hypertension?
No Yes No Yes
Markedly symptomatic? No TV surgery
No Yes
No or mild symptoms
but progressive RV
dilatation/dysfunction?
No Yes
Conservative TV repair (TVR when repair not feasible)
treatment
* Tricuspid annulus ≥ 40 mm or 21 mm/m2
)
Tricuspid stenosis
Etiology
• Rheumatic (often combined with TR in pts with left-
sided valve lesions, particularly mitral stenosis)
• Other causes are rare:
– congenital
– drug-induced valve
– Whipple's disease
– Endocarditis
– large right atrial tumour.
Evaluation
• Echocardiography
– anatomy of the valve and its subvalvular
apparatus
– mean gradient ≥5 mmHg at normal heart rate is
considered indicative of clinically significant
tricuspid stenosis.

Tricuspid stenosis
Surgery is indicated in symptomatic patients with severe tricuspid
I C
stenosis.
Surgery is indicated in patients with severe tricuspid stenosis under-
I C
going left-sided valve intervention.
)

Tricuspid stenosis
I C
stenosis.
I C
)

Tricuspid stenosis
I C
stenosis.
I C
)

Tricuspid stenosis
I C
stenosis.
I C
)
Type of intervention
• Intervention on the tricuspid valve is usually carried out at the time of intervention
on the other valves
• Balloon commissurotomy can be considered in the rare cases with anatomically
suitable valves when tricuspid stenosis is isolated or additional mitral stenosis can
also be treated interventionally.
– limited number of cases
– frequently induces significant regurgitation
– lack of data on long-term results
• The choice between surgical repair or replacement depends on valve anatomy and
surgical expertise.
• The choice of the prosthesis is still a matter of debate
– biological prostheses usually preferred (less thrombotic risk and satisfactory long-term
durability)
Key points
• Tricuspid stenosis is rare, whereas tricuspid regurgitation is more
frequent, (especially secondary TR).
• For appropriate management, secondary TR has to be clearly
distinguished from primary TR.
• Primary TR requires intervention sufficiently early to avoid
secondary RV damage, which is associated with poor outcome.
• Secondary TR should be liberally treated at the time of left-sided
valve surgery.
• Isolated TR surgery after previous left-sided valve surgery requires
comprehensive assessment of the underlying disease, pulmonary
haemodynamics, and RV function.
Gaps in evidence
• Criteria for optimal timing of surgery in primary TR require
refinement.
• Criteria for concomitant tricuspid valve surgery at the time of
left-sided surgery in patients without severe TR require
refinement.
• The potential role of transcatheter tricuspid valve treatment
in high-risk patients needs to be determined.
Thank you!
ESC Guidelines 2017
Valvular Heart Disease
Prosthetic Valves
Bernard Iung
Bichat Hospital, Paris Diderot University, France
on behalf of the Task Force
2
Choice of the aortic/mitral prosthesis in
favour of a mechanical prosthesis
A mechanical prosthesis is recommended according to the
desire of the informed patient and if there are no contra- I C
indications to long-term anticoagulation*.
A mechanical prosthesis is recommended in patients at risk of
I C
accelerated structural valve deterioration**.
A mechanical prosthesis should be considered in patients
already on anticoagulation because of a mechanical prosthesis IIa C
in another valve position.
* Increased bleeding risk because of comorbidities, compliance concerns or geographic, lifestyle or
occupational conditions
** Young age (<40 years), hyperparathyroidism
Choice of the aortic/mitral prosthesis
in favour of a mechanical prosthesis
(continued)
A mechanical prosthesis should be considered in patients aged
<60 years for prostheses in the aortic position and <65 years IIa C
for prostheses in the mitral position*.
A mechanical prosthesis should be considered in patients with
a reasonable life expectancy, for whom future redo valve IIa C
surgery would be at high-risk.
A mechanical prosthesis may be considered in patients already
on long-term anticoagulation due to high-risk for thrombo- IIb C
embolism.
* Between 60 and 65 (aortic prosthesis) / 65 and 70 years (mitral prosthesis), both valves are acceptable
and the choice requires careful analysis of factors other than age
in favour of a bioprosthesis
A bioprosthesis is recommended according to the desire of the
I C
informed patient.
A bioprosthesis is recommended when good-quality
anticoagulation is unlikely (compliance problems, not readily
available) or contra-indicated because of high bleeding risk I C
(previous major bleed, comorbidities, unwillingness,
compliance problems, lifestyle, occupation).
A bioprosthesis is recommended for reoperation for
mechanical valve thrombosis despite good long-term anti- I C
coagulant control.
in favour of a bioprosthesis (continued)
A bioprosthesis should be considered in patients for whom
there is a low likelihood and/or a low operative risk of future IIa C
redo valve surgery.
A bioprosthesis should be considered in young women
IIa C
contemplating pregnancy.
A bioprosthesis should be considered in patients aged
>65 years for a prosthesis in the aortic position, or age
IIa C
>70 years in a mitral position*, or those with life expectancy
lower than the presumed durability of the bioprosthesis.
* Between 60 and 65 (aortic prosthesis) / 65 and 70 years (mitral prosthesis), both valves are acceptable
and the choice requires careful analysis of factors other than age
Age thresholds and choice of the
type of prosthesis
(Nishimura et al. J Am Coll Cardiol 2017;70:252-89)
Long-term survival and type of
prosthesis
Observational series in pts aged 50-69 yrs with mechanical
or biological aortic prostheses.
Comparison of survival in propensity-matched groups.
2 groups of 1001 pts 2 groups of 1099 pts
No difference for 50-59 and 60-69 yrs
(Chiang et al. JAMA 2014;312:1323-29) (Glaser et al. Eur Heart 2016;37:2658-67)
Indications for antithrombotic therapy
for mechanical prostheses
Mechanical prosthesis
Oral anticoagulation using a VKA is recommended lifelong for all
I B
patients.
Bridging using therapeutic doses of UFH or LMWH is recommended
I C
when VKA treatment should be interrupted.
The addition of low-dose aspirin (75-100 mg/day) to VKA should be
IIa C
considered after thromboembolism despite an adequate INR.
The addition of low-dose aspirin (75-100 mg/day) to VKA may be
IIb C New
considered in the case of concomitant atherosclerotic disease.
INR self-management is recommended provided appropriate training
I B New
and quality control are performed.
Target INR for mechanical prostheses
Prosthesis Patient-related riskfactorsa
thrombogenicity None ≥1 risk factor
Lowb 2.5 3.0
Mediumc 3.0 3.5
Highd 3.5 4.0
a Mitral or tricuspid valve replacement, previous thromboembolism, atrial fibrillation,
mitral stenosis of any degree, LVEF <35%
b Carbomedics, Medtronic Hall, ATS, Medtronic Open-Pivot, St. Jude Medical, On-X, Sorin Bicarbon
c Other bileaflet valves with insufficient data
d Lillehei-Kaster, Omniscience, Starr-Edwards (ball-cage), Björk-Shiley and other tilting-disc valves
Lower target INR for mechanical
aortic prostheses ?
(Nishimura et al.
J Am Coll Cardiol 2017;70:252-89)
PROACT trial
• 375 pts randomized after AVR (ON-X valve): INR [1.5-2.0] vs. [2.0-3.0] (+ASA 81 mg/j).
Decrease of major (1.5% vs. 3.3%, p=0.047) and minor bleeding (1.3% vs. 3.4%, p=0.021) with
no difference in thromboembolic events (3.0% vs. 1.8%, p=0.18).
• Limitations
− Single type of prosthesis
− Lack of statistical power for thromboembolic risk
− Weekly INR self-monitoring (Puskas et al. J Thorac Cardiovasc Surg 2014;147:1202-11)
Systematic association of aspririn
for mechanical prostheses ?
(Nishimura et al.
J Am Coll Cardiol 2017;70:252-89)
Thromboembolism Major Bleeding
(Massel and Little Cochrane Database Syst Rev 2013:CD003464)
INR self-monitoring
Meta-analysis of 11
randomized trials
(6417 pts)
•Significant benefit for the
prevention of
thromboembolic events
•Particularly marked benefit
in patients with mechanical
prostheses
for mechanical prostheses (continued)
Mechanical prosthesis
In patients treated with coronary stent implantation, triple therapy
with aspirin (75-100 mg/day), clopidogrel (75 mg/day), and VKA New
IIa B
should be considered for 1 month, irrespective of the type of stent
used and the clinical presentation (i.e. ACS or stable CAD).
Triple therapy comprising aspirin (75-100 mg/day), clopidogrel
(75 mg/day), and VKA for longer than 1 month and up to 6 months
should be considered in patients with high ischaemic risk due to ACS IIa B New
or other anatomical/procedural characteristics that outweigh the
bleeding risk.
for mechanical prostheses (continued)
Mechanical prosthesis (continued)
Dual therapy comprising VKA and clopidogrel (75 mg/day) should be
considered as an alternative to 1-month triple antithrombotic therapy IIa A New
in patients in whom the bleeding risk outweighs the ischaemic risk.
In patients who have undergone PCI, discontinuation of antiplatelet New
IIa B
treatment should be considered at 12 months.
In patients requiring aspirin and/or clopidogrel in addition to VKA, the
dose intensity of VKA should be carefully regulated with a target INR New
IIa B
in the lower part of the recommended target range and a time in
therapeutic range >65-70%.
The use of NOACs is contra-indicated. III B New
Antithrombotic therapy in patients with mechanical
valve prosthesis after undergoing PCI
(Adapted from the 2017 ESC Focused Update on Dual Antiplatelet Therapy)
Patients with a mechanical valve undergoing PCI
Concerns about
ischaemic risk Concerns about
prevailing bleeding risk prevailing
Time from
treatment
initiation A C O A C O C O
1 mo. Triple Therapy 1 mo. Triple Therapy Dual Therapy
Class IIa B Class IIa B up to 12 mo.
1 mo. Class IIa A
Antithrombotic therapy in patients with mechanical
valve prosthesis after undergoing PCI (continued)
(Adapted from the 2017 ESC Focused Update on Dual Antiplatelet Therapy)
A C O C O OR A O C O
3 mo.
Triple Therapy Dual Therapy Dual Therapy
up to 6 mo. up to 12 mo.
Dual Therapy up to 12 mo.
Class IIa B Class IIa A Class IIa A
up to 12 mo.
6 mo. Class IIa A
C O A O
Dual Therapy up to 12 mo.
Class IIa A
12mo.
O
Beyond OAC alone
12 mo. Class IIa B
A = Aspirin C = Clopidogrel O = Oral anticoagulation with VKA

Non-cardiac intervention in a patient with a mechanical
prosthesis
" It is recommended not to interrupt oral anticoagulation for most
minor surgical interventions (including dental extraction, cataract removal)
"
(www.societechirorale.com
Main bridging steps for an intervention requiring
interruption of oral anticoagulation in a patient with
a mechanical prosthesis
(Reproduced with permission from Iung and Rodes-Cabau)
Intervention
Days -6 -5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5 +6
Stop VKA Restart VKA
Begin LMWH Switch LMWH Restart LMWH Stop heparin when
or UFH for IV UFH or continue INR > 2.0 (aortic)
UFH INR > 2.5 (mitral)
Stop IV LMWH Restart IV UFH
6 hours before 12 to 24 hours
intervention After intervention
Timing should be individualized according to patient characteristics, actual INR, and the type of intervention
for bioprostheses
Bioprostheses
Oral anticoagulation is recommended lifelong for patients with
surgical
I C
or transcatheter implanted bioprostheses who have other indications
for anticoagulation.
Oral anticoagulation using a VKA should be considered for the first
3 months after surgical implantation of a mitral or tricuspid IIa C
bioprosthesis.
Oral anticoagulation using a VKA should be considered for the first
IIa C
3 months after surgical mitral or tricuspid valve repair.
Low-dose aspirin (75-100 mg/day) should be considered for the first
3 months after surgical implantation of an aortic bioprosthesis or valve IIa C
-sparing aortic surgery.
Early antithrombotic therapy after
AVR using a bioprosthesis
4075 patients undergoing AVR (1997-2009).
Of 881 pts without post-op warfarin, 181 received ASA
(Merie et al.
JAMA
2012;308:2118-25)
26 656 patients ≥ 65 yrs undergoing AVR (1997-2009)
ASA Warfarin Warfarin + ASA

(58%) (14%) (28%)
Death 3.0 4.0 3.1
(Nishimura et al. J Am Coll Cardiol 2017;70:252-89) Embolism 1.0 1.0 0.6
(Brennan et al. J Am Coll Cardiol 2012;60:971-7)
Bleeding 1.0 1.4 2.8
for bioprostheses (continued)
Bioprostheses (continued)
Dual antiplatelet therapy should be considered for the first 3-
6 months after TAVI, followed by lifelong single antiplatelet therapy in IIa C New
patients who do not need oral anticoagulation for other reasons.
Single antiplatelet therapy may be considered after TAVI in the case of
IIb C New
high bleeding risk.
Oral anticoagulation may be considered for the first 3 months after
IIb C
surgical implantation of an aortic bioprosthesis.
Antithrombotic therapy after TAVI
Aspirin + clopidogrel vs. aspirin alone

(2RCTs and 2 observational series with propensity-matched subgroups totalling 435 pts)
(Hassell et al. Heart 2015;101:1118-25)
TAVI thrombosis diagnosed by CT scan
• 16/156 pts (10%)
Small but significant increase in gradients
(Pache et al. Eur Heart J 2016; 37, 2263–71)
• 23/405 pts (7%)
Increased gradients
(Hansson et al. J Am Coll Cardiol 2016;68:2059-69)
• 10/752 (13%)
(4% for surgical bioprosthesis)
Increased incidence of TIA
(Chakravarty et al. Lancet 2017;389:2383-92)
Less frequent under anticoagulants vs. antiplatelets

Resolution under anticoagulant therapy in most cases
Management of prosthetic
valve dysfunction
Mechanical prosthetic thrombosis
Urgent or emergency valve replacement is recommended for
obstructive thrombosis in critically ill patients without serious I C
comorbidity.
Fibrinolysis (using recombinant tissue plasminogen activator
10 mg bolus + 90 mg in 90 minutes with UFH, or streptokinase
1,500,000 U in 60 minutes without UFH) should be considered IIa C
when surgery is not available or is very high-risk, or for
thrombosis of right-sided prostheses.
Surgery should be considered for large (>10 mm) non-
IIa C
obstructive prosthetic thrombus complicated by embolism.
Management of left-sided obstructive mechanical prosthetic thrombosis
Suspicion of thrombosis
Echo (TTE + TOE/fluoroscopy)
Obstructive thrombus
Critically ill?
No Yes
Recent inadequate anticoagulation? Surgery immediately available?
No Yes No Yes
Fibrinolysis* Surgery*
IV UFH ± aspirin
Success/failure?
Failure Success
High-risk for surgery?
No Yes
Surgery* Fibrinolysis* Follow-up
* Risk and benefits of both treatments should be individualized. The presence of a first-generation prosthesis
is an incentive to surgery.
Obstructive mechanical prosthetic
thrombosis:
Fibrinolysis vs. surgery
Meta-anaysis of 7 studies (690 pts with obstructive thrombosis)
Restoration of normal valve function
(Karthikeyan et al. Eur Heart J 2013;34:1557-66)

Management
of mechanical
prosthetic thrombosis
Non-Obstructive
thrombosis
Management of prosthetic valve
dysfunction (continued)
Bioprosthetic thrombosis
Anticoagulation using a VKA and/or UFH is recommended in
bioprosthetic valve thrombosis before considering I C New
reintervention.
Haemolysis and paravalvular leak
Reoperation is recommended if paravalvular leak is related to
endocarditis or causes haemolysis requiring repeated blood I C
transfusions or leading to severe symptoms.
Transcatheter closure may be considered for paravalvular
leaks with clinically significant regurgitation in surgical high- IIb C New
risk patients (Heart Team decision).
Management of prosthetic valve
dysfunction (continued)
Bioprosthetic failure
Reoperation is recommended in symptomatic patients with a
significant increase in transprosthetic gradient (after exclusion I C
of valve thrombosis) or severe regurgitation.
Reoperation should be considered in asymptomatic patients
with significant prosthetic dysfunction, if reoperation is at low- IIa C
risk.
Transcatheter valve-in-valve implantation in aortic position
should be considered by the Heart Team depending on the risk IIa C New
of reoperation and the type and size of prosthesis.
Conclusion
The choice between a mechanical prosthesis and
a bioprosthesis should not overstress age but
fully take into account patient’s wishes.
Patients with a mechanical prosthesis require
lifelong VKA with a target INR adapted to the
prosthesis and patient characteristics.
The addition of low-dose aspirin to VKA is
restricted to selected patients.
After ACS or PCI in a patient with mechanical
prosthesis, antithrombotic therapy should be
individualized according to ischaemic and
bleeding risks. (European Heart Journal 2017 - doi:10.1093/eurheartj/ehx391)

Gaps in evidence
• Safety and efficacy of very low target INRs (median <2.5) in patients
with a mechanical prosthesis in aortic position.
• Safety and efficacy of NOACs in patients with a mechanical prosthesis.

• Safety and efficacy of low-dose aspirin associated with contemporary
target INRs in patients with a mechanical prosthesis, according to the
presence or absence of atherosclerosis.
• Optimal early antithrombotic therapy after implantation of surgical and

transcatheter aortic bioprostheses.
• Long-term outcome data of transcatheter valve-in-valve and valve-in-

ring procedures.
www.escardio.org/guidelines
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2017 ESC Guidelines for

v ACCA - Acute Cardiovascular Care Association

19 Authors v EAPCI - European Association of PCI

ESC EAPC -- European Association of Preventive cardiology

EHRA - European Heart Rhythm Association

v 30 Reviewers EACVI - European Association of Cardiovascular Imaging

-1224 comments v vv HFA - Heart Failure Association v

vv v v vv Council – for Cardiology practice

v v WG - Myocardial and Pericardial Diseases

Class IIb Usefulness/efficacy is less well May be 92

<10’ Primary <60’ Reperfusion

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

Valgimigli et al. Lancet 2015;385:2465-76

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Silvain et al, BMJ 2012 Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Early Hospital Discharge

Oxygen when SaO2 <90%

DES over BMS EXAMINATION, COMFORTABLE-AMI,

Complete Revascularization PRAMI, DANAMI-3-PRIMULTI,

Stubb et al, Circ 2015 Thrombus Aspiration

Early Hospital Discharge

Oxygen when SaO2 <90%

2012 GL: IIaA Rescue

2017 GL: IA 24 hours

Online & Offline

Recommendations Class Level

Recommendations Class Level

IIaC Inotropic/vasopressor agents IIbC

IIaB Ultrafiltration IIbB

IIbC Mechanical support IIbC

Recommendations Class Level

Recommendations Class Level

Transient, self-terminating AF during STEMI relates to a significantly

2017 ESC Guidelines on the Diagnosis

Coronary Artery Subclavian steal syndrome,

Address general CV risk Address related symptoms

Recommendations Class Level

In healthcare centres, it is recommended to set up a

Fontaine classification Rutherford classification

Fontaine classification Rutherford classification