(8.2.3)--2020ESC非ST段抬高型急性冠状动脉综合征指南.pdf

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1、2020 ESC Guidelines for the management ofacute coronary syndromes in patientspresenting without persistent ST-segmentelevationThe Task Force for the management of acute coronary syndromesin patients presenting without persistent ST-segment elevation ofthe European Society of Cardiology(ESC)Authors/T

2、ask Force Members:Jean-Philippe Collet*(Chairperson)(France),Holger Thiele*(Chairperson)(Germany),Emanuele Barbato(Italy),Olivier Barthe le my(France),Johann Bauersachs(Germany),Deepak L.Bhatt(United States of America),Paul Dendale(Belgium),Maria Dorobantu(Romania),Thor Edvardsen(Norway),Thierry Fol

3、liguet(France),Chris P.Gale(United Kingdom),Martine Gilard(France),Alexander Jobs(Germany),Peter Ju ni(Canada),Ekaterini Lambrinou(Cyprus),Basil S.Lewis(Israel),Julinda Mehilli(Germany),Emanuele Meliga(Italy),Be la Merkely(Hungary),Christian Mueller(Switzerland),Marco Roffi(Switzerland),Frans H.Rutt

4、en(Netherlands),Dirk Sibbing(Germany),George C.M.Siontis(Switzerland)*Corresponding authors:Jean-Philippe Collet,Sorbonne Universite,ACTION Study Group,INSERM UMRS 1166,Institut de Cardiologie,Ho pital Pitie-Salp etrie re(AssistancePublique-Ho pitaux de Paris)(AP-HP),83,boulevard de lHo pital,75013

5、Paris,France.Tel 33 01 42 16 29 62,E-mail:jean-philippe.colletaphp.frHolger Thiele,Department of Internal Medicine/Cardiology,Heart Center Leipzig at University of Leipzig,Stru mpellstr.39,04289 Leipzig,Germany.Tel:49 341 865 1428,Fax:49 341 865 1461,E-mail:holger.thielemedizin.uni-leipzig.deESC Com

6、mittee for Practice Guidelines(CPG)and National Cardiac Societies document reviewers,and Author/Task Force Member affiliations:listed in the Appendix.ESC entities having participated in the development of this document:Associations:Association for Acute CardioVascular Care(ACVC),Association of Cardi

7、ovascular Nursing&Allied Professions(ACNAP),European Association ofCardiovascular Imaging(EACVI),European Association of Preventive Cardiology(EAPC),European Association of Percutaneous Cardiovascular Interventions(EAPCI),EuropeanHeart Rhythm Association(EHRA),Heart Failure Association(HFA).Councils

8、:Council for Cardiology Practice.Working Groups:Cardiovascular Pharmacotherapy,Cardiovascular Surgery,Coronary Pathophysiology and Microcirculation,Thrombosis.The content of these European Society of Cardiology(ESC)Guidelines has been published for personal and educational use only.No commercial use

9、 is authorized.No part ofthe ESC Guidelines may be translated or reproduced in any form without written permission from the ESC.Permission can be obtained upon submission of a written request toOxford University Press,the publisher of the European Heart Journal and the party authorized to handle suc

10、h permissions on behalf of the ESC().Disclaimer.The ESC Guidelines represent the views of the ESC and were produced after careful consideration of the scientific and medical knowledge,and the evidence avail-able at the time of their publication.The ESC is not responsible in the event of any contradi

11、ction,discrepancy and/or ambiguity between the ESC Guidelines and any other offi-cial recommendations or guidelines issued by the relevant public health authorities,in particular in relation to good use of healthcare or therapeutic strategies.Healthprofessionals are encouraged to take the ESC Guidel

12、ines fully into account when exercising their clinical judgment,as well as in the determination and the implementation of pre-ventive,diagnostic,or therapeutic medical strategies;however,the ESC Guidelines do not override,in any way whatsoever,the individual responsibility of health professionals to

13、make appropriate and accurate decisions in consideration of each patients health condition and in consultation with that patient and,where appropriate and/or necessary,thepatients caregiver.Nor do the ESC Guidelines exempt health professionals from taking into full and careful consideration the rele

14、vant official updated recommendations orguidelines issued by the competent public health authorities,in order to manage each patients case in light of the scientifically accepted data pursuant to their respective ethicaland professional obligations.It is also the health professionals responsibility

15、to verify the applicable rules and regulations relating to drugs and medical devices at the time ofprescription.VCThe European Society of Cardiology 2020.All rights reserved.For permissions,please email:.European Heart Journal(2020)00,1?79ESC GUIDELINESdoi:10.1093/eurheartj/ehaa575Downloaded from ht

16、tps:/ by guest on 31 August 2020.Document Reviewers:Adnan Kastrati(CPG Review Coordinator)(Germany),Mamas A.Mamas(CPGReview Coordinator)(United Kingdom),Victor Aboyans(France),Dominick J.Angiolillo(United States ofAmerica),Hector Bueno(Spain),Raffaele Bugiardini(Italy),Robert A.Byrne(Ireland),Silvia

17、 Castelletti(Italy),Alaide Chieffo(Italy),Veronique Cornelissen(Belgium),Filippo Crea(Italy),Victoria Delgado(Netherlands),Heinz Drexel(Austria),Marek Gierlotka(Poland),Sigrun Halvorsen(Norway),KristinaHermann Haugaa(Norway),Ewa A.Jankowska(Poland),Hugo A.Katus(Germany),Tim Kinnaird(UnitedKingdom),J

18、olanda Kluin(Netherlands),Vijay Kunadian(United Kingdom),Ulf Landmesser(Germany),Christophe Leclercq(France),Maddalena Lettino(Italy),Leena Meinila(Finland),Darren Mylotte(Ireland),Gjin Ndrepepa(Germany),Elmir Omerovic(Sweden),Roberto F.E.Pedretti(Italy),Steffen E.Petersen(United Kingdom),Anna Sonia

19、 Petronio(Italy),Gianluca Pontone(Italy),Bogdan A.Popescu(Romania),Tatjana Potpara(Serbia),Kausik K.Ray(United Kingdom),Flavio Luciano Ribichini(Italy),Dimitrios J.Richter(Greece),Evgeny Shlyakhto(Russian Federation),Iain A.Simpson(United Kingdom),Miguel Sousa-Uva(Portugal),Robert F.Storey(United Ki

20、ngdom),Rhian M.Touyz(United Kingdom),Marco Valgimigli(Switzerland),Pascal Vranckx(Belgium),Robert W.Yeh(United States of America)The disclosure forms of all experts involved in the development of these guidelines are available on theESC website www.escardio.org/guidelinesFor the Supplementary Data w

21、hich include background information and detailed discussion of the datathat have provided the basis for the Guidelines see European Heart Journal online.KeywordsGuidelinesacute cardiac careacute coronary syndromeangioplastyanticoagulationantiplateletapixabanaspirinatherothrombosisbetablockersbleedin

22、gsbivalirudinbypass surgerycan-grelorchest pain unitclopidogreldabigatrandiabetesdual antithrombotic therapyearly inva-sive strategyedoxabanenoxaparinEuropean Society of Cardiologyfondaparinuxglycoprotein IIb/IIIa inhibitorsheparinhigh-sensitivity troponinminocamyocardial ischaemiamyocardial infarct

23、ionnitratesnon-ST-elevation myocardial infarctionplatelet inhibitionprasugrelrecommendationsrevascularizationrhythm monitoringrivaroxabanstentticagrelortriple therapyunstable anginaTable of contentsAbbreviationsandacronyms.51 Preamble.72 Introduction.82.1 Definitions.82.1.1 Universal definitionofmyo

24、cardialinfarction.82.1.1.1Type 1myocardialinfarction.82.1.1.2Type 2myocardialinfarction.92.1.1.3Types3?5 myocardial infarction.92.1.2 Unstableanginainthe eraofhigh-sensitivity cardiactroponinassays.92.2 Epidemiology.92.3 Whatisnew?.92.4 Numberandbreakdownofclassesofrecommendations(SupplementaryData)

25、.103 Diagnosis.103.1 Clinicalpresentation(SupplementaryData).103.2 Physicalexamination(SupplementaryData).103.3 Diagnostictools.103.3.1 Electrocardiogram.103.3.2 Biomarkers:high-sensitivity cardiactroponin.113.3.2.1Centrallaboratoryvs.point-of-care.123.3.2.2 Otherbiomarkers.133.3.3 Rapidrule-inandru

26、le-out algorithms.133.3.4 Observe.153.3.4.1 Caveatsofusing rapidalgorithms.153.3.4.2 Confoundersofcardiactroponinconcentration.153.3.4.3 Practical guidance onhowtoimplementtheEuropeanSocietyofCardiology0 h/1h algorithm.163.3.4.4 Avoidingmisunderstandings:time to decision=timeofblooddrawrn-aroundtime

27、.163.3.5 Non-invasiveimaging.173.3.5.1 Functional evaluation.173.3.5.2 Anatomical evaluation.173.4Differentialdiagnosis.174Risk assessmentandoutcomes.194.1Electrocardiogramindicators(SupplementaryData).194.2Biomarkers.194.3Clinical scoresforrisk assessment(SupplementaryData).194.4Bleedingriskassessm

28、ent.204.5Integrating ischaemicandbleedingrisks.215Pharmacological treatments.215.1Antithrombotictreatment.215.1.1 Antiplateletdrugsandpre-treatment.235.1.1.1 Antiplateletdrugsanddual antiplatelettherapy.232ESC GuidelinesDownloaded from https:/ by guest on 31 August 2020.5.1.1.2Pre-treatment.245.1.2

29、Peri-interventionalanticoagulanttreatment.265.1.3 Peri-interventionalantiplatelettreatment.275.1.4 Post-interventionalandmaintenancetreatment.275.2 Pharmacological treatmentofischaemia(SupplementaryData).305.2.1 Supportivepharmacological treatment(SupplementaryData).305.2.2 Nitratesandbeta-blockers(

30、Supplementary Data).305.3 Managingoral antiplateletagentsinpatientsrequiringlong-termoralanticoagulants.305.3.1 Patientswithatrialfibrillationwithoutmechanicalprostheticheartvalvesormoderate-to-severe mitralstenosisundergoingpercutaneouscoronaryinterventionormanagedmedically(Supplementary Data).305.

31、3.2 PatientsrequiringvitaminKantagonistsorundergoingcoronary artery bypasssurgery.325.4 Managementofacute bleedingevents(SupplementaryData).345.4.1 General supportivemeasures(SupplementaryData).345.4.2 Bleedingeventsonantiplateletagents(SupplementaryData).345.4.3 BleedingeventsonvitaminKantagonists(

32、SupplementaryData).345.4.4 Bleedingeventsonnon-vitaminKantagonistoralanticoagulants(SupplementaryData).345.4.5 Non-access-relatedbleedingevents(SupplementaryData).345.4.6 Bleedingeventsrelatedto percutaneouscoronaryintervention(Supplementary Data).345.4.7 Bleedingeventsrelatedto coronaryarterybypass

33、surgery(SupplementaryData).345.4.8 Transfusiontherapy(Supplementary Data).345.4.9 Recommendationsforbleedingmanagementandbloodtransfusion in non-ST-segmentelevationacutecoronary syndromesforanticoagulatedpatients.346 Invasivetreatments.346.1 Invasive coronaryangiography andrevascularization.346.1.1

34、Routineinvasivevs.selectiveinvasiveapproach(SupplementaryData).346.1.2 Timingofinvasive strategy.356.1.2.1Immediate invasive strategy(2h).356.1.2.2Earlyinvasivestrategy(_75 years(2 points),Diabetes,Stroke(2points)?Vascular disease,Age 65?74,Sexcategory(female)CHAMPIONCangrelor versus Standard Therap

35、y toAchieve Optimal Management of PlateletInhibitionCIConfidence intervalCKCreatine kinaseCKDChronic kidney diseaseCK-MBCreatine kinase myocardial bandCMRCardiac magnetic resonanceCOACTCoronary Angiography after Cardiac ArrestCOMPASSCardiovascular OutcoMes for People usingAnticoagulation StrategieSC

36、PGClinical practice guidelinesCPRCardiopulmonary resuscitationCrClCreatinine clearanceCRUSADECan Rapid risk stratification of Unstableangina patients Suppress ADverse outcomeswith Early implementation of the ACC/AHAguidelinesCSCardiogenic shockCTComputed tomographyCULPRIT-SHOCKCulprit Lesion Only PC

37、I versus MultivesselPCI in Cardiogenic ShockCVDCardiovascular diseaseCYPCytochrome P450DAPTDual antiplatelet therapyDATDual antithrombotic therapyDESDrug-eluting stentEACTSEuropean Association for Cardio-ThoracicSurgeryECGElectrocardiogram/electrocardiographyEchoEchocardiogrameGFREstimated glomerula

38、r filtration rateELISAEarly or Late Intervention in unStable AnginaENTRUST-AF PCIEdoxabaN TRreatment versUS VKA inpaTients with AF undergoing PCIESCEuropean Society of CardiologyFAMOUS-NSTEMIFractional flow reserve versus angiography inguiding management to optimize outcomes innon-ST-elevation myoca

39、rdial infarctionFFRFractional flow reserveFFR-CTFractional flow reserve-computedtomographyGDF-15Growth differentiation factor 15GPGlycoproteinGRACEGlobal Registry of Acute Coronary EventsHAS-BLEDHypertension,abnormal renal and liverfunction(1 point each),stroke,bleedinghistory or predisposition,labi

40、le INR,elderly(65 years),drugs and alcohol(1 point each)HBRHigh bleeding riskh-FABPHeart-type fatty acid-binding proteinESC Guidelines5Downloaded from https:/ by guest on 31 August 2020.HITHeparin-induced thrombocytopeniaHRHazard ratiohs-cTnHigh-sensitivity cardiac troponinIABPIntra-aortic balloon p

41、umpIABP-SHOCK IIIntraaortic Balloon Pump in cardiogenicshock IIICAInvasive coronary angiographyiFRInstantaneous wave-free ratioIMRIndex of microcirculatory resistanceINRInternational normalized ratioISAR-REACTIntracoronary stenting and Antithromboticregimen?Rapid Early Action for CoronaryTreatmentIS

42、AR-TRIPLETriple Therapy in Patients on OralAnticoagulation After Drug Eluting StentImplantationi.v.IntravenousIVUSIntravascular ultrasoundLBBBLeft bundle branch blockLDLoading doseLDL-CLow-density lipoprotein cholesterolLIPSIA-NSTEMILeipzig Immediate versus early and latePercutaneouS coronary Interv

43、ention triAl inNSTEMILMWHLow-molecular-weight heparinLVLeft ventricularLVEFLeft ventricular ejection fractionMACEMajor adverse cardiovascular eventsMATRIXMinimizing Adverse Haemorrhagic Events byTRansradial Access Site and SystemicImplementation of angioXMDMaintenance doseMDCTMultidetector computed

44、tomographyMIMyocardial infarctionMINOCAMyocardial infarction with non-obstructivecoronary arteriesMRAMineralocorticoid receptor antagonistNOACNon-vitamin K antagonist oral anticoagulantNPVNegative predictive valueNSTE-ACSNon-ST-segment elevation acute coronarysyndromeNSTEMINon-ST-segment elevation m

45、yocardialinfarctionNT-proBNPN-terminal pro-B-type natriuretic peptideOACOral anticoagulation/anticoagulantOASIS-5Fifth Organization to Assess Strategies inAcute Ischemic SyndromesOCTOptical coherence tomographyo.d.Once dailyOROdds ratioPPrasugrelPADPeripheral artery diseasePCIPercutaneous coronary i

46、nterventionPCSK9Proprotein convertase subtilisin kexin 9Pd/PaDistal coronary to aortic pressure ratioPEGASUS-TIMI 54Prevention of Cardiovascular Events inPatients with Prior Heart Attack UsingTicagrelor Compared to Placebo on aBackground of Aspirin-Thrombolysis inMyocardial Infarction 54PLATOPLATele

47、t inhibition and patient OutcomesPOCTPoint-of-care testPPVPositive predictive valuePRECISE-DAPTPREdicting bleeding Complications In patientsundergoing Stent implantation andsubsEquent Dual Anti Platelet TherapyPRECOMBATPremier of Randomized Comparison ofBypass Surgery versus Angioplasty UsingSirolim

48、us-Eluting Stent in Patients with LeftMain Coronary Artery DiseasePROMsPatient-reported outcome measuresQIQuality indicatorRBBBRight bundle branch blockRCTRandomized controlled trialRE-DUAL PCIRandomized Evaluation of DualAntithrombotic Therapy with Dabigatranversus Triple Therapy with Warfarin inPa

49、tients with Nonvalvular Atrial FibrillationUndergoing Percutaneous CoronaryInterventionREDUCE-ITReduction of Cardiovascular Events withIcosapent Ethyl?Intervention TrialRFRResting full-cycle ratioRIDDLE-NSTEMIRandomized Study of Immediate VersusDelayed Invasive Intervention in PatientsWith Non-ST-Se

50、gment Elevation MyocardialInfarctionRIVALRadIal Vs femorAL access for coronaryinterventionRRRelative riskSAPTSingle antiplatelet therapySCAARSwedish Coronary Angiography andAngioplasty RegistrySCADSpontaneous coronary artery dissectionSISCAComparison of Two Treatment Strategies inPatients With an Ac