Management of Patients with

ACS: Differences between ESC

and AHA
Deborah B. Diercks, MD
Professor of Emergency Medicine
University of California, Davis Medical Center
Sacramento, CA

Objectives
Review how sets of guidelines are created
Discuss STEMI guidelines
Review NSTE-ACS differences

How the guidelines are created

ESC
Experts in the field
Comprehensive review
of published literature
Critical review
assessing risk and
benefit
Level of evidence and
strength of evidence
are graded
All have provided
disclosure

AHA/ACC
Experts selected with
addition of appropriate
additional specialties
Formal literature
review
Level of evidence and
strength are graded
All have provided
disclosure
1 ED physician
supported by ACEP

How data driven are these

guidelines
Data from all ACC/AHA practice guidelines issued from 1984 to
September 2008 were abstracted by personnel in the ACC Science
and Quality Division.
Fifty-three guidelines on 22 topics, including a total of 7196
recommendations, were abstracted.
The number of recommendations and the distribution of classes of
recommendation (I, II, and III) and levels of evidence (A, B, and C)
were determined.
Considering the 16 current guidelines reporting levels of evidence,
314 recommendations of 2711 total are classified as level of evidence A
(median, 11%)
1246 (median, 48%) are level of evidence C.
245 of 1305 class I recommendations have level of evidence A (median,
19%).

JAMA. 2009 Feb 25;301(8):831-41

Joint projects
Classification of Myocardial Infarction by Type:
1 Spontaneous MI related to ischemia due to a primary coronary
event, such as plaque erosion and/or rupture, fissuring, or dissection
2 MI secondary to ischemia due to an imbalance of O2 supply and
demand, as from coronary spasm or embolism, anemia,
arrhythmias, hypertension, or hypotension
3 Sudden unexpected cardiac death, including cardiac arrest, often
with symptoms suggesting ischemia with new ST-segment
elevation; new left bundle branch block; or pathologic or
angiographic evidence of fresh coronary thrombusin the absence
of reliable biomarker findings
4a MI associated with PCI
4b MI associated with documented in-stent thrombosis
5 MI associated with CABG surgery

Circulation 2007;116:2634-2653

Differences are largely system

driven
Prehospital
Resource Allocation
Percutaneous Coronary Intervention
Capable

STEMI differences
Overall minimal difference in treatment
Some on timing: B-blockers
Reperfusion therapy

Variation in time door to balloon

recommendation
(DB)-(DN)>60 minutes
< 3 hours of symptoms all equal
Acceptable door to balloon time
European Heart Journal 2008;29:2909-2945
Circulation 2008; 117:296329

Controversial study
ESC has taken an individual approach
Current guidelines base decisions of a PCI
time <2 hours
Systematic review that reported PCI delay
<35 minutes was threshold of increased risk
Retrospective review of NRMI data: DB-DN
threshold varies based on age and location of
the infarct.
European Heart Journal 2008;29:2909-2945
Eur Heart J. 2006 Apr;27(7):779-88
Circulation 2006;114:2019-2025

NSTE-ACS differences
Hospital Resources
Observation Unit
Strategy
Invasive vs Conservative
Urgent vs Early vs Conservative

Biomarker
Multi-marker
Single marker
European Heart Journal 2007;28:1598-1660
JACC 2007;50:e2-e157

Time to Intervention
Both guidelines are risk based
AHA
Invasive strategy

ESC
Urgent (2-15%)

Refractory angina
Dynamic ST deviation
Heart failure
Arrhythmia
Hemodynamic instability

Same as urgent
Low EF
Positive NI test
Previous PCI or CABG

Conservative

Early (<72 hours)

Intermediate to high risk
features

Conservative
European Heart Journal 2007;28:15981660
JACC 2007;50:e2-e157

Controversial study-ICTUS
ICTUS
Early invasive strategy (within 48 hours) was
associated with an increased risk of MI
15.0 vs 10.0%
RR 1.5 (95 % CI 1.1-2.10)

No difference

N Engl J Med. 2005 Sep 15;353(11):1095-104

Assessment of Bleeding
Higher focus of bleeding assessment
Independent predictors identified by risk

Age
Female
History of bleeding
History of renal insufficiency

European Heart Journal 2003;24:1815-1823

Observation Unit
ACC/AHA
Observation units
Critical pathway based units with protocols to
determine if a patient has ACS
Appropriate patients
Patients wieht possible ACS that is sl atypical and is pain
free now with nl or unchanged ECG and normal
biomarkers
Patients with possible or definite based on symptoms
with non-diagostic ECG and negative biomakers

JACC 2007;50:e2-e157

Biomarkers
Differences in strategy
ESC
Single troponin > 12 hours after symptoms
Serial troponin at presentation and 6-12 hours after

ACC/AHA
If neg biomarkers within 6 hours of symptoms repeat markers
should be measured 8-12 hrs after symptom onset. (LOE I)
It is reasonable remeasure markers at 6-8 hours intervals (LOE
IIa)
If present within 6 hours it is reasonable to add an early marker,
delta 2 hours CK-MB and delta troponin can be measures,
evaluation of myoglobin,CK-MB mass, and troponin can be
measured at 0 and 90 minutes. (LOE IIb)
European Heart Journal 2007;28:15981660
JACC 2007;50:e2-e157

More alike than different

Key components of acute care
Risk stratification

History
ECG
Biomarkers
Non-invasive studies

Treatment

Little guidance for ED

physicians
Despite extrapolation
Do these guidelines address our EM practical
issues?
Admit all
Serial markers prior to admission

ILCOR
More involvement of ED physicians from
Canada and US
Addressing time frames in the pre-hospital
setting and ED

Solution
Take advantage of anything you can
If information changes to educate ED
physicians we need to get information into our
literature
To get information into our literature we need
to be involved with the process

Conclusion
Consistent therapeutic recommendations
Variations largely based on resources
Both lack emergency medicine
representation