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Acca-Toolkit 2018 PDF
Acca-Toolkit 2018 PDF
Acca-Toolkit 2018 PDF
MAKING TOOLKIT
Instant guidance
2018 edition for diagnosis, risk management
and treatment
The
Clinical Decision Making
Toolkit is produced by the Acute Cardiovascular
Care Association (ACCA), developed and distributed
through an educational grant from AstraZeneca.
AstraZeneca was not involved in the development
of this publication and in no way influenced its content.
The Acute Cardiovascular Care Association
Clinical Decision-Making
TOOLKIT
ISBN: 978-2-9537898-7-4
Preface
II
The best care of patients with acute cardiovascular syndromes
relies not only on specialists but also on systems of care that
involve many non-cardiologists. Several of these syndromes
require immediate diagnosis and decisions on treatment, The ACCA Toolkit is available
some of them life-saving. Critical decisions must often be through different platforms:
made quickly by professionals with different backgrounds
and levels of expertise with limited resources. This poses a • Printed booklet, available at congresses
significant clinical challenge. where ESC-ACCA is represented
Against this background, the ACCA Clinical Decision- • Web-based pdf file downloadable at:
Making Toolkit was created as a comprehensive resource www.escardio.org/ACCA
encompassing all aspects of acute cardiovascular care but
structured as an easy-to-use instrument in environments • Mobile application for smartphones/tablets
where initial acute cardiovascular care is typically initiated. available in both Apple & Googleplay stores
Comprehensive tables, clear diagrams and algorithms, based
on the ESC clinical practice guidelines as well as in clinical
experience should provide diagnostic and therapeutic
guidance at a glance.
Héctor Bueno
This 2018 Edition of the Clinical Decision Making Toolkit
has been updated with the 2016 and 2017 ESC Guidelines, M.D., PhD., FESC
a chapter on secondary prevention was added and the chapter Editor in Chief
on acute heart failure benefited a major update. However, it
does not replace textbooks and other sources of information
that need to be consulted to reach an optimal management
of these patients.
7 DAYS F R O M C A R D I A C E V E N T
U NTI L PATI E NT S TA B I LISATI O N
C ARDIAC AR RE S T , S T E M I , A CS , A H F ,
C ARDIOGENIC S H O CK, A RRH YT H M I A S ,
VAS C ULAR S YN DRO M E S
E M E RG E N CY ROO M CCU G E NE R A L
C O R O NA R Y HO S P I TA L
PRE- HOS PITAL CA RE C A R E U NI T ICCU
I NTE NS I V E
CARDIAC
C A R E UNI T
Contents
IV
List of Authors �������������������������������������������������������������������������������������������������������������������������� VI
CHAPTER 1
KEY SYMPTOMS
1. Presentation
2. ECG
3. Troponin
Other
4. Diagnosis Noncardiac UA Cardiac NSTEMI STEMI
Likelihood of ACS
Emergency care:
Resuscitation, hemodynamic or
rhythm restoration (see chapter 5)
Hospital admission
to the ED/CPU
ECG, decision for reperfusion,
antithrombotics, immediate
transport to ED/CPU/ICCU/Cathlab
(see chapter 2) Cardiology Non-cardiology Discharge after
ward ward prolonged observation
Factors to be considered in the evaluation
during the first medical contact for CHEST PAIN 1.1
P.6
First medical contact Higher death risk / probability for ACS Lower death risk / probability for ACS
Yes No
Resuscitation, hemodynamic
or respiratory support ECG <10 min → ACS ?
(see chapters 4 & 5)
Other CVD
Yes No
or No ACS
STEMI,
Resuscitation, hemodynamic NSTE-ACS with persistent pain,
or respiratory support Hemodynamic distress
(see chapters 4 & 5)
Yes No
Reference: Ray P et al. Acute respiratory failure in the elderly: etiology, emergency diagnosis and prognosis. Critical Care (2006); 10 (3):R82.
DYSPNEA: Acute heart failure (see chapter 4.1) 1.2
BASIC WORK-UP P.10
• Immediate 12-lead ECG, cardiac monitor, BP, respiratory rate, • Chest X-ray (lung ultrasound)
pulse oximetry • Echocardiogram
• Clinical findings During admission (earlier if decompensated
Most commonly: lower extremity edema, jugular venous aortic stenosis or endocarditis are suspected)
distension, rales, work up for underlying cardiac disease and triggers • Coronary angiography
• Laboratory findings Emergent in patients with ACS; delayed in
Complete blood count, chemistries, cardiac enzymes, BNP, patients with suspected coronary artery disease
TSH, ABG as needed
Reference: Ware L B and Matthay M A. Acute Pulmonary Edema. New Engl J Med (2005); 353:2788-2796.
DYSPNEA: Acute pulmonary embolism (see chapter 7.2) 1.2
P.12
Priorities: 1. Vital signs 2. Diagnostic screening dependent upon clinical stratification
ABG, ECG, chest X-ray plus clinical assessment of PE probability (risk factors) plus monitoring
Copyright: Stein PD, Woodard PK, Weg JG, et al. Diagnostic pathways in acute pulmonary embolism: recommendations of the PIOPED II investigators.
Am J Med (2006); 119:1048–55. - Goldhaber SZ. Pulmonary embolism. Lancet (2004); 363 (9417) 1295-1305. - Agnelli G and Becattini C. Acute Pulmonary
Embolism. New Engl J Med (2010); 363:266-274.
DYSPNEA: COPD exacerbation 1.2
DYSPNEA: COPD EXACERBATION P.14
• Verify diagnosis (DD: PE, acute heart failure, pneumothorax)
• Oxygen administration → SpO2 target 88-92% (Beware of carbonarcosis: ABC after 1 h)
• Laboratory findings: Blood count, coagulation, ProCT, perhaps BNP, D-Dimers • Hospitalisation indicated?
• Chest X-ray; ECG (exclusion of differential diagnoses)
• Sputum cultures (always in case of hospitalisation or previous • Evaluate ICU criteria
outpatient antibiotic treatment) • NIV indicated?
Definition
Complications
Copyrights: Mandell LA et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis. (2007); 44 Suppl 2:S27-72. - Halm EA and Teirstein AS. Management of Community-Acquired Pneumonia New Engl J Med
(2002); 347:2039-2045. - Woodhead M et al. Guidelines for the management of adult lower respiratory tract infections ERJ December 1, (2005); 26 (6) 1138-1180.
SYNCOPE: Assessment of patients
with transient loss of conscioussness (TLOC) 1.3
P.16
Syncope is a transient loss of consciousness due to global cerebral hypoperfusion (usually, itself due to
period of low blood pressure) characterised by rapid onset, short duration, spontaneous and complete recovery.
The differentiation between syncope and non-syncopal conditions with real or apparent LOC can be achieved
in most cases with a detailed clinical history but sometimes can be extremely difficult. The following
questions should be answered:
• Was LOC complete?
• Was LOC transient with rapid onset and short duration?
• Did the patient recover spontaneously, completely and without sequelae?
• Did the patient lose postural tone?
If the answers to these questions are positive, the episode has a high likelihood of being syncope. If the answer to
one or more of these questions is negative, exclude other forms of LOC before proceeding with syncope evaluation.
No • Accidental • Fall
Loss of Consciousness?
• Other abnormal mental state
Yes
Transient, rapid onset, No • Coma • Metabolic disturbance
short time, self-terminating • Intoxication • Aborted sudden death
Yes
Initiate therapy
Inpatient SMU, outpatient SMU or
Risk stratification personal physician as appropriate
Copyright: Sutton R, Brignole M, Benditt DG. Key challenges in the current management of syncope. Nat Rev Cardiol. (2012 ); (10):590-8.
SYNCOPE: Diagnostic criteria (2)
Diagnostic criteria with provocation maneuvers 1.3
P.19
CHAPTER 2
ACUTE CORONARY SYNDROMES
ECG
No hs-cTn>ULN hs-cTn<ULN
Potential
Consider noncardiac
STEMI causes for Pain onset <6 h Pain onset >6 h
abnormal Tn
hs-cTn >x5 ULN Re-test hs-cTn (3h later)
or See next page for 1 h rule-in & rule-out algorithm
clinical
diagnosis
clear ∆ hs-cTn hs-cTn
(1 value >ULN) no change
STEMI
A B C D E
hs-cTnT (Elecsys)* 5 12 3 52 5
hs-cTnl (Architect)* 2 5 2 52 6
hs-cTnl (Dimension Vista)* 0,5 5 2 107 19
*Cut-off levels are assay-specific.
14 days 0
0-1 2 3 4 5 >=6
TIMI Risk Score
Risk calculation Risk calculation
http://www.gracescore.org/WebSite/WebVersion.aspx http://www.timi.org/index.php?page=calculators
* At admission.
NON ST-SEGMENT ELEVATION ACS: Risk stratification (2) 2.2
P.30
Bleeding risk
CRUSADE risk score
Predictive Factors Risk calculation
• Sex www.crusadebleedingscore.org
• HR*
• SBP* Probability of in-hospital major bleeding(%)
• Creatinine (mg/dl)* 50
• Baseline hematocrit* 40
• GFR: Cockcroft-Gault*
30
• Diabetes
• Prior vascular disease 20
Outcome 0
0 20 40 60 80 100
In-hospital major bleeding
CRUSADE Bleeding Score
* At admission.
Copyrights: Eagle KA et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month post-discharge death
in an international registry. JAMA. (2004); 291(22):2727-33. - Antman EM, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method
for prognostication and therapeutic decision making. JAMA. (2000); 284(7):835-42. - Subherwal S, et al Baseline risk of major bleeding in non-ST-segment-
elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation
of the ACC/AHA Guidelines) Bleeding Score. Circulation (2009); 119(14):1873-82.
NON ST-SEGMENT ELEVATION ACS: Treatment (1)
General overview 2.2
P.31
Initial treatment*
• Nitrates Pharmacological Myocardial
• Morphine treatment* revascularisation
• Oxygen (if SpO2 <90%)
Anticoagulation Antiplatelets
One of the following: Aspirin + one of: Optionally:
• Fondaparinux • Ticagrelor • GP IIb/IIIa inhibitors
• Enoxaparin • Prasugrel • Cangrelor
• UFH • Clopidogrel
• Bivalirudin
*
For more information on individual drug doses and indications,
SEE CHAPTER 3 SECONDARY PREVENTION AFTER ACS & CHAPTER 9 DRUGS USED IN ACUTE CARDIOVASCULAR CARE
NON ST-SEGMENT ELEVATION ACS: Treatment (2)
Risk criteria mandating invasive strategy in NSTE-ACS 2.2
P.32
Same-day transfer
High High
Transfer
Intermediate Intermediate
Transfer optional
Low Low
Therapeutic
strategy
Bolus of
10 min
fibrinolyticb
Strategy clock
Transfer
60-90min
to PCI centre
Wire crossing
90 min
≥120min
(reperfusion)
2 hours
Routine PCI strategy
24 hours
a
If fibrinolysis is contra-indicated, direct for primary PCI strategy regardless of time to PCI.
b
10 min is the maximum target delay time from STEMI diagnosis to fibrinolytic bolus administration, however, it should be given as soon as
possible after STEMI diagnosis (after ruling out contra-indications).
Reference: Ibañez B. Eur Heart J 2018; 39:119-177.
STEMI Treatment (2): 2.3
Medical management of patients treated with primary PCI
P.35
Oxygen when SpO2 <90%
STEMI Aspirin Prasugrel or ticagrelor loading
i.v. Beta-blocker
diagnosis Loading (clopidogrel as alternative)
i.v. Opioids/tranquilizer
ACE inhibitor
Aspirin Clopidogrel
10min
loading loading
ACE inhibitor
1- Acute care
• Drug therapy
• Coronary revascularisation
2- Cardiovascular risk assessment (e.g. concealed and uncontrolled risk factors)
3- Initiate secondary prevention and set treatment goals
Re-evaluate lifestyle, control of risk factors, psychosocial factors and adherance to therapy
Adjustment of secondary prevention therapies. Consider polypill, if needed
Reinforce education
Psychosocial support After 12 months Consider adding Consider Consider
consider*: Ezetimibe* dose adjustment SGLT2 inhibitor*
After Discharge Ticagrelor PCSK9 inhibitor* Consider ARNI* GLP-1 agonists*
60 mg bid
Anticoagulation?**
* When individually indicated and without specific contraindications. - ** Rivaroxaban 2.5 mg bid pending approval for indication in chronic CAD.
Reference modified from Cortés-Beringola A. Eur J Prev Cardiol 2017; 24(3 suppl): 22-28.
After ACS: POTENTIAL STRATEGIES
TO OPTIMIZE SECONDARY PREVENTION THERAPY 3.1
P.40
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260. A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
ANTITHROMBOTIC TREATMENT:
Dual antiplatelet therapy duration in patients with ACS (2) 3.2
P.42
CABG Medical Treatment Alone
12mo
A T or A T or A C
30mo AP AC
>12mo DAPT >12mo DAPT
Class IIb C Class IIb C
Reference: Valgimigli M, et al. Eur Heart J. 2018; 39:213-260. A = Aspirin C = Clopidogrel P = Prasugrel T = Tricagrelor
ANTITHROMBOTIC TREATMENT:
Switching between P2Y12 inhibitors for DAPT after ACS (1) 3.2
P.43
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dual therapy
STEP 1:
(e.g. NSAIDs or antiplatelets), alcohol abuse, ABC score: Age, Biomarkers (GDF-15, hs cTnT, Hb) and Clinical history of prior bleeding
• HIGH RISK OF RECURRENT CORONARY ISCHEMIC EVENTS? immediately after
ACS at presentation, prior ST, stenting of last remaining vessel, CrCL <60 ml/min, ≥3 stents implanted or lesions treated, stent implantation
bifurcation with 2 stents, overall stentlengh >60 mm, treatment of CTO clopidogrel should
be selected as
single antiplatelet
OAC: • NOAC* (preferable) agent. Aspirin
DUAL SAPT: • Clopidogrel 75 mg q.d. - Apixaban 5 mg b.i.d. (reduce to 2.5 mg b.i.d. (1) should however
THERAPY (preferable)* - Dabigatran 110 mg b.i.d. (preferable while on DAPT) be administered
Treatment type
BR>IR TRIPLE (for 1 mo.) DUAL (up to 12 mo.) OAC alone concomitant use
TRIPLE THERAPY strategy: of verapamil,
DUAL quinidine or
BR<IR TRIPLE (up to 6 mo.) (up to 12 mo.) OAC alone dronedarone.
(3)
CrCl 30-49 ml/min.
PRASUGREL PRASUGREL(2)
STOP
CLOPIDOGREL SURGERY CLOPIDOGREL
STOP
TICAGRELOR TICAGRELOR(2)
STOP
ASPIRIN(1)
//••••••9••••••8••••••7••••••6••••••5••••••4••••••3••••••2••••••1•••••• 0••••••••••••••••••1-4
a
Consider shortening DAPT duration or switching to less potent P2Y12 inhibitor (i.e. from ticagrelor/prasugrel to clopidogrel), especially if recurrent bleeding occurs
Reinitiate treatment within one week if clinically indicated. For Vitamin-K antagonist consider a target INR of 2.0-2.5 unless overriding indication (i.e. mechanical
b
heart valves or cardiac assist device) for NOAC consider the lowest effective dose. - c In case of triple therapy consider downgrading to dual therapy, preferably with
clopidogrel and OAC. - d If patients on dual therapy, consider stopping antiplatelet therapy if deemed safe.
Reference: Valgimigli et al. Eur Heart J.2018; 39:213-260.
ANTITHROMBOTIC TREATMENT:
Management of antiplatelet therapy after acute GI bleeding 3.2
P.49
Upper GI endoscopy demonstrates a nonvariceal source of bleeding (e.g. peptic ucler bleed)
High risk endoscopic stigmata identified Low risk endoscopic stigmata identified
(Forrest classification* Ia, Ib, IIa, IIb) (Forrest classification* IIc, III)
APT used for secondary prophylaxis APT used for secondary prophylaxis
(known cardiovascular disease) (known cardiovascular disease)
Patients on low dose ASA alone Patients on low dose ASA alone
• Resume low-lose ASA by day 3 following in dex endoscopy • Continue low-dose ASA without interruption
• Second-look endoscopy at the discretion
of the endoscopist may be considered Paptients on dual antiplatelet therapy (DAPT)
• Continue DAPT without interruption
Paptients on dual antiplatelet therapy (DAPT)
• Continue low dose ASA without interruption *The Forrest classification in defined as follows: Ia spuring
• Early cardiology consultation for recommendation hemorrhage, Ib oozing hemorrhage, IIa nonbleeding visible
of second resumption/ continuation of second APT vessel, IIb an adherent clot, IIc flat pigmented spot, and III clean
• Second-look endoscopy at the discretion of the base ucler.
endoscopoist may be considered
Reference: Halvorsen et al. Eur Heart J 2017; 38: 1455-62.
4
CHAPTER 4
ACUTE HEART FAILURE
HYPOPERFUSION (+)
Cold sweaty extremities, Oliguria,
COLD-DRY COLD-WET
Mental confusion, Dizziness,
Narrow pulse pressure
Hypoperfusion is not synonymous with hypotension, but often hypoperfusion is accompanied by hypotension.
Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8):891-975. DOI: 10.1002/ejhf.592.
ACUTE HEART FAILURE: Diagnosis and causes (2) 4.1
P.53
1 Symptoms: Dyspnea (on effort or at rest)/
FACTORS TRIGGERING ACUTE HEART FAILURE
breathlessness, fatigue, orthopnea, cough,
weight gain/ankle swelling. • Acute coronary syndrome
• Tachyarrhythmia (e.g. atrial fibrillation, ventricular tachycardia)
2 Signs: Tachypnea, tachycardia, low or normal blood
• Excessive rise in blood pressure
pressure, raised jugular venous pressure,
3rd/4th heart sound, rales, oedema, intolerance • Infection (e.g. pneumonia, infective endocarditis, sepsis).
of the supine position. • Non-adherence with salt/fluid intake or medications
• Toxic substances (alcohol, recreational drugs)
3 Cardiovascular risk profile: Older age, HTN, diabetes,
• Drugs (e.g. NSAIDs, corticosteroids, negative inotropic
smoking, dyslipidemia, family history, history of CVD. substances, cardiotoxic chemotherapeutics)
4 Precipitants/causes that need urgent management • Exacerbation of chronic obstructive pulmonary disease
(CHAMP): Acute coronary syndrome. Hypertensive • Pulmonary embolism
emergency. Rapid arrhythmias or severe • Surgery and perioperative complications
bradyarrhythmia/conduction disturbance. Mechanical • Increased sympathetic drive, stress-related cardiomyopathy
causes. Pulmonary embolism. • Metabolic/hormonal derangements (e.g. thyroid dysfunction,
5 Differential diagnosis: Exacerbated pulmonary disease, diabetic ketosis, adrenal dysfunction, pregnancy and
pneumonia, pulmonary embolism, pneumothorax, peripartum related abnormalities)
acute respiratory distress syndrome, (severe) anaemia, • Cerebrovascular insult
hyperventilation (metabolic acidosis), sepsis/septic • Acute mechanical cause : myocardial rupture complicating
shock, redistributive/hypovolemic shock. ACS (free wall rupture, ventricular septal defect, acute
mitral regurgitation), chest trauma or cardiac intervention,
acute native or prosthetic valve incompetence secondary
Reference: McMurray JJ et al. Eur Heart J (2012); 33:1787-847. to endocarditis, aortic dissection or thrombosis
Ponikowski P et al. Eur J Heart Fail. 2016; 18:891-975.
Initial management of a patient with ACUTE HEART FAILURE 4.1
Patient with suspected AHF P.54
Circulatory support
1. Cardiogenic shock ? • pharmacological
Urgent phase after Yes • mechanical
first medical contact No
2. Respiratory failure ? Ventilatory support
Yes • oxygen
No • non-invasive positive
pressure ventilation (CPAP, BiPAP)
• mechanical ventilation
Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8): 891-975. DOI: 10.1002/ejhf.592.
ACUTE HEART FAILURE: Airway (A) and breathing (B)
Oxygen therapy and ventilatory support in acute heart failure 4.1
In hospital No
"PERSISTENT" RESPIRATORY DISTRESS?
Yes
Venous/Arterial blood gases
Conventional Intolerance
oxygen therapy PS-PEEP CPAP
Intubation
After Weaning
60-90 min SUCCESS FAILURE
Room air
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17:544-58.
ACUTE HEART FAILURE: Initial diagnosis (CDE) 4.1
P.56
C - CIRCULATION *
HR (bradycardia [<60/min], normal [60-100/min], tachycardia [>100/min]), rhythm (regular, irregular), SBP (very low
[<90 mmHg], low, normal [110-140 mmHg], high [>140 mmHg]), and elevated jugular pressure should be checked.
References: Mebazaa A et al. Intensive Care Med. (2016); 42(2):147-63; Mueller C et al. Eur Heart J Acute Cardiovasc Care. (2017); 6(1):81-6.
ACUTE HEART FAILURE: Management of patients with acute heart
failure based on clinical profile during an early phase 4.1
P.58
PRESENCE OF CONGESTIONa?
Yes No
(95% of all AHF patients) (5% of all AHF patients)
Symptoms/signs of congestion: orthopnoea, paroxysmal nocturnal dyspnoea, breathlessness, bi-basilar rales, abnormal blood pressure response to the
a
Valsalva maneuver (left-sided); symptoms of gut congestion, jugular venous distension, hepatojugular reflux, hepatomegaly, ascites, and peripheral
oedema (right-sided).
Reference: Ponikowski P et al. Eur J Heart Fail. 2016; 18(8):891-975. DOI: 10.1002/ejhf.592.
ACUTE HEART FAILURE: Management of acute heart failure 4.1
P.60
DIAGNOSTIC TESTS
OBSERVATION UP TO 120 min
REASSESSMENT
Clinical, biological and psychosocial parameters by trained nurses
ADMISSION/DISCHARGE
Discharge home
Reference adapted from Mebazaa A et al. Eur J Heart Fail. (2015); 17(6):544-58.
ACUTE HEART FAILURE: Treatment (C) and preventive measures (Cont.) 4.1
Management of oral therapy in AHF in the first 48 hours P.62
Some patients with CS will require increased PEEP to attain functional residual capacity and maintain oxygenation,
and peak pressures above 30 cm H2O to attain effective tidal volumes of 6-8 ml/kg with adequate CO2 removal.
Early coronary angiography Pump failure • Acute severe mitral valve regurgitation Aortic
± Pulmonary artery catheter RV, LV, both • Ventricular septum rupture dissection
Short-term mechanical
1-month ...
2-weeks
72-hrs
IABP Impella 2.5 Impella 5.0 Tandem- Levitronix ECMO Implantable
heart
Left ventricular support BiVentricular support
Pulmonary support
Level of support
4.2
P.69
Type Support Access
Intra-aortic balloon Balloon Pulsatile flow <0.5 L Arterial: 7.5 French
pump counterpulsation
Impella Recover Axial flow Continuous flow
LP 2.5 <2.5 L Arterial: 12 French
CP <4.0 L Arterial: 14 French
LP 5.0 <5.0 L Arterial: 21 French
Tandemheart <5.0 L Venous: 21 French
Arterial: 15-17 French
Cardiohelp Centrifugal flow Continuous flow
Venous: 15-29 French
<5.0 L Arterial: 15-29 French
Different systems for mechanical circulatory support are available to the medical community.
The available devices differ in terms of the insertion procedure, mechanical properties, and
mode of action. A minimal flow rate of 70 ml/kg/min, representing a cardiac index of at least
2.5 L/m2, is generally required to provide adequate organ perfusion. This flow is the sum
of the mechanical circulatory support output and the remaining function of the heart.
The SAVE-score may be a tool to predict survival for patients receiving ECMO for refractory
cardiogenic shock (www.save-score.com).
5
P.71
CHAPTER 5
CARDIAC ARREST AND
CARDIOPULMONARY RESUSCITATION
N. Nikolaou, L. Bossaert
Monsieurs KG, et al. European Resuscitation Council Guidelines for Resuscitation 2015. Section 1
Executive Summary. Resuscitation 2015; 95C:1-80, DOI:10.1016/j.resuscitation.2015.07.038
OUT
OUT OF HOSPITAL
OF HOSPITAL CARDIAC
CARDIAC ARREST: ARREST:
Assessment
ASSESSMENT of a collapsed
OF A COLLAPSED VICTIMvictim andTREATMENT
AND INITIAL initial treatment 5
P.72
VICTIM COLLAPSES
Approach safely
Check response
Victim responds
Victim unresponsive
Continue until victim starts to wake up: to move, open eyes, and breathe normally
IN-HOSPITAL
IN-HOSPITAL CARDIAC ARREST:
CARDIAC ARREST:
Assessment 5
ASSESSMENT OFofAaCOLLAPSED
collapsed victim and INITIAL
VICTIM AND initial treatment
TREATMENT
P.74
Collapsed/sick patient
Call resuscitation
team
Assess ABCDE
Recognise & treat
oxygen; monitoring, i.v. access
CPR 30:2
with oxygen and airway adjuncts
5
Apply pads/monitor Call resuscitation team P.75
Attempt defibrillation if appropriate
if appropriate
Call resuscitation
team
CPR 30:2
Attach defibrillator/monitor
Minimise interruptions
Assess
rhythm
Shockable Non-shockable
(VF/Pulseless VT) (PEA/Asystole)
5
Return of
1 Shock P.77
spontaneous circulation
Immediately resume:
IMMEDIATE POST CPR for 2 min
Immediately resume: CARDIAC Minimise interruptions
CPR for 2 min ARREST TREATMENT
Minimise interruptions • Use ABCDE approach
• Aim for SaO2 94-98%
DURING CPR • Aim for normal PaCO2 REVERSIBLE CAUSES
• Ensure high-quality • 12-lead ECG • Hypoxia
chest compressions • Treat precipitating cause • Hypovolaemia
• Minimise interruptions • Temperature control / • Hypo-/hyperkalaemia/metabolic
to compressions • Hypothermia
Therapeutic hypothermia
• Give Oxygen
• Thrombosis
• Use waveform capnography CONSIDER • Tamponade - cardiac
• Continuous chest compressions • Ultrasound imaging • Toxins
when advanced airway in place • Mechanical chest • Tension pneumothorax
• Vascular access (intravenous, compressions to facilitate
intraosseous) transfer/treatment
• Give adrenaline every 3-5 min • Coronary angiography
• Give amiodarone after 3 shocks and PCI
• Correct reversible causes • Extracorporeal CPR
IN-HOSPITAL CARDIAC ARREST:
Drug therapy during advanced life support 5
P.78
IN-HOSPITAL CARDIAC ARREST: DRUG THERAPY DURING ADVANCED LIFE SUPPORT
Cardiac Arrest
Give adrenaline and amiodarone Adrenaline: 1mg i.v. (10 ml 1:10,000 or 1 ml 1:1000)
after 3rd shock given as soon as circulatory access is obtained
Repeat every 3-5 min (alternate loops)
Give without interrupting chest compressions
CHAPTER 6
RHYTHM DISTURBANCES
Regular Irregular
QRS morphology similar to QRS morphology QRS morphology similar to QRS morphology
in sinus rhythm? in sinus rhythm?
YES NO YES NO
QRS complex QRS complex QRS complex QRS complex QRS complex QRS complex Variable QRS
<120 msec >120 msec <120 msec >120 msec <120 msec >120 msec morphology
Vagal maneuvers
or
i.v. adenosine
Hemodynamically
Hemodynamically Hemodynamically
Hemodynamically Less than
Less48thanhours
48 hours Hemodynamically non-stable
Hemodynamically non-stable
non-stable
non-stable stablestable since since
initiation
initiation
AND AND Immediate electrical
Immediate electrical
hemodynamically
hemodynamically
stablestable Cardioversion
Cardioversion
Immediate
Immediate
electrical
electrical VagalVagal
maneuvers
maneuvers
cardioversion
cardioversion and/orand/or
i.v. Adenosine
i.v. Adenosine Cardioversion
Cardioversion If no cardioversion
If no cardioversion
Electrical
Electrical or pharmacological is considered:
or pharmacological rate control
is considered: rate control
using using
oral ororali.v. or i.v. flecainide
flecainide using using
betablockers
betablockers
or or
(only in
(only
normal
in normal
heart)heart) calcium calcium
antagonists,
antagonists,
or i.v. or i.v. vernakalant
vernakalant togethertogether
with proper
with proper
No termination
No termination Termination
Termination
anticoagulation, if required
anticoagulation, if required
Anticoagulation
Anticoagulation
is initiated
is initiated
using using
i.v. heparine
i.v. heparine
NarrowNarrow
QRS QRS Wide QRS
Wide QRS
complex
complex
tachycardia
tachycardia complex
complex
tachycardia
tachycardia More More
than 48
than hours
48 hours
OR OR
unknown
unknown
time oftime
initiation,
of initiation,
Reconsider
Reconsider
diagnosis:
diagnosis: Reconsider
Reconsider
the diagnosis
the diagnosis
of of AND AND
sinus sinus
tachycardia,
tachycardia, Ventricular
Ventricular
Tachycardia even even
Tachycardia Patient
Patient
chronically
chronically
anticoagulated
anticoagulated
atrial atrial
tachycardia
tachycardia if hemodynamically
if hemodynamically
stablestable OR OR
a TEEashowing
TEE showing
no thrombus
no thrombus
If no evidence:
If no evidence: Do not
Doadminister
not administer
Intravenous
Intravenous
verapamil
verapamil verapimil
verapimil Electrical
Electrical
or pharmacological
or pharmacological
Cardioversion
Cardioversion
TACHYARRHYTHMIAS: Therapeutic algorithms (2) 6.1
P.83
TACHYARRHYTHMIAS: THERAPEUTIC ALGORITHMS (2)
Irregular and wide QRS complex Tachycardia
No
No
No
Yes
VT Aberrant conduction VT Vi/Vt ≤1
No
Aberrant conduction
Management of wide QRS TACHYSCARDIAS 6.2
MANAGEMENT OF WIDE QRS TACHYCARDIAS
P.86
Hemodynamic Tolerance
Non-stable Stable
• Sinus bradycardia: It is a rhythm that originates • First degree AV block: Atrioventricular impulse
from the sinus node and has a rate of under 60 beats transmission is delayed, resulting in a PR interval
per minute longer than 200 msec
• Sinoatrial exit block: The depolarisations that occur in • Second degree AV block: Mobitz type I (Wenckebach
the sinus node cannot leave the node towards the atria block): Progressive PR interval prolongation, which
precedes a nonconducted P wave
• Sinus arrest: Sinus pause or arrest is defined as the
transient absence of sinus P waves • Second degree AV block: Mobitz type II: PR interval
on the ECG remains unchanged prior to a P wave that suddenly fails
to conduct to the ventricles
• Third degree (complete) AV block:
No atrial impulses reach the ventricle
BRADYARRHYTHMIAS: Treatment (1) 6.3
P.88
Be Careful!
• Complications are common!
• Shall not be used routinely
• Use only as a last resource when chronotropic drugs are insufficient
• Every effort should be made to implant a permanent pacemaker
as soon as possible, if the indications are established.
• Documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms
• Symptomatic chronotropic incompetence
• Symptomatic sinus bradycardia that results from required drug therapy for medical conditions
• Asymptomatic patients
• Patients for whom the symptoms suggestive of bradycardia
have been clearly documented to occur in the absence of bradycardia
• Symptomatic bradycardia due to nonessential drug therapy
BRADYARRHYTHMIAS: Treatment (3)
Pacemaker therapies in atrioventricular blocks 6.3
P.90
Permanent pacemaker therapy is indicated in the following settings regardless of associated symptoms:
• Third-degree AV block
• Advanced second-degree AV block
• Symptomatic Mobitz I or Mobitz II second-degree AV block
• Mobitz II second-degree AV block with a wide QRS or chronic bifascicular block
• Exercise-induced second- or third-degree AV block
• Neuromuscular diseases with third- or second-degree AV block
• Third- or second-degree (Mobitz I or II) AV block after catheter ablation or valve surgery
when block is not expected to resolve
• Asymptomatic patients
• Patients for whom the symptoms suggestive of bradycardia have been clearly documented
to occur in the absence of bradycardia
• Symptomatic bradycardia due to nonessential drug therapy
7
CHAPTER 7
ACUTE VASCULAR SYNDROMES
Stanford Classification
De Bakey Type I Type II Type III
• Type A includes all dissections involving the ascending
aorta regardless of entry site location
• Type B dissections include all those distal to the
brachiocephalic trunk, sparing the ascending aorta
Time course
• Acute: <14 days
• Subacute: 15-90 days
• Chronic: >90 days
Stanford Type A Type A Type B
Adapted with permission from Nienaber CA, Eagle KA,
Circulation 2003;108(6):772-778. All rights reserved.
Copyright: Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up.
Circulation (2003); 108(6),772-778.
ACUTE AORTIC SYNDROME:
Clinical suspicion and differential diagnosis 7.1
P.94
Copyright: Hiratzka et al. 2010 Guidelines on Thoracic Aortic Disease. Circulation. (2010) ; 121: page-310 (fig 25 step 2).
Laboratory tests required for patients
with ACUTE AORTIC dissection 7.1
P.96
Laboratory tests To detect signs of:
Red blood cell count Blood loss, bleeding, anaemia
White blood cell count Infection, inflammation (SIRS)
C-reactive protein Inflammatory response
ProCalcitonin Differential diagnosis between SIRS and sepsis
Creatine kinase Reperfusion injury, rhabdomyolysis
TroponinIorT Myocardial ischaemia, myocardial infarction
D-dimer Aortic dissection, pulmonary embolism, thrombosis
Creatinine Renal failure (existing or developing)
Aspartate transaminase / alanine aminotransferase Liver ischaemia, liver disease
Lactate Bowel ischaemia, metabolic disorder
Glucose Diabetes mellitus
Blood gases Metabolic disorder, oxygenation
TTE + TOE/CT° Low probability (score 0-1) High probability (score 2-3)
or typical chest pain
Flowchart for decision-making based on pre-test sensitivity of acute aortic syndrome. Reference: Eur Heart J 2014; eurheartj.ehu281.
Details required from imaging in ACUTE AORTIC dissection 7.1
P.98
Type A Type B
(Ascending aorta (No ascending
involvement) aorta involvement)
Complicated
Uncomplicated (malperfusion,
rupture)
3 • Intravenous line, blood sample (CK, cTn, myoglobin, white blood count, D-dimer, hematocrit, LDH)
4 • Monitoring: HR and BP
7 • Transfer to ICU
Consider further
risk stratificaiton
a
If echocardiography has already been performed during diagnostic work-up for PE and detected RV dysfunction,
or if the CT already performed for diagnostic work–up has shown RV enlargement (RV/LV (left ventricular)
ratio ≥0.9, a cardiac troponin test should be performed except for cases in which primary reperfusion is
not a therapeutic option (e.g. due to severe comorbidity or limited life expectancy of the patient).
b
arkers of myocardial injury (e.g. elevated cardiac troponin I or T concentrations in plasma), or of heart failure as a
M
result of (right) ventricular dysfunction (elevated natriuretic peptide concentrations in plasma). If a laboratory test for
a cardiac biomarker has already been performed during initial diagnostic work-up (e.g. in the chest pain unit) and was
positive, then an echocardiogram should be considered to assess RV function, or RV size should be (re)assessed on CT.
c
atients in the PESI Class I-II, or with sPESI of 0, and elevated cardiac biomarkers or signs of RV dysfunction on imaging tests, are
P
also to be classified into the intermediate-low risk category. This might apply to situations in which imaging or biomarker results
become available before calculation of the clinical severity index. These patients are probably no candidates for home treatment.
d
hrombolysis, if (and as soon as) clinical signs of haemodynamic decompensation appear; surgical
T
pulmonary embolectomy or percutaneous catheter-directed treatment may be considered as
alternative options to systemic thrombolysis, particularly if the bleeding risk is high.
e
onitoring should be considered for patients with confirmed PE and a positive troponin test,
M
even if there is no evidence of RV dysfunction on echocardiography or CT.
f
he simplified version of the PESI has not been validated in prospective home treatment trials; inclusion
T
criteria other than the PESI were used in two single-armed (non-randomized) management studies.
Reference: Eur Heart J 2014; 35:3033-3073.
ACUTE PULMONARY EMBOLISM: DIAGNOSIS
ACUTE PULMONARY EMBOLISM: Diagnosis 7.2
P.104
CARDIOVASCULAR RESPIRATORY
Symptoms/Signs Symptoms/Signs
including but not limited to: Dyspnea including but not limited to:
YES
Shock? or NO
SBP <90 mmHg?
or
SBP fall by >40 mmHg?
persisting >15 min, otherwise unexplained
Echocardiography CT*
(bedside) Angio
patient stabilised
RV pressure overload
Right heart,
Yes CUS pulmonary artery or
venous thrombi?
TEE
No
Yes positive
No further diagnostic
tests feasible
Search for other causes
Primary PA reperfusion
Primary PA reperfusion not justified
negative
* Consider also pulmonary angiography if unstable patient in hemodynamic lab.
Reference: IACC Textbook (2015) chapter 66 Pulmonary embolism - page 639 - figure 66.2.
ACUTE PE: Management strategy for initially unstable patients
with confirmed high risk pulmonary embolism 7.2
P.106
Contraindications
No Relative Absolute
for thrombolysis
Low-dose Surgical or
Primary PA
transcatheter Percutaneous catheter
reperfusion Thrombolysis
thrombolysis / embolectomy
strategy
clot fragmetation (availability/experience)
Supportive treatment i.v. UFH, STABILISE SYSTEMIC BLOOD PRESSURE, CORRECT HYPOXEMIA
Management algorithm for initially stable patients
MANAGEMENT ALGORITHM
with suspected FOR INITIALLY
ACUTE PULMONARYSTABLE PATIENTS WITH
EMBOLISM 7.2
SUSPECTED ACUTE PULMONARY EMBOLISM
P.107
Asses clinical (pre-test) probalility
negative D-dimer
positive CUS
negative
negative positive Confirm by CUS positive
V/Q scan or angiography
Reference: IACC Textbook (2015) chapter 66 Pulmonary embolism - page 640 - figure 66.3.
Suggested management strategy for initially stable patients
with (non-high risk) confirmed PE 7.2
P.108
* When all markers are positive. - ** When at least one marker is positive. - *** When all markers are negative.
CHAPTER 8
ACUTE MYOCARDIAL/
PERICARDIAL SYNDROMES
8.1 ACUTE MYOCARDITIS ����������������������������������������������������� p.112
A. Keren, A. Caforio
CAUSES OF MYOCARDITIS
OR
when the patient is asymptomatic, two or more diagnostic criteria from different categories (I to IV)*
• Patients with a life-threatening presentation should be sent to specialised units with capability for
hemodynamic monitoring, cardiac catheterisation and expertise in endomyocardial biopsy.
• Heart transplant should be deferred in the acute phase, because recovery may occur, but can be considered
for hemodynamically unstable myocarditis patients, including those with giant cell myocarditis, if optimal
pharmacological support and mechanical assistance cannot stabilise the patient
• ICD implantation for complex arrhythmias should be deferred until resolution of the acute episode, with
possible use of a lifevest during the recovery period.
Yes Equivocal or no
Consider Consider
cardiac alternative
MRI diagnoses
Percutaneous
pericardiocentesis & drainage
Consider surgical drainage
Avoid PEEP ventilation Tamponade
9
P.121
CHAPTER 9
DRUGS IN
ACUTE CARDIOVASCULAR
CARE
Ana de Lorenzo
Oral antiplatelets 9
P.122
Dose
Drug Indications Dose Comments
adjustments
Primary (not universally approved) LD (if ACS): Major contraindications:
Aspirin
risk of ischaemic events, e.g. elevated MD: 90 mg oral BID - hemorrhage, severe hepatic impairment,
cardiac troponins) strong CYP3A4 inhibitors
Secondary prevention MD: 60 mg oral BID
1-3 years post-MI -
ACS with planned PCI LD: 60 mg oral MD: 5 mg QD Contraindication:
Prasugrel
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral antiplatelets (Cont.) 9
P.123
Dose
Drug Indications Dose Comments
adjustments
ACS + PCI or medical management LD: 300-600 mg Prasugrel and ticagrelor have not been studied
(patients who cannot receive oral as adjuncts to fibrinolysis and oral anticoagulants
ticagrelor or prasugrel) and in MD: 75 mg oral QD
-
ACS patients at high bleeding risk
(e.g. patients who require oral
Clopidogrel
anticoagulation)
STEMI LD: 300 mg oral
-
+ fibrinolysis <75 years MD: 75 mg oral QD
STEMI LD: 75 mg oral Prasugrel and ticagrelor have not been studied
-
+ fibrinolysis ≥75 years MD: 75 mg oral QD as adjuncts to fibrinolysis and oral anticoagulants
Secondary prevention >12 months MD: 75 mg oral QD
-
post coronary stenting
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Intravenous antiplatelets 9
P.124
Dose
Drug Indications Dose Comments
adjustments
Adjunct to PCI for bailout LD: 0.25 mg/Kg i.v. Contraindications:
situations or thrombotic MD: 0.125 μg/Kg/ Active internal bleeding - History of CVA within 2 years
complications min i.v. (max: 10 μg/ - Bleeding diathesis - Preexisting thrombocytopenia
Abciximab
If STEMI and PCI: 30-50 ml/min surgery within the preceding 6 weeks - Stroke within
add a second 30 days or any history of hemorrhagic stroke -
180 mcg/kg i.v. Coadministration of another parenteral GP II b/III a
bolus inhibitor - Severe renal impairment or dependency on
at 10 min renal dialysis - History of intracranial disease - Clinically
MD: 2 μg/Kg/min i.v. significant hepatic impairment - Thrombocytopenia -
infusion Prothrombine time >1.2 times control or INR ≥2
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Intravenous antiplatelets (Cont.) 9
P.125
Dose
Drug Indications Dose Comments
adjustments
ACS treated medically LD: 25 μg/Kg i.v. CrCl <30 ml/min: Contraindications:
or with PCI over 5 min decrease 50%
Tirofiban
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral anticoagulants and antagonists 9
P.126
Drug Indications Dose Dose adjustments Comments
Treatment and INR goal of 2-3 Assessing individual risks for
Acenocoumarol
Contraindicated if CrCl <15 ml/min
Treatment of DVT and PE 10 mg oral BID for the first or severe hepatic impairment
7 days -
followed by 5 mg oral BID
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral anticoagulants and antagonists (Cont.) 9
P.127
Drug Indications Dose Dose adjustments Comments
Prevention of stroke 150 mg oral BID 110 mg BID Contraindicated if CrCl <30 ml/min
and systemic embolism (if age ≥80, increased bleeding or severe hepatic impairment
in NVAF risk or concomitant use of Active clinically significant bleeding
verapamil)
Dabigatran
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral anticoagulants and antagonists (Cont.) 9
P.128
Drug Indications Dose Dose adjustments Comments
Prevention of stroke and 20 mg oral QD CrCl <50 ml/min: 15 mg QD Contraindicated if CrCl <15 ml/min
systemic embolism in or hepatic disease associated with
NVAF coagulopathy and clinically relevant
Rivaroxaban
bleeding risk
Treatment of DVT and 15 mg oral BID for the first Reduce the maintenance dose to
PE and prevention of 3 weeks 15 mg QD if bleeding risk outweighs Rivaroxaban can be initiated
recurrent DVT and PE followed by 20 mg QD the risk for recurrent DVT and PE in patients who may require
(not formally approved) cardioversion
Anticoagulant antagonists
Specific reversal agent 5g i.v. over 5 to 10 min Dabigatran treatment can be re-
for dabigatran Another 5g dose if prolonged initiated 24h after administration of
Idarucizumab
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Oral anticoagulants and antagonists (Cont.) 9
P.129
Drug Indications Dose Dose adjustments Comments
Anticoagulant antagonists
Patients with asymptomatic high INR with or without mild haemorrhage
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Parenteral anticoagulants (Cont.) 9
P.131
Drug Indications Dose Dose adjustments Comments
PCI for NSTE-ACS 0.75 mg/kg i.v. bolus followed immediatelly Patients undergoing PCI Contraindicated
by 1.75 mg/kg/h infusion which may be with CrCl 30-50 ml/min should if CrCl <30 ml/min
continued for up to 4h post PCI as clinically receive a lower infusion rate of
warranted and further continued at a reduced 1.4 mg/kg/h Active bleeding or increased
infusion dose of 0.25 mg/kg/h for 4-12h as risk of bleeding, severe
No change for the bolus dose
clinically necessary uncontrolled hypertension,
subacute bacterial endocarditis
Bivalirudin
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Parenteral anticoagulants (Cont.) 9
P.132
Drug Indications Dose Dose adjustments Comments
NSTE-ACS 30 mg i.v. + 1 mg/kg s.c. BID If >75 years: no LD and MD Monitoring for HIT
0.75 mg/Kg BID s.c. Anti Xa monitoring during
CrCl <30 ml/min: no LD and MD treatment with LMWH might
1 mg/Kg QD s.c. be helpful in pregnancy,
If >75 years and CrCl <30 ml/min: extreme body weights and renal
no LD and 0.75 mg/Kg QD s.c. impairment
STE-ACS Primary PCI: 0.5 mg/Kg i.v. bolus In patients with CrCl <30 ml/min:
Fibrinolysis/No reperfusion: regardless of age, the s.c. doses
Enoxaparin
a) Age <75 years: 30 mg i.v. bolus followed by are given once daily
1 mg/Kg BID s.c. until hospital discharge for a
max of 8 days
The first two doses should not exceed 100 mg
b) Age >75 years: no bolus; 0.75 mg/Kg
BID s.c. - The first two doses should not
exceed 75 mg
Treatment of DVT 1 mg/Kg s.c. BID or 1.5 mg/Kg s.c. QD CrCl <30 ml/min: 1 mg/Kg/24h
and PE s.c.
Prevention of VTE 40 mg s.c. QD CrCl <30 ml/min: 20 mg s.c. QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Parenteral anticoagulants (Cont.) 9
P.133
Drug Indications Dose Dose adjustments Comments
Prevention of VTE 3,500 IU s.c. QD (moderate risk) Monitoring for HIT
Tinzaparin
-
4,500 IU s.c. QD (high risk) Anti Xa monitoring during
Treatment of DVT 175 IU/Kg s.c. QD treatment with LMWH might
- be helpful in pregnancy,
and PE
extreme body weights and renal
Prevention of VTE 2,500 IU s.c. QD (moderate risk) impairment
-
5,000 IU s.c. QD (high risk) Dalteparin:
Treatment of DVT 200 IU/Kg QD or 100 IU/Kg BID s.c. Anti Xa monitoring In cancer patients, dose of
Dalteparin
patients with HIT (not to exceed 10 μg/kg/min) caution advised 1.5 to 3.0 times the initial
Patients undergoing PCI: 350 μg/kg i.v. baseline value
followed by 25 μg/kg/min i.v.
PCI: ACT goal: 300-450s
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Fibrinolytics 9
P.134
Dose
Drug Indications Dose Comments
adjustments
STEMI <12 hours 1.5 million units over 30-60 min Absolute contraindications to
i.v. - fibrinolytics:
Streptokinase (SK)
STEMI <12 hours 15 mg i.v. bolus: Recent major trauma/surgery/head injury
0.75 mg/kg over 30 min (within the preceding 3 weeks)
Alteplase (tPA)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Fibrinolytics (Cont.) 9
P.135
Dose
Drug Indications Dose Comments
adjustments
STEMI <12 hours 10 units + 10 units i.v. bolus given Renal and hepatic Absolute contraindications to
30 min apart impairment: fibrinolytics:
Reteplase
caution advised
(rt-PA)
40 mg if 70 to <80kg
(TNK-tPA)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiischemic drugs 9
P.136
Drug Indications Dose Dose adjustments Comments
Beta-blockers: Preferred over calcium channel blockers - Contraindicated if coronary spasm, severe bradycardia, AV block, severe bronchospasm
CrCl 15-35 ml/min:
STEMI 25-100 mg QD, max dose 50 mg/day;
titrate as tolerated up to 100 mg QD CrCl <15 ml/min:
only if no LVSD or CHF max dose 25 mg/day
NSTE-ACS LD: 3.125-25 mg oral Caution in elderly and hepatic Preferred if LVSD/HF
Carvedilol
NSTE-ACS LD: 1.25-10 mg oral Caution in renal or hepatic impairment Preferred if LVSD/HF
Bisoprolol
MD: 1.25-10 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiischemic drugs (Cont.) 9
P.137
Drug Indications Dose Dose adjustments Comments
Beta-blockers: Preferred over calcium channel blockers - Contraindicated if coronary spasm, severe bradycardia, AV block, severe bronchospasm
NSTE-ACS LD: 25-100 mg oral Caution in hepatic impairment Preferred if LVSD/HF
Metoprolol
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiischemic drugs (Cont.) 9
P.138
Drug Indications Dose Dose adjustments Comments
Calcium antagonists: Consider if beta-blockers are contraindicated. First option in vasospastic angina
ACS LD: 5-10 mg oral, MD: 5-10 mg QD Caution in hepatic impairment Contraindicated
Amlodipine
if hypotension
Nitrates
ACS If intolerant or unresponsive to Contraindicated
nitroglycerin s.l. 5 μg/min - Increase by if severe
5 mcg/min q 3-5 min up to 20 μg/min hypotension and co-
i.v.
-
If 20 mcg/min is inadequate, increase by administration with
10 to 20 μg/min every 3 to 5 min phosphodiesterase
Nitroglycerin
i.v. nitroglycerin
tablet
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiischemic drugs (Cont.) 9
P.139
Drug Indications Dose Dose adjustments Comments
Angina 5-10 mg BID with the two doses given Contraindicated
Isosorbide mononitrate
3 times/day
MD: 10 to 40 mg orally 2 or 3 times a day -
Extended release: 40 to 160 mg/day
orally
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiischemic drugs (Cont.) 9
P.140
Drug Indications Dose Dose adjustments Comments
Other antiishemic drugs
Stable angina 5-7.5 mg oral BID Caution in elderly and CrCl <15 ml/min Contraindicated
Ivabradine
if severe hepatic
impairment
Stable angina Initial dose: 375 mg oral BID Use with caution in renal and hepatic Contraindicated
After 2-4 weeks, the dose should be impairment, CHF, elderly, low weight if CrCl <30 ml/
Ranolazine
parkinsonian
symptoms, tremors,
restlessleg syndrome,
movement disorders,
severe renal
impairment
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Lipid lowering drugs 9
P.141
Drug Indications Dose Dose adjustments Comments
Statins: Primary or secondary prevention of cardiovascular disease
For secondary prevention, start with high doses initiated early after admission and downtitrate if side effects.
Target LDL-C levels <70 mg/dl
Atorvastatin -
LDL-C reduction
CrCl <30 ml/min: start 5 mg QD,
Rosuvastatin <30% 30-40% 40-50% >50% max: 10 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Lipid lowering drugs (Cont.) 9
P.142
Drug Indications Dose Dose adjustments Comments
Others
Hypercholesterolaemia 10 mg oral QD Avoid use if moderate-severe
Ezetimibe hepatic impairment
-
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Lipid lowering drugs (Cont.) 9
P.143
Drug Indications Dose Dose adjustments Comments
PCSK9 Inhibitors
Hypercholesterolaemia 140 mg s.c. Most common side
and mixed dyslipidaemia every 2 weeks effects:
or 420 mg every month Nasopharingitis, upper
Homozygous familial respiratory tract
hypercholesterolaemia Homozygous familial infection, headache and
Evolocumab hypercholesterolaemia:
-
back pain
420 mg s.c every month
Up-titrate to 420 mg
every 2 weeks if a
response is not achieved
Hypercholesterolaemia Start dose: If a larger LDL-C reduction (>60%) Most common side
and mixed dyslipidaemia 75 mg s.c. every 2 weeks is required, the start dose could effects:
be 150 mg every 2 weeks, or Upper respiratory tract
300 mg every 4 weeks signs and symptoms,
Alirocumab pruritus and injection site
The dose can be individualised reactions
based on LDL-C level, goal of
therapy, and response. Max dose:
150 mg once every 2 weeks
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension 9
P.144
Drug Indications Dose Dose adjustments Comments
ACEI
HF Start: 6.25 mg oral TID CrCl >50 ml/min: 75-100% Check renal function,
Target dose: 50 mg TID of the normal dose electrolytes,
Captopril
Target dose: 10-20 mg BID CrCl 10-30 ml/min: start 2.5 mg/day stenosis, pregnancy (risk)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.145
Drug Indications Dose Dose adjustments Comments
HF Start: 2 mg oral QD CrCl >60 ml/min: start 4 mg/day Check renal function,
Perindopril
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.146
Drug Indications Dose Dose adjustments Comments
ARB
HF, HTN Start: 4-8 mg oral QD If renal or hepatic impairment: If ACEI is not tolerated
Candesartan
Major contraindications:
HF Start: 50 mg oral QD CrCl <20 ml/min: 25 mg QD History of angioedema,
known bilateral renal artery
Losartan
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.147
Drug Indications Dose Dose adjustments Comments
Neprilysin inhibitor/ARB
Symptomatic Start: 49 mg/51 mg Do not initiate if K >5.4 mmol/l Do not co-administer with an ACEI or ARB. It must not
chronic HF oral BID or SBP <100 mmHg be started for at least 36 hours after discontinuing
with reduced Target dose: an ACEI
Sacubitril/Valsartan
ejection 97 mg/103 mg BID Start dose of 24 mg/26 mg BID Contraindicated if history of angioedema related
fraction if SBP 100-110 mmHg to ACEI or ARB
or CrCl 30-60 ml/min
Hereditary or idiopathic angioedema
Concomitant use with aliskiren if diabetes mellitus
or renal impairment
Severe hepatic impairment, biliary cirrhosis and
cholestasis
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.148
Drug Indications Dose Dose adjustments Comments
Beta-blockers: Check 12 - lead ECG
HTN Start: 25 mg oral QD CrCl 10-50 ml/min: Major contraindications:
Atenolol
Usual dose: 50-100 mg QD decrease dose 50% asthma, 2nd or 3rd degree
CrCl <10 ml/min: AV block
decrease dose 75%
HTN 100-400 mg QD
Max dose: 400 mg QD
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.149
Drug Indications Dose Dose adjustments Comments
Beta-blockers: Check 12- lead ECG
HF Start: 1.25 mg oral QD Renal impairment or elderly: start Major contraindications:
Cardioselective (2)
Target dose: 10 mg QD dose 2.5 mg QD, titrate to 5 mg QD asthma, 2nd or 3rd degree
Hepatic impairment: contraindicated AV block
Nebivolol
impairment
Carvedilol
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.150
Drug Indications Dose Dose adjustments Comments
Other vasodilators
HTN Start: 5 mg oral QD, Elderly or secondary agent: Contraindicated if
Amlodipine
Dose: 80-120 mg oral TID; or small stature patients bradycardia, HF, LVSD
Start: 80 mg TID;
Max: 480 mg/day
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.151
Drug Indications Dose Dose adjustments Comments
Loop diuretics
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.152
Drug Indications Dose Dose adjustments Comments
Thiazides
Indapamide Hydrochlorothiazide Chlorthalidone
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Heart failure & hypertension (Cont.) 9
P.153
Drug Indications Dose Dose adjustments Comments
Aldosterone-antagonists
HF Start 25 mg oral QD CrCl <10 ml/min, anuria or acute Check renal function,
Spironolactone
Others
HF 5-7.5 mg oral BID Caution in elderly Contraindicated if severe
Ivabradine
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Inotropics & vasopressors 9
P.154
Drug Indications Dose Dose adjustments Comments
HF/cardiogenic LD: 6 to 12 μg/kg i.v. Avoid use if CrCl <30 ml/min or Calcium sensitizer and ATP-dependent
Levosimendan
shock over 10 min (given only severe hepatic impairment potassium channel opener
if immediate effect is
needed) followed by
0.05 to 0.2 μg/kg/min
as a continuous infusion
for 24h
HF/cardiogenic 50 μg/kg i.v. in 10-20 min, Renal: Same bolus. Adjust infusion: Phosphodiesterase inhibitor
shock continuous 0.375- CrCl 50 ml/min: start 0.43 μg/kg/min Caution if atrial flutter
Milrinone
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics 9
P.156
Drug Indications Dose Dose adjustments Comments
Group I
AF 15-18 mg/kg i.v. over 60min, followed by Reduce LD to 12 mg/kg in severe renal Hypotension
Procainamide
Pulseless 1-1.5 mg/kg i.v./i.o. bolus (can give 1-2 mg/min infusion if liver disease Contraindicated if advanced
VT/VF additional 0.5-0.75 mg/kg i.v./i.o. push or HF AV block, bradycardia,
every 5-10 min if persistent VT/VF, max hypersensitivity to local
cumulative dose = 3 mg/kg), followed
Lidocaine
anesthetics
by infusion of 1-4 mg/min
Caution in HF, renal
i.v.
Stable VT 1-1.5 mg/kg i.v. bolus (can give additional impairment and elderly
(with a pulse) 0.5-0.75 mg/kg i.v. push every 5-10 min May cause seizures, psychosis
if persistent VT, max cumulative dose
= 3 mg/kg), followed by infusion Stop if QRS widens >50%
of 1-4 mg/min
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics (Cont.) 9
P.157
Drug Indications Dose Dose adjustments Comments
Group I
SVT, 2 mg/kg (max 150 mg) i.v. over 30 min Severe renal impairment: caution Contraindicated if cardiogenic
ventricular This may be followed by an infusion at advised shock, recent MI, 2nd or 3rd
arrhythmias a rate of 1.5 mg/kg/h for 1 h, reduced to degree AV block
Flecainide
PSVT, LD: 0.5-2 mg/kg i.v. direct over May need to reduce dose in renal Contraindicated if unstable
ventricular aminimum of 3-5min or hepatic failure HF, cardiogenic shock,
Propafenone
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics (Cont.) 9
P.158
Dose
Drug Indications Dose Comments
adjustments
Group II
Arrhythmias 2.5 mg i.v. over 2.5 min every 5 min Caution in Contraindicated if cardiogenic shock, bradycardia
Atenolol
(max 10 mg) elderly and/or and greater than first-degree block, unstable HF
i.v.
severe renal
impairment
Arrhythmias 2.5-5 mg i.v. over 5min, Caution if Contraindicated if cardiogenic shock, bradycardia
Metoprolol
may repeat every 5 min severe hepatic and greater than first-degree block, unstable HF
(max 15 mg) impairment
i.v.
Arrhythmias Initially given as slow i.v. boluses of Contraindicated if cardiogenic shock, bradycardia
Propranolol
1 mg, repeated at 2 min intervals and greater than first-degree block, asthma,
(max: 10 mg in conscious patients unstable HF
i.v.
-
and 5 mg if under anesthesia)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics (Cont.) 9
P.159
Dose
Drug Indications Dose Comments
adjustments
Group III
AF (termination) 5 mg/Kg i.v. over 30min, followed Reduce infusion rate if bradycardia, AV block,
by infusion of 1 mg/min for 6h, - hypotension
then 0.5 mg/min
Bolus should be avoided if hypotension or severe
Amiodarone
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics (Cont.) 9
P.160
Dose
Drug Indications Dose Comments
adjustments
Group IV
PSVT; AF (rate control) 0.25 mg/kg i.v. over 2 min Hepatic
Diltiazem
PSVT; AF (rate control) 2.5-5 mg i.v. over 2 min Contraindicated if AF+WPW, tachycardias QRS
(may repeat up to max cumulative (except RVOT-VT), fascicular VT, bronchospasm,
Verapamil
infusion of 2.5-10 mg/h -
Antidote:
- LVD: Calcium gluconate, dobutamine
- Bradycardia/AV block: Atropine, Isoproterenol
Rapid conversion to a Rapid i.v. boluses separated by Contraindicated if sick sinus syndrome, second or
normal sinus rhythm 2 min: 6 mg → 6 mg → 12 mg third degree Atrio-Ventricular (AV) block (except in
Adenosine
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Antiarrhythmics (Cont.) 9
P.161
Dose
Drug Indications Dose Comments
adjustments
Others
VT-Torsades Bolus: 1-2g i.v./i.o. over 5 min Caution if Contraindicated if myasthenia gravis
de Pointes Perfusion: 5-20 mg/min i.v. severe renal
Magnesium
sulfate
failure
Conversion 3 mg/kg i.v. over 10 min Contraindicated if ACS within the last 30 days,
of recent onset AF severe aortic stenosis, SBP <100 mmHg,
Vernakalant
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs 9
P.162
Drug Indications Dose Dose adjustments Comments
Benzodiazepines: Use of benzodiazepines may lead to the development of physical and psychic dependence
upon these products. The risk of dependence increases with dose and duration of treatment. Benzodiazepines
may induce anterograde amnesia. Discontinuation: dosage should be reduced slowly
Short-acting benzodiazepines
Moderate or 250-500mcg oral TID as short as Elderly or debilitating Contraindicated if myasthenia gravis,
severe anxiety possible, increasing if required to a disease: 250mcg BID or TID severe respiratory insufficiency, sleep
Alprazolam
or anxiety total of 3 mg daily and gradually increased apnoea syndrome, severe hepatic
associated with if needed and tolerated insufficiency
depression Renal impairment
or mild-moderate hepatic
impairment: caution
Insomnia 1 mg oral at bedtime. This may Frail, debilitated or elderly: Contraindicated if acute pulmonary
be increased to 1.5 mg or 2 mg if start with half a tablet. Max insufficiency, severe respiratory
Loprazolam
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs 9
P.163
Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Severe anxiety Anxiety: 1-4 mg oral in divided doses Elderly: may respond Contraindicated if acute pulmonary
Premedication Insomnia: 1-2 mg oral before retiring to lower doses insufficiency, respiratory depression,
Lorazepam oral
before surgery Premedication before surgery: 2-3 mg Renal or hepatic sleep apnoea, obsessional states,
oral the night before operation 2-4 mg impairment: lower doses severe hepatic insufficiency,
oral 1-2h before the procedure may be sufficient myasthenia gravis
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.164
Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Short-term 0.5-1.5 mg oral before retiring. The Elderly: may respond to Contraindicated if myasthenia gravis,
Lormetazepam oral
treatment of initial dosage may be increased to lower doses severe respiratory insufficiency, sleep
insomnia 2 mg in individual cases if this proves Chronic respiratory apnoea syndrome, acute intoxication
necessary insufficiency: a lower dose with alcohol, hypnotics, analgesics
is recommended or psychotropic drugs, severe liver
Severe renal impairment: insufficiency
caution
COMMENTS: Caution in adults >60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.165
Drug Indications Dose Dose adjustments Comments
Short-acting benzodiazepines
Short-acting DOSE / DOSE ADJUSTMENTS:
sleep-inducing
drug Indications Adults <60 y Adults ≥60 y/debilitated or chronically ill
Conscious sedation i.v. Initial dose: 2-2.5 mg i.v Initial dose: 0.5-1 mg
Titration doses: 1 mg Titration doses: 0.5-1 mg
Midazolam injection (1)
COMMENTS: Caution in adults >60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.166
Drug Indications Dose Dose adjustments Comments
Short-acting DOSE / DOSE ADJUSTMENTS:
sleep-inducing
drug Indications Adults <60 y Adults ≥60 y/debilitated or chronically ill
Anaesthesia induction i.v. 0.15-0.2 mg/kg i.v. 0.05-0.15 mg/kg
(0.3-0.35 without premedication) (0.15-0.3 without premedication)
Midazolam injection (2)
Sedative component in i.v. Intermittent doses of 0.03-0.1 mg/kg i.v. Lower doses than recommended
combined anaesthesia or continuous infusion of for adults <60 years
0.03-0.1 mg/kg/h
Sedation in ICU i.v. LD: 0.03-0.3 mg/kg in increments of 1-2.5 mg
MD: 0.03-0.2 mg/kg/h
COMMENTS: Caution in adults >60years, chronically ill or debilitated patients, patients with chronic
respiratory insufficiency, patients with chronic renal failure, impaired hepatic function or with impaired
cardiac function - Contraindicated if conscious sedation in patients with severe respiratory failure or
acute respiratory depression - Severe cardiorespiratory adverse events have been reported (respiratory
depression, apnoea, respiratory arrest and/or cardiac arrest). Such life-threatening incidents are
more likely to occur when the injection is given too rapidly or when a high dosage is administered
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.167
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Insomnia, 1.5-3 mg oral up to TID Elderly or hepatic Contraindicated if myasthenia gravis,
Bromazepam
short-term If a severe condition: 6-12 mg oral BID or TID impairment: severe hepatic impairment, severe
treatment lower doses are respiratory insufficiency, sleep apnoea
of anxiety or recommended syndrome
panic attacks
Anxiety, Anxiety: 20-30 mg oral daily in divided doses Elderly: lower doses Contraindicated if history of drug or
adjunctive or as a single dose given at night. Doses up to may be used alcohol dependence, myasthenia gravis,
therapy in 60 mg daily have been used in severe anxiety Chronic or acute severe respiratory insufficiency, sleep
epilepsy apnoea syndrome, severe hepatic
Clobazam
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.168
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Epileptic Oral: Initial dose not to exceed 1 mg/day; MD: Elderly: initial dose Contraindicated if acute pulmonary
disease and 4-8 mg should not exceed insufficiency, severe respiratory
Clonazepam
seizures i.v.: 1 mg by slow injection or slow infusion. 0.5 mg/day insufficiency, sleep apnoea syndrome,
Repeat dose if needed (1-4 mg are usually Chronic pulmonary myasthenia gravis, severe hepatic
sufficient) insufficiency, renal insufficiency, coma or in patients known
or mild-moderate to be abusing pharmaceuticals, drugs or
hepatic impairment: alcohol
may require lower
doses
Anxiety, 5-30 mg oral at bedtime Elderly, renal and Contraindicated if myasthenia gravis,
Clorazepate oral
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.169
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Agitation, Agitation, confusion, aggressiveness: Elderly, renal and Contraindicated if myasthenia gravis,
confusion, 20-200 mg/day, i.m./i.v. followed by oral therapy hepatic impairment: severe decompensated respiratory
Clorazepate
muscle spasm, dose up to 30 mg in divided doses increasing debilitated patients, insufficiency, sleep apnoea, respiratory
symptomatic to a max of 100 mg/day, in divided doses, renal or hepatic depression, phobic and obsessional
relief of adjusted on an individual basis impairment: dosage states, chronic psychosis, severe hepatic
acute alcohol Insomnia associated with anxiety: 10-30 mg should not exceed impairment, myasthenia gravis
withdrawal oral at bedtime half the adult dose
Muscle spasm: 10-30 mg/day oral in divided doses
Alcohol withdrawal: 25-100 mg, repeated
if necessary, in 2-4h
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.170
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Anxiety 5-30 mg oral daily in divided doses Elderly and Contraindicated if phobic or
or debilitated obsessional states; chronic
10 mg i.v. or i.m. and repeated after an interval patients: half of the psychosis, hyperkinesis, acute
of not less than 4h recommended dose pulmonary insufficiency;
respiratory depression, acute
Diazepam (1)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.171
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Muscle spasm 5-15 mg oral daily in divided doses or Elderly and Contraindicated if phobic or
10 mg i.v. or i.m. and repeated after after an debilitated obsessional states; chronic
interval of not less than 4h patients: half of the psychosis, hyperkinesis, acute
Diazepam (2)
0.5 mg/Kg rectal. Dose can be repeated every recommended dose pulmonary insufficiency;
4-12h. Max 30 mg respiratory depression, acute
Hepatic impairment or chronic severe respiratory
Tetanus 0.1-0.3 mg/Kg i.v. and repeated every 1-4h; and severe renal insufficiency, myasthenia gravis,
alternatively, a continuous infusion of 3-10 mg/ impairment: sleep apnoea, severe hepatic
kg/24h may be used. a lower dose is impairment, acute porphyria
0.5 mg/kg rectal. Dose can be repeated every recommended
4-12h. Max 30 mg
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.172
Dose
Drug Indications Dose Comments
adjustments
Long-acting benzodiazepines
Epilepsy 2-60 mg oral daily in divided doses Elderly and Contraindicated if phobic or
or debilitated obsessional states; chronic
10-20 mg i.v.or i.m. The dose can be repeated if patients: half of the psychosis, hyperkinesis, acute
necessary after 30-60min. If indicated, this may recommended dose pulmonary insufficiency;
be followed by slow i.v. infusion (max total dose respiratory depression, acute
3 mg/kg over 24h) Hepatic impairment or chronic severe respiratory
Diazepam (3)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.173
Drug Indications Dose Dose adjustments Comments
Long-acting benzodiazepines
Insomnia 15 mg oral at bedtime. Elderly, chronic pulmonary Contraindicated if myasthenia
Flurazepam
Other sedatives
Management of 192 mg (1 capsule) oral TID Elderly, renal impairment, gross Contraindicated if acute
Clomethiazole (1)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.174
Drug Indications Dose Dose adjustments Comments
Other sedatives
INDICATIONS: Alcohol withdrawal Elderly, renal impairment, gross Contraindicated if acute
Clomethiazole (2)
INITIAL DOSE : 2-4 capsules oral, if necessary repeated after some hours liver damage, decreased liver pulmonary insufficiency
function, sleep apnoea and Alcohol combined with
Day 1: first 24h: 9-12 capsules, Days 4-6: A gradual chronic pulmonary insufficiency: clomethiazole particularly
divided into 3 or 4 doses reduction in dosage until the caution in alcoholics with cirrhosis
Day 2: 6-8 capsules, final dose can lead to fatal respiratory
divided into 3 or 4 doses depression even with short
Administration for more than term use
Day 3: 4-6 capsules,
divided into 3 or 4 doses 9 days is not recommended
Sedation of adult ICU Switch to dexmedetomidine: initial i.v. Caution if hepatic impairment, The drug provides analgesia
Dexmedetomidine
patients infusion rate of 0.7 mcg/kg/h impaired peripheral autonomic and does not cause respiratory
Titrate upwards to achieve desired activity, pre-existing depression. Associated with a
level of sedation, bradycardia lower prevalence of ICU delirium
range 0.2-1.4 mcg/kg/h Frail patients: a lower starting compared to benzodiazepines.
Max dose: 1.4 mcg/kg/h infusion rate should be Primary adverse effects are
Max duration: 14 days considered dose-related bradycardia and
hypotension.
Dexmedetomidine should not
be administered by loading
or bolus dose
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.175
Drug Indications Dose Dose adjustments Comments
Other sedatives
Insomnia 12.5-25 mg oral at bedtime Renal and hepatic impairment: Contraindicated if hypersensitive
Doxylamine
Sedation during Initiate at 5 mcg/Kg/min i.v. Elderly: rate of infusion should Rapid onset (1-2 min) and short
intensive care (0.3 mcg/Kg/h) and titrate to achieve be reduced. Rapid bolus duration (3-5 min or longer if
sedation goals by 5 mcg/Kg/min administration is not indicated prolonged infusion)
Propofol
Other sedatives
Insomnia 10 mg oral at bedtime Elderly, debilitated patients, Contraindicated if obstructive
Zolpidem
Max duration: 4 weeks hepatic impairment: initial dose sleep apnoea, myasthenia
5 mg gravis, severe hepatic
insufficiency, acute and/or
severe respiratory depression
Insomnia 7.5 mg oral at bedtime Elderly, hepatic or renal Contraindicated if myasthenia
Zopiclone
Max duration: 4 weeks impairment: initial dose 3.75 mg gravis, severe sleep apnoea
syndrome, severe respiratory
or severe hepatic insufficiency
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.177
Dose
Drug Indications Dose Comments
adjustments
Neuroleptics: Extrapyramidal symptoms and neuroleptic malignant syndrome may occur with all neuroleptics.
Elderly people with dementia who are treated with antipsychotics are at a small increased risk of death
compared with those who are not treated
Typical neuroleptics
Schizophrenia and Oral: Initially 25 mg TID or 75 mg at Elderly Contraindicated if liver or renal dysfunction,
other psychoses bedtime increasing by daily amounts of (schizophrenia, epilepsy, Parkinson, hypothyroidism, cardiac
25 mg to an effective MD (75-300 mg nausea and failure, phaeochromocytoma, agranulocytosis
daily, some patients may require up to 1g) vomiting): start myasthenia gravis, prostate hypertrophy,
Chlorpromazine
I.M.: 25-50 mg every 6-8h with ⅓ - ½ usual history of narrow angle glaucoma
adult dose Caution in patients with risk factor for stroke,
Intractable hiccup Oral: 25-50 mg TID or QD seizures, cardiovascular disease or a family
I.M.: 25-50 mg and if this fails 25-50 mg history of QT prolongation
by slow i.v. infusion
Nausea and Oral: 10-25 mg every 4-6h
vomiting in terminal I.M.: 25 mg initially then 25-50 mg every
illness 3-4h until vomiting stops, then change
to orally
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.178
Dose
Drug Indications Dose Comments
adjustments
Typical neuroleptics
Schizophrenia and Patients without previous exposure of Elderly Contraindicated if comatose states, marked
other psychoses fluphenazine: start 12.5 mg i.m (over 60): cerebral atherosclerosis, liver failure, renal
Fluphenazine
Next dose depends on patient’s response a lower dose is failure, phaeochromocytoma, severe cardiac
(12.5-100 mg) recommended insufficiency, severely depressed states,
When administered as maintenance Liver and renal existing blood dyscrasias
therapy, a single injection may be disease: caution Caution if arrythmias, Parkinson, narrow angle
effective for up to 4weeks or longer glaucoma, thyrotoxicosis, hypothyroidism,
epilepsy, myasthenia gravis, prostatic
hypertrophy, severe respiratory disease
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
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Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Schizophrenia, psychoses Acute phase: 2-20 mg/day oral as DOSE ADJUSTMENTS:
and mania a single dose or in divided doses Elderly: start with half the dosage stated for adults
Chronic phase: 1-3 mg oral TID, and adjusted according to the results if necessary
may be increased up to 20 mg/day
in divided doses, depending on the COMMENTS: Contraindicated if comatose states,
Haloperidol oral (1)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
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Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Gilles de la Tourette Starting dose 1.5 mg oral TID DOSE ADJUSTMENTS:
Haloperidol
syndrome, severe tics, adjusted according to response Elderly: start with half the dosage stated for adults
oral (2)
intractable hiccup A daily MD of 10 mg may be and adjusted according to the results if necessary
required in Gilles de la Tourette
syndrome
COMMENTS: Contraindicated if comatose states,
Max daily dose: 20 mg
CNS depression, Parkinson, lesions of the basal ganglia,
clinical significant cardiac disorders, QT interval prolongation,
Rapid control of the Initial doses of 2-10 mg i.m. history of ventricular arrhythmia or Torsades de pointes,
symptoms of hostility,
Haloperidol injection
Depending on the response of the clinically significant bradycardia, 2nd or 3rd degree heart block,
aggression, hyperactivity, patients, subsequent doses may uncorrected hypokalaemia and use of other QT prolonging drugs
disruptive and violent be given every 4-8h up to a max of
behaviour, confusion, Caution if renal failure, liver disease, epilepsy, hyperthyroidism,
18 mg/day
emotional withdrawal, phaeochromocytoma
hallucinations and delusions Bioavailability from the oral route is about 60% of that from
associated with acute and the i.m. route and readjustment of dose may be required
chronic schizophrenia,
mania, and hypomania, and
i.v. haloperidol can be associated with QT prolongation and
organic brain syndrome
torsades de pointes
Nausea and vomiting
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
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Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Management of pain, 12.5-25 mg i.m. or i.v. injection. In Elderly: caution Caution if liver dysfunction
restlessness or cases of severe agitation, up to 50 mg or cardiac disease, bradycardia
Levomepromazine
distress in terminally may be used, repeated every 6-8h or 2nd or 3rd degree heart block,
ill patient or risk of QT interval prolongation
25-200 mg/day by continuos s.c. infusion
or
12.5-50 mg oral every 4-8h
Psychiatric Bed patients: initially the total
conditions daily dose 100-200 mg oral, usually
divided into 3 doses, gradually
increased to 1g daily if necessary
Typical neuroleptics
Anxiety, psichiatric DOSE: 4 mg oral TID. Titrate according to DOSE ADJUSTMENTS:
conditions, nausea and patient response. Max daily dose: 24 mg Elderly: one quarter or one half of the recommended adult dosage
Perphenazine
vomiting, intractable
hiccup
COMMENTS: Contraindicated if leucopenia, or in association with drugs liable to cause bone marrow
depression, or to patients in comatose states - Caution if liver disease, severe respiratory disease,
renal failure, epilepsy, Parkinson, history of narrow angle glaucoma, hypothyroidism, myasthenia gravis,
phaeochromocytoma, prostatic hypertrophy, risk of QT interval prolongation
response and tolerance
COMMENTS: Contraindicated if risk of QT interval prolongation,
known uncorrected hypokalaemia, hypomagnesaemia, clinically
Other psychoses: an initial dose
significant cardiac disorders, clinically significant bradycardia,
of 4 mg oral daily which may then
severe central nervous system depression, depression,
be gradually increased, if necessary,
Parkinson, concomitant use with CYP3A4 or CYP2D6 inhibiting
according to response, max 16 mg
drugs, serotonin uptake inhibitors
daily
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.183
Drug Indications Dose Dose adjustments Comments
Typical neuroleptics
Anxiety, depressive Low dosage: 2-4 mg/day oral, given DOSE ADJUSTMENTS:
Trifluoperazine
symptoms, agitation, in divided doses, according to the Elderly: starting dose should be reduced by at least half
nausea and vomiting severity of the patient’s condition
High dosage: 5 mg oral BID, after a
week this may be increased to 15 mg/ COMMENTS: Contraindicated if comatose patients, existing
day. If necessary, further increases blood dyscrasias or known liver damage, uncontrolled cardiac
of 5 mg may be made at three-day decompensation
intervals Caution if CV disease , Parkinson, risk of QT interval prolongation
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.184
Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics: 3 differences with typical neuroleptics: the risk of extrapyramidal symptoms is lower,
tardive dyskinesia is reduced and the ability to block serotonin-2 receptors is present. Atypical neuroleptics
have been associated with new-onset diabetes and metabolic syndrome
Schizophrenia For acute psychotic episodes: Elderly: caution Contraindicated if concomitant
Amisulpride
episodes The dose can be increased to 10 mg BID impairment: caution prolongation, seizures
associated with based on individual clinical response Do not use in severe hepatic
bipolar type I and tolerability impairment or CrCl <15ml/min
disorder Do not chew or swallow tablets
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.185
Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Schizophrenia, Oral: 10-15 mg QD with a MD Caution if elderly, severe Orodispersible tablet should be placed
manic episodes of 10-30 mg QD hepatic impairment in the mouth, it will rapidly disperse
in saliva
Aripiprazole
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.186
Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Schizophrenia, 6 mg oral QD, administered in the Caution if elderly patients Caution if severe hepatic impairment,
schizoaffective morning. Some patients may benefit with dementia with risk seizures, Parkinson, risk of QT interval
disorder from lower or higher doses within the factors for stroke prolongation, low leukocyte and/
recommended range of 3-12 mg QD Mild renal impairment: or neutrophil counts for any reason,
Paliperidone
(6-12 mg for schizoaffective disorder) initial dose 3 mg QD known CV disease, cerebrovascular
(max 6 mg) disease or conditions that predispose
Moderate-severe renal the patient to hypotension
impairment: Do not chew, divide, or crush
initial dose 1.5 mg QD Take it the same way with regard
(max 3 mg) to meals
CrCl <10 ml/min:
not recommended
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.187
Dose
Drug Indications Dose Comments
adjustments
Atypical neuroleptics
Schizophrenia IRF: Total daily dose for the first 4 days is: 50 mg (Day 1), 100 mg DOSE ADJUSTMENTS:
(Day 2), 200 mg (Day 3) and 300 mg (Day 4), then 150-750 mg/day Elderly, hepatic impairment: caution,
Administered in 2 divided doses a lower dose may be necessary
PRF: Starting dose 300 mg oral on Day 1 and 600 mg on Day 2
MD: 400-800 mg/day
COMMENTS: Contraindicated if
Moderate-severe IRF: Total daily dose for the first 4 days is: 100 mg (Day 1), 200 mg concomitant administration of
manic episodes (Day 2), 300 mg (Day 3) and 400 mg (Day 4) cytochrome P450 3A4 inhibitors,
in bipolar Further dosage adjustments up to 800 mg/day
such as HIV-protease inhibitors, azole-
Quetiapine
Atypical neuroleptics
Schizophrenia Start 2 mg/day oral (QD or in 2 divided doses) Elderly: 0.5 mg BID Caution if known
The dosage may be increased on the 2nd day to 4 mg Caution if renal or cardiovascular disease,
MD: 4-6 mg hepatic impairment low leukocyte and/or
neutrophil counts for any
Manic episodes Start with 2 mg oral QD Elderly: start with reason, Parkinson, risk of
in bipolar disorder Dosage adjustments, if needed, should occur 0.5 mg BID QT interval prolongation
Risperidone (1)
at intervals of not less than 24h and in dosage This dosage can be Orodispersable tablet:
increments of 1 mg/day. Max daily dose 6 mg individually adjusted place the tablet on the
with 0.5 mg BID tongue
increments to
1-2 mg BID
Caution if renal
or hepatic impairment
Persistent aggression in Start with 0.25 mg oral BID Caution if renal
patients with moderate This dosage can be individually adjusted by or hepatic impairment
to severe Alzheimer’s increments of 0.25 mg BID, not more frequently
dementia than every other day, if needed. Optimum dose is
0.5 mg BID for most patients
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.189
Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Conduct disorder ≥50kg: starting dose 0.5 mg oral QD Caution if renal or Caution if known
Risperidone (2)
DISCLAIMER: The guidance suggested in this document does not override the individual responsibility of the healthcare professional
to make appropriate decisions according to each patient’s circumstances and profile, as well as local regulations and licenses.
Sedatives and neuropsychiatric drugs (Cont.) 9
P.190
Drug Indications Dose Dose adjustments Comments
Atypical neuroleptics
Behavioral disorders Starting dose 50 mg oral/i.m./i.v. Elderly: caution Contraindicated if phaeochromocytoma,
in dementia patients BID, increasing if necessary concomitant prolactin-dependent
to 100 mg TID CrCl 30-60 ml/min: tumours, association with levodopa
Tiapride
ACCA, the worldwide reference for all professionals in Acute Cardiovascular Care
www.escardio.org/ACCA-membership
Habib G, et al. 2015 ESC Guidelines for the management of infective endocarditis.
European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv319.
Priori, SG, et al. 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the
prevention of sudden cardiac death.
European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv316 .
Adler Y, et al. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases.
European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv318 .
Roffi M, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation.
European Heart Journal Aug 2015, DOI: 10.1093/eurheartj/ehv320 .
Erbel R, et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.
European Heart Journal Aug 2014, DOI: 10.1093/eurheartj/ehu281 .
Konstantinides SV, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism.
European Heart Journal Nov 2014, 35 (43) 3033-3073; DOI: 10.1093/eurheartj/ehu283.
Lip GYH, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute
coronary syndrome and/or undergoing percutaneous coronary or valve interventions: a joint consensus
document of the European Society of Cardiology Working Group on Thrombosis, European Heart Rhythm
Association (EHRA), European Association of Percutaneous Cardiovascular Interventions (EAPCI)
and European Association of Acute Cardiac Care (ACCA) endorsed by the Heart Rhythm Society (HRS)
and Asia-Pacific Heart Rhythm Society (APHRS).
European Heart Journal Dec 2014, 35 (45) 3155-3179; DOI: 10.1093/eurheartj/ehu298.
References and copyright acknowledgments (Cont.)
P.199
Windecker S, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization.
European Heart Journal Oct 2014, 35 (37) 2541-2619; DOI: 10.1093/eurheartj/ehu278.
Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of
knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the
European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.
European Heart Journal (2013); July 3. DOI: 10.1093/eurheartj/eht210.
McMurray JJ, Adamopoulos S, Anker SD, Auricchio A, Böhm M, Dickstein K et al. ESC Guidelines for the
diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and
Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology.
Developed in collaboration with the Heart Failure Association (HFA) of the ESC.
European Heart Journal (2012) DOI: 10.1093/eurheartj/ehs104.
Steg G, James SK Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC Guidelines for the
management of acute myocardial infarction in patients presenting with ST-segment elevation.
European Heart Journal (2012); DOI: 10.1093/eurheartj/ehs215.
Steg PG, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with
ST-segment elevation. European Heart Journal Oct 2012, 33 (20) 2569-2619; DOI: 10.1093/eurheartj/ehs215.
Moya A, Sutton R, Ammirati F, Blanc JJ, Brignole M, Dahm JB, et al. ESC Guidelines for the diagnosis
and management of syncope. European Heart Journal (2009); DOI:10.1093/eurheartj/ehp298.
Ibañez B, et al. 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 (ESC), European Heart Journal (2017) 00, 1–66 doi:10.1093/eurheartj/ehx393.
References and copyright acknowledgments (Cont.)
P.200
M Valgimigli et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease
developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery
disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic
Surgery (EACTS).
European Heart Journal (2018) 39, 3, 213–260.
DOI:10.1093/eurheartj/ehx419.
Halvorsen et Al. Management of antithrombotic therapy after bleeding in patients with coronary artery
disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working
Group on Thrombosis.
Eur Heart J. 2017 May 14; 38(19):1455-1462. doi: 10.1093/eurheartj/ehw454.
Reproduced with permission from John Wiley & Sons © European Society of Cardiology
Mebazaa A et al. Eur J Heart Fail. (2015); Recommendations on pre-hospital and early hospital
management of acute heart failure.
DOI:10.1093/eurheartj/ehv066.
Disclaimer and Copyrights
This is a publication of the Acute Cardiovascular Care Association (ACCA), a branch of the
European Society of Cardiology. Its content reflects the opinion of the authors based on the
evidence available at the time it was written and does not necessarily imply an endorsement
by ACCA or the ESC.
The guidance suggested in the Clinical Decision Making Toolkit does not override the
individual responsibility of the healthcare professional to make appropriate decisions
according to each patient’s circumstances and profile, as well as local regulations
and licenses.
Some content, illustrations/tables/figures were inspired and/or adapted from ESC Guidelines
and other existing sources, with permission granted by the original publishers.
Acknowledgements
We are indebted to all the authors for their commitment and for the strong effort to
synthesise their wide scientific knowledge and clinical experience into simple algorithms
and schemes using the aim to help clinicians in everyday clinical practice in the easiest
possible manner as the main driver of their work.
The support of this initiative by the ACCA board members was essential to launch this
initiative as was the hard work of the ESC staff to make this project move forward.
January 2018
Clinical Decision Making TOOLKIT
European Society of Cardiology
Acute Cardiovascular Care Association (ACCA)
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