Professional Documents
Culture Documents
Clinical Decision-Making: Acute Cardiovascular Care Association
Clinical Decision-Making: Acute Cardiovascular Care Association
Clinical Decision-Making
TOOLKIT
Acute Cardiovascular Care Association
Acute
Cardiovascular
www.escardio.org/ACCA Care Association
A Registered Branch of the ESC
The ACCA Clinical Decision-Making Toolkit is produced by the Acute
Cardiovascular Care Association. Developed and distributed through
an educational grant from AstraZeneca and Novartis Pharma AG.
AstraZeneca and Novartis Pharma AG were not involved in the
development of this publication and in no way influenced its contents.
The Acute Cardiovascular Care Association I
Clinical Decision-Making p.I
TOOLKIT
Héctor Bueno, M.D., PhD., FESC, FAHA
Editor in Chief
Acute
Cardiovascular
Care Association
A Registered Branch of the ESC
ISBN: 978-0-19-968703-9
Preface II
The best care of patients with acute cardiovascular syndromes relies not only on specialists but also on p.II
systems of care that involve many non-cardiologists. Several of these syndromes require immediate diagnosis
and decisions on treatment, some of them life-saving. Critical decisions must often be made quickly by professionals with
different backgrounds and levels of expertise with limited resources. This poses a significant clinical challenge.
Against this background, the ACCA Clinical Decision-Making Toolkit was created as a comprehensive resource
encompassing all aspects of acute cardiovascular care but structured as an easy-to-use instrument in environments
where initial acute cardiovascular care is typically initiated. 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.
The Second Edition of the ACCA Toolkit has been updated with the 2014 and 2015 ESC Guidelines, and enriched with
a new chapter with up-to-date coverage of drugs most frequently used in acute cardiovascular care. However, it does
not replace textbooks and other sources of information that need to be consulted to reach an optimal management of
these patients.
1. Presentation
2. ECG
3. Troponin
Other
4. Diagnosis Noncardiac UA NSTEMI STEMI
Cardiac
STEMI = ST-elevation myocardial infarction; NSTEMI = non-ST-elevation myocardial infarction; UA = unstable angina.
Reference: Roffi et Al. Eur Heart J 2015;eurheartj.ehv320
Factors to be considered in the evaluation
1.1
after the first call for chest pain
p.3
Resuscitation, hemodynamic
or respiratory support ECG <10 min → ACS ?
(see chapters 3 & 4)
Other CVD
Yes No
or No ACS
STEMI,
Resuscitation, hemodynamic NSTEACS with persistent pain,
or respiratory support Hemodynamic distress
(See chapters 3 & 4)
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 3.1) 1.2
DYSPNEA: ACUTE HEART FAILURE (see chapter 3.1) p.10
BASIC WORK-UP
• Immediate 12-lead ECG, cardiac monitor, BP, respiratory • Chest X-ray (lung ultrasound)
rate, pulse oximetry • Echocardiogram
• Clinical findings During admission (earlier if decompensated aortic
Most commonly: lower extremity edema, jugular venous distension, stenosis or endocarditis are suspected)
rales; work up for underlying cardiac disease and triggers • Coronary angiography
• Laboratory findings Emergent in patients with ACS; delayed in patients
Complete blood count, chemistries, cardiac enzymes, BNP, TSH, with suspected coronary artery disease
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 6.2)
DYSPNEA: ACUTE PULMONARY EMBOLISM (see chapter 6.2) 1.2
Priorities: 1. Vital signs 2. Diagnostic screening dependent upon clinical stratification p.12
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:
DYSPNEA: COPD
COPD exacerbation
EXACERBATION 1.2
• Verify diagnosis (DD: PE, acute heart failure, pneumothorax) p.14
• 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 outpatient antibiotic • Evaluate ICU criteria
treatment) • NIV indicated?
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
1.3
with transient loss of conscioussness (TLOC)
Syncope is a transient loss of consciousness due to global cerebral hypoperfusion (usually, itself due to a period p.16
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
Outpatient SMU
Hospital admission for diagnosis, treatment
Inpatient SMU and follow-up 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)
1.3
1.0
Diagnostic criteria with provocation maneuvers
p.19
ECG
Work-up
NSTEMI Unstable Angina differential diagnoses
Reference: Roffi M. Eur Heart J 2015;eurheartj.ehv320
ACUTE CORONARY SYNDROMES: Diagnosis (2)
2.1
0-1 H Rule-in & rule out test for NSTEMI
p.25
Suspected NSTEMI
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.
• NSTEMI can be ruled-out at presentation, if hs-cTn concentration is very low
• NSTEMI can be ruled out by the combination of low baseline levels and the lack of a relevant increase within 1 h
• NSTEMI is highly likely if initial hs-cTn concentration is at least moderately elevated or hs-cTn concentrations show
a clear rise within the first hour
Reference: Roffi M. Eur Heart J 2015;eurheartj.ehv320
ACUTE CORONARY SYNDROMES: Differential diagnosis (1)
2.1
Causes of chest pain Causes of troponin elevation
p.26
Not related to ACS Not related to acs
Primary cardiovascular Primary cardiovascular
• Acute pericarditis, pericardial effusion • Acute myo(peri)carditis
• Acute myocarditis • Severe hypertensive crisis
• Severe hypertensive crisis • Pulmonary edema or severe congestive heart failure
• Stress cardiomyopathy (Tako-Tsubo syndrome) • Stress cardiomyopathy (Tako-Tsubo syndrome)
• Hypertrophic cardiomyopathy, aortic stenosis • Post- tachy- or bradyarrhythmias
• Severe acute heart failure • Cardiac contusion or cardiac procedures (ablation, cardioversion, or
• Acute aortic syndrome (dissection, hematoma) endomyocardial biopsy)
• Pulmonary embolism, pulmonary infarction • Aortic dissection, aortic valve disease or hypertrophic cardiomyopathy
• Cardiac contusion • Pulmonary embolism, severe pulmonary hypertension
Primary non-cardiovascular Primary non-cardiovascular
• Oesophageal spasm, oesophagitis, Gastro • Renal dysfunction (acute or chronic)
Esophageal Reflux (GER) • Critical illness (sepsis, repiratory failure…)
• Peptic ulcer disease, cholecystitis, pancreatitis • Acute neurological damage (i.e. stroke, subarachnoid hemorrhage)
• Pneumonia, bronchitis, asthma attack • Severe burns (affecting >30% of body surface area)
• Pleuritis, pleural effusion, pneumothorax • Rhabdomyolysis
• Pulmonary embolism, severe pulmonary • Drug toxicity (chemotherapy with adriamycin, 5-fluorouracil,
hypertension herceptin, snake venoms…)
• Thoracic trauma • Inflammatory or degenerative muscle diseases
• Costochondritis, rib fracture • Hypothyroidism
• Cervical / thoracic vertebral or discal damage • Infiltrative diseases (amyloidosis, hemochromatosis, sarcoidosis)
• Herpes Zoster • Scleroderma
ACUTE CORONARY SYNDROMES: Differential diagnosis (2)
2.1
Causes of repolarisation abnormalities in the ECG not related to ACS
p.27
ST-segment elevation Negative T waves
Fixed • Normal variants, i.e. women (right
• LV aneurysm precordial leads), children, teenagers
• LBBB, WPW, hypertrophic cardiomyopathy, LVH • Evolutive changes post myocardial
• Pacemaker stimulation infarction
• Early repolarisation (elevated J-point) • Chronic ischemic heart disease
Dynamic • Acute (myo)pericarditis, cardiomyopathies
• Acute (myo)pericarditis • BBB, LVH,WPW
• Pulmonary embolism • Post-tachycardia or pacemaker stimulation
• Electrolyte disturbances (hyperkalemia) • Metabolic or ionic disturbances
• Acute brain damage (stroke, subarachnoid haemorrhage)
• Tako Tsubo syndrome
ST-segment depression Prominent T waves
Fixed • Normal variants, i.e. early repolarisation
• Abnormal QRS (LBBB, WPW, pacemaker stimulation…) • Metabolic or ionic disturbances
• LVH, hypertrophic cardiomyopathy (i.e. hyperkalemia)
• Chronic ischemic heart disease • Acute neurological damage
Dynamic (stroke, subarachnoid haemorrhage)
• Acute (myo)pericarditis • Severe hypertensive crisis
• Acute pulmonary hypertension • Drug effects (digoxin)
• Electrolyte disturbances (hyperkalemia) • Shock, pancreatitis
• Intermitent LBBB, WPW, pacing • Hyperventilation
• Post-tachycardia / cardioversion • Tako Tsubo syndrome
GENERALGeneral approach
APPROACH to the
TO THE patient with
PATIENT WITHchest pain/suspected
CHEST ACS
PAIN / SUSPECTED ACS 2.1
1 2 3 4 5
Clinical ECG Diagnosis / Medical Invasive p.28
Evaluation (<10 min) Risk assessment Treatment Strategy
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)
2.2
General overview
p.31
Initial treatment*
• Nitrates Pharmacological Myocardial
• Morphine treatment* revascularisation
• Oxygen (if SatO2 < 95%)
Anticoagulation Antiplatelets
One of the following: Aspirin + one of:
• Fondaparinux • Ticagrelor
• Enoxaparin • Prasugrel
• UFH • Clopidogrel
• Bivalirudin Optionally: For more information on individual drug doses
• GP IIb/IIIa inhibitors and indications, See chapter 8: Use of drugs in
• Cangrelor Acute Cardiovascular Care.
NON ST-SEGMENT ELEVATION ACS: Treatment (2)
2.2
Antithrombotic strategies in patients with NSTE-ACS and non-valvular atrial fibrillation
p.32
NSTE-ACS patients with non-valvular atrial fibrillation
0 a
Dual therapy with oral anticoagulation and clopidogrel may
Triple or dual
Triple therapy a be considered in selected patients (low ischaemic risk).
therapy
Time from PCI/ACS
O A C
4 weeks Dual b
A spirin as an alternative to clopidogrel may be considered
therapy b
O A C in patients on dual therapy (i.e., oral anticoagulation plus
Dual single antiplatelet); triple therapy may be considered up to
6 months therapy b 12 months in patients at very high risk for ischaemic events.
Dual O C or A
therapy b O C or A c
Dual therapy with oral anticoagulation and one antiplatelet
agent (aspirin or clopidogrel) beyond one year may be
O C or A considered in patients at very high risk of coronary events.
12 months
d
In patients undergoing coronary stenting, dual antiplatelet
Lifelong therapy may be an alternative to triple or a combination
O Monotherapy c
of anticoagulants and single antiplatelet therapy if the
CHA2DS2-VASc score is 1 (males) or 2 (females).
O Oral anticoagulation (VKA or NOACs) A Aspirin 75–100 mg daily C Clopidogrel 75 mg daily
Very high
Immediate transfer to PCI center Very high
Same-day transfer
Risk stratification
High High
Transfer
Intermediate Intermediate
Transfer
optional
Low Low
Therapeutic
strategy
Immediately
Immediate transfer
No to PCI center
Immediate
Successful fibrinolysis?
fibrinolysis
Yes
Preferably 3–24 h
Coronary angiography
a
The time point the diagnosis is confirmed with patient history and ECG ideally
Reference: Steg G et al. Eur Heart J. (2012);33:2569-619 (6). within 10 min from First Medical Contact (FMC). All delays are related to FMC.
STEMI: Treatment (2)
2.3
Primary PCI - First 24 hours and days 2-7
p.37
For more information on individual drug doses and indications, See chapter 8: Use of drugs in
Acute Cardiovascular Care.
Pre hospital PCI CCU/ICCU Medication
Titration Day 2-7
Acetylicsalisylic Acid 300 mg Bivalirudin Acetylicsalisylic Acid 75 mg x 1
Heparin 70 IU/kg or GPI: Eptifibatide Ticagrelor 90 mg x 2
Tirofiban or Prasugrel 10/5 mg x 1
Ticagrelor 180 mg Abxicimab or Clopidogrel 75 mg x 1
or Prasugrel 60 mg Follow local in-lab instruction / dosing
or Clopidogrel 600 mg Metoprolol 200mg x 1
or carvedilol 25 mg x 2
Metoprolol 25 mg x 2 or bisoprolol 5 mg x 2
or carvedilol 3,25 mg x 2 or Ca-antagonist (see chapter 2.2)
or bisoprolol 2,5 mg x 2
Start ACE-i or ARB in DM, LVSD, CHF, or to control BP
Atorvastatin 80 mg x 1 Aldosterone RB
or Rosuvastatin 40 mg x 1 Start or continue anti-diabetic medication
No
Yes 60-80%
Intermediate to high
likelihood of
Rapid onset of, History of acute heart failure*
or worsening heart failure
of symptoms No 20-40%
and signs Yes
of heart failure*
No Intermediate likelihood
of acute heart failure*
No
Yes
RESUSCITATION AREA/CCU/ICU
To stabilize vital signs (echo if needed) and/or
immediate non-invasive ventilation
No
(see chapter 3.1 page 44)
INITIAL 30-60 MIN
Algorithm for the management of acute heart failure. Depicted from Mebazaa A et al. Eur J Heart Fail. (2015);17(6):544-58.
Acute heart failure: Initial diagnosis and treatment
3.1
Airway
ACUTE HEART FAILURE: (A) & Breathing
INITIAL DIAGNOSIS(B) AND TREATMENT
AIRWAY (A) & BREATHING (B) p.44
No
AB Sufficient oxygenation OXYGEN* (+ oropharyngeal airway [Guedel/Mayo]/
(SpO2>90%) nasopharyngeal airway and upright position)
Nasal: 1 ltr = FiO2 22%, 2 ltr = 25%, 3 ltr = 27%, 4 ltr = 30%, 5 ltr = 35%
Mask: 2 ltr = FiO2 25%, 4 ltr = 30%, 6 ltr = 40%, 7 ltr = 45%, >8 ltr = 50%
Mask + reservoir: 6 ltr = FiO2 60%, 7 ltr = 70%, 8 ltr = 80%, 10 ltr = 90%
Venturimask**: 24% = FiO2 24%, 35% = 35%, 40% = 40%, 60% = 50%
Yes
Sufficient oxygenation (SpO2>90%)
No
No
3.1
Sufficient oxygenation (SpO2>90%) p.45
Yes
No
References: Mebazaa A et al. Intensive Care Med. (2015) Sep 14. [Epub ahead of print]; Mueller C et al. Eur Heart J Acute Cardiovasc Care. (2015) Jun 29.
ACUTE HEART FAILURE: INITIAL TREATMENT (C) CLINICAL SCENARIOS*
Yes No
C: Volume overload, SBP>110 mmHg?
No
Low cardiac output Yes
<10% >60%
* Use higher dose in patients on chonic diuretic treatment for HF (i.e. 2.5 times normal dose).
MANAGEMENT OF ACUTE HEART FAILURE 3.1
p.48
DIAGNOSTIC TESTS
OBSERVATION UP TO 120 MIN
REASSESSMENT
Clinical, biological and phychosocial parameters
by trained nurses
3.1
p.49
ADMISSION/DISCHARGE
Discharge home
Algorithm for the management of acute heart failure. Depicted from Mebazaa A et al.
Eur J Heart Fail. (2015);17(6):544-58
ACUTE HEART FAILURE: Treatment (C) and preventive measures 3.1
Management of oral therapy in AHF in the first 48 hours p.50
ACE-I/ARB Review/increase Reduce/ Stop No change No change Review/ Stop Review Stop
stop increase
Beta-blocker No change Reduce/ Stop Reduce Stop No change No change No change No change
stop
MRA No change No change Stop No change No change Review/ Stop Reduce Stop
increase
Diuretics Increase Reduce Stop No change No change Review/ Review/ No change Review
No change increase
CCB, calcium channel blockers (mg/dL); Cr, creatinine blood level (mg/dL); eGFR, estimated glomerular filtration rate ml/min/1.73 m2; MRA, mineralocorticoid receptor antagonist;
(*) amiodarone. - Depicted from Mebazaa A et al. Eur J Heart Fail. (2015);17(6):544-58.
ACUTE HEART FAILURE: Treatment (C) and preventive measures (Cont.) 3.1
Management of oral therapy in AHF in the first 48 hours p.51
Other heart Review Reduce/ Stop Reduce/ Stop Review/ No change No change No change
rate slowing stop stop stop (*)
drugs
(amiodarone,
CCB,
Ivabradine)
Thrombosis prophylaxis should be started in patients not anticoagulated (enoxaparin 1 mg/kg as first dose)
Maintain an adequate nutritional status with a nutritional support of 20-25 kcal/kg/day within the first 48 hours
CCB, calcium channel blockers (mg/dL); Cr, creatinine blood level (mg/dL); eGFR, estimated glomerular filtration rate ml/min/1.73 m2; MRA, mineralocorticoid receptor antagonist;
(*) amiodarone. - Depicted from Mebazaa A et al. Eur J Heart Fail. (2015);17(6):544-58.
Cardiogenic shock: Definition 3.2
p.52
Clinical condition defined as the inability of the heart to deliver an adequate amount of blood to the
tissues to meet resting metabolic demands as a result of impairment of its pumping function.
• Systolic blood pressure <80 to 90 mmHg or mean arterial pressure 30 mmHg lower than baseline
of measuring central venous oxygen over a 30-minute period to achieve a central venous pressure of 8 to 12 mmHg or
saturation until perfusion improves (with a maximum of 500 ml)
• CONSIDER NIVmechanical ventilation for comfort (fatigue, distress) or as needed:
• Standard transthoracic echocardiogram - To correct acidosis - To correct hypoxemia
to assess left (and right) ventricular • INOTROPIC SUPPORT (dobutamine and/or vasopressor support)
function and for the detection of potential
mechanical complications following MI TREATMENT GOALS
60 min • a mean arterial pressure of 60 mmHg or above,
• Early coronary angiography in specialized • a mean pulmonary artery wedge pressure of 18 mmHg or below,
myocardial intervention center when signs • a central venous pressure of 8 to 12 mmHg,
and/or symptoms of ongoing myocardial • a urinary ouput of 0,5 ml or more per hour per kilogram of body weight
ischemia (e.g. ST segment elevation • an arterial pH of 7.3 to 7.5
myocardial infarction). • a central venous saturation (ScvO2) ≥70% (provided SpO2 ≥93% and Hb level ≥9 g/dl)
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 6-8ml/kg with adequate CO2 removal.
Cardiogenic shock: management following STEMI 3.2
p.56
CARDIOGENIC SHOCK: MANAGEMENT FOLLOWING STEMI
± Pulmonary artery catheter RV, LV, both valve regurgitation Pericardial tamponade p.57
± IABP in selected patients • Ventricular septum
in a specialised Myocardial Intervention rupture
Center • Severe aortic/mitral
valve stenosis
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
Type Support Access 3.2
Intra-aortic Balloon Pulsatile flow <0.5 L Arterial: 7.5 French p.59
balloon 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 ).
3.2
p.60
Chapter 4: CARDIAC ARREST 4
p.61
AND CARDIOPULMONARY RESUSCITATION
THE CHAIN OF SURVIVAL
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 of hospital
HOSPITAL cardiac
CARDIAC arrest:
ARREST: 4
Assessment
ASSESSMENT of a collapsed
OF A COLLAPSED victim
VICTIM ANDand initialTREATMENT
INITIAL treatment
p.62
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 CARDIAC
IN-HOSPITAL cardiac ARREST:
arrest:
4
ASSESSMENT OF A COLLAPSED VICTIM ANDinitial
Assessment of a collapsed victim and treatment
INITIAL TREATMENT
p.64
Collapsed/sick patient
Call resuscitation
team
Assess ABCDE
Recognise & treat
oxygen; monitoring, i.v. access
CPR 30:2
with oxygen and airway adjuncts
4
Apply pads/monitor Call resuscitation team p.65
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)
Return of
1 Shock 4
spontaneous circulation
p.67
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
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
No
No
No
Yes
VT Aberrant conduction VT Vi/Vt ≤1
Aberrant conduction
Management of
MANAGEMENT OFwide
WIDEQRS
QRStachyscardias
TACHYCARDIAS 5.2
Hemodynamic Tolerance
p.76
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 • Second degree AV block. Mobitz type I
occur in the sinus node cannot leave the node towards (Wenckebach block): Progressive PR interval
the atria prolongation, which precedes a nonconducted P wave
• Sinus arrest. Sinus pause or arrest is defined as • Second degree AV block. Mobitz type II: PR
the transient absence of sinus P waves interval remains unchanged prior to a P wave that
on the ECG suddenly fails to conduct to the ventricles
• Third degree (complete) AV block.
No atrial impulses reach the ventricle
BRADYARRHYTHMIAS: Treatment (1)
5.3
p.78
• Rule out and treat any underlying causes of bradyarrhythmia
• Treat symptomatic patients only
For more information on individual drug doses and indications, See chapter 8: Use of
drugs in Acute Cardiovascular Care.
• 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)
5.3
Pacemaker therapies in atrioventricular blocks
p.80
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
TITRE
6
TITRE
TITRE p.81
DeBakey’s Classification
• Type I and type II dissections both originate in the ascending aorta
In type I, the dissection extends distally to the descending aorta
In type II, it is confined to the ascending aorta
• Type III dissections originate in the descending aorta
Stanford Classification
• 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 Adapted with permission from Nienaber CA, Eagle KA, Circulation
• Chronic: > 90 days 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
6.1
and differential diagnosis
p.84
Copyright: Hiratzka et al. 2010 Guidelines on Thoracic Aortic Disease. Circulation. (2010) ;121: page-310 (fig 25 step 2).
Laboratory tests required for patients
6.1
with acute aortic dissection
p.86
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/ Liver ischaemia, liver disease
alanine aminotransferase
Lactate Bowel ischaemia, metabolic disorder
Glucose Diabetes mellitus
Blood gases Metabolic disorder, oxygenation
*SIRS = systemic inflammatory response syndrome.
Reference: Eur Heart J 2014;eurheartj.ehu281.
ACUTE CHEST PAIN
acute chest pain
6.1
Medical history + clinic al examination + ECG STEMIa : see ESC guidelines 169
p.87
UNSTABLE HAEMODYNAMIC STATE STABLE
TTE + TOE/CT° Low probability (score 0-1) High probability (score 2-3)
or typical chest pain
Type A Type B
(Ascending aorta (No ascending
involvement) aorta involvement)
Complicated
Uncomplicated (malperfusion,
rupture)
For more information on individual drug doses and indications, See chapter 8: Use of drugs in
Acute Cardiovascular Care.
ACUTE
ACUTE AORTIC
AORTIC SYNDROMES:
SYNDROMES: SurgicalMANAGEMENT
SURGICAL management 6.1
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
M arkers of myocardial injury (e.g. elevated cardiac troponin I or T concentrations in plasma), or of heart failure as a 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
P 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 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 pulmonary embolectomy or percutaneous catheter-directed treatment
T
may be considered as alternative options to systemic thrombolysis, particularly if the bleeding risk is high.
e
Monitoring should be considered for patients with confirmed PE and a positive troponin test, even if there is no evidence of RV dysfunction on echocardiography or CT.
f
The simplified version of the PESI has not been validated in prospective home treatment trials; inclusion criteria other than the PESI were used in two single-armed
(non-randomized) management studies.
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
6.2
with confirmed high risk pulmonary embolism
p.96
Shock or
YES
hypotension
Contraindications
No Relative Absolute
for thrombolysis
Low-dose/ Surgical or
Primary PA
transcatheter Percutaneous catheter
reperfusion Thrombolysis
thrombolysis/ embolectomy
strategy
clot fragmetation (availability/experience)
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
6.2
with (non-high risk) confirmed
p.98
Markers for
Positive Positive Negative
myocardial injury
Pharmacological treatment:
For more information on individual drug doses and indications, See chapter 8: Use of drugs in
Acute Cardiovascular Care.
Pulmonary embolism: Pharmacological treatment 6.2
Key drugs for initial treatment of patients with confirmed PE p.99
For more information on individual drug doses and indications, See chapter 8: Use of
drugs in Acute Cardiovascular Care.
5.3 Bradyarrhythmias
7.1 acute myocarditis ���������������������������������������������������������������������������������������������������� p.102
A. Keren, A. Caforio
CAUSES OF MYOCARDITIS
OR
when the patient is asymptomatic, two or more diagnostic criteria from different categories (I to IV)*
in the absence of:
1) angiographically detectable coronary artery disease
2) known pre-existing cardiovascular disease or extra-cardiac causes that could explain the syndrome
(e.g. valve disease, congenital heart disease, hyperthyroidism, etc.)
Endomyocardial biopsy is necessary to: 1) confirm the diagnosis of clinically suspected myocarditis,
3) identify the type and aetiology of inflammation, and 2) provide the basis for safe immunosuppression
(in virus negative cases).
• 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
• I CD 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
7.2
p.110
Chapter 5
Titre 8
p.111
RHYTHM DISTURBANCES
5.3 Bradyarrhythmias
cardiovascular care
Ana de Lorenzo
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 8
p.112
Dose
Drug Indications Dose Comments
adjustments
Primary (not universally approved) and LD (if ACS): - Major contraindications:
Aspirin
ischaemic events, e.g. elevated cardiac troponins) MD: 90 mg oral BID previous intracerebral hemorrhage
Secondary prevention MD: 60 mg oral BID - Major contraindications:
1-3 years post-MI previous intracerebral hemorrhage
ACS with planned PCI LD: 60 mg oral MD: 5 mg QD Contraindication: previous stroke/TIA
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.) 8
p.113
Dose
Drug Indications Dose Comments
adjustments
STEMI LD: 300 mg oral -
+ fibrinolysis < 75 years MD: 75 mg oral QD
Clopidogrel
STEMI LD: 75mg oral. - Prasugrel and ticagrelor have not been studied as
+ fibrinolysis ≥ 75 years MD: 75 mg oral QD adjuncts to fibrinolysis and oral anticoagulants
Secondary prevention >12 months post MD: 75 mg oral QD -
coronary stenting
Co-administered with aspirin and, where 2.08 mg oral QD - Initiated at least 2 weeks after a MI and
Vorapaxar
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 8
p.114
Dose
Drug Indications Dose Comments
adjustments
Adjunct to PCI for bailout situations or LD: 0.25 mg/Kg i.v. - Contraindications: Active internal bleeding
thrombotic complications MD: 0.125 μg/Kg/min - History of CVA within 2 years - Bleeding
i.v. (max: 10 μg/min) diathesis - Preexisting thrombocytopenia
for 12h - Recent (within 2 months) intracranial or
Abciximab
a second 180 mcg/kg 30-50ml/min within the preceding 6 weeks - Stroke within
i.v. bolus 30 days or any history of hemorrhagic stroke
at 10 min - Coadministration of another parenteral GP
MD: 2 μg/Kg/min i.v. IIb/IIIa inhibitor - Dependency on renal dialysis
infusion - Known hypersensitivity to any component of
the product
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.) 8
p.115
Dose
Drug Indications Dose Comments
adjustments
ACS treated medically or with PCI LD: 25 μg/Kg i.v. CrCl < 30ml/min: Contraindications:
over 5 min decrease 50% Severe hypersensitivity reaction to tirofiban
MD: 0.15 μg/Kg/min bolus and infusion A history of thrombocytopenia following prior
Tirofiban
immediate onset + rapid offset IV infusion of Transition to oral P2Y12 inhibitors variable
(platelet recovery in 60 min) 4 μg/kg/min according to type of agent
For at least 2 hours
from start of PCI
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 8
p.116
Dose
Drug Indications Dose Comments
adjustments
Treatment and prophylaxis INR goal of 2-3 Assessing individual risks for -
Acenocoumarol
of thrombosis (INR: 2.5-3.5 for mechanical mitral valve prostheses or thromboembolism and bleeding
Warfarin
impairment
in patients who have been
Active pathological
treated with a parenteral
bleeding
anticoagulant for 5-10 days
Idarucizumab:
and prevention of recurrent
specific antidote
DVT and PE in patients who
(not yet available)
have been previously treated
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 (Cont.) 8
p.117
Dose
Drug Indications Dose Comments
adjustments
Prevention of stroke and 20 mg oral QD CrCl < 50ml/min: 15 mg QD Contraindicated if
systemic embolism in NVAF CrCl < 15ml/min
Rivaroxaban
or hepatic disease
Treatment of DVT and PE 15 mg oral BID for the first 3 weeks Reduce the maintenance dose to
associated with
and prevention of recurrent followed by 20 mg QD 15 mg QD if bleeding risk outweighs
coagulopathy and
DVT and PE the risk for recurrent DVT and PE
clinically relevant
(not formally approved)
bleeding risk
Prevention of atherothrombotic 2.5 mg oral BID -
events after an ACS
Prevention of stroke and 5 mg oral BID 2.5 mg oral BID Contraindicated if
systemic embolism in NVAF 1) when at least 2 of the following CrCl < 15ml/min
characteristics: age ≥ 80, or severe hepatic
Apixaban
GP-IIb/IIIa inhibitor is planned. 50-60 IU/Kg i.v. bolus 2.0 times that of control to be
with GP-IIb/IIIa inhibitors - Fibrinolysis/No reperfusion: monitored at 3, 6, 12 and 24h reaction
60 IU/kg i.v. bolus (max: 4000 IU) followed by an i.v.
infusion of 12 IU/kg (max: 1000 IU/h) for 24-48h
Treatment of DVT and PE 80 IU/Kg i.v. bolus According to aPTT,
followed by 18 IU/Kg/h thromboembolic and bleeding risk
NSTE-ACS 2.5 mg QD s.c. - Severe hepatic
impairment: caution
Fondaparinux
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/Subcutaneous Anticoagulants (Cont.) 8
p.119
Dose
Drug Indications Dose Comments
adjustments
PCI for NSTE-ACS 0.75 mg/kg i.v. bolus followed immediatelly by Patients undergoing PCI with CrCl Contraindicated if
1.75 mg/kg/h infusion which may be continued for 30-50ml/min should receive a CrCl < 30ml/min
up to 4h post PCI as clinically warranted and further lower infusion rate of 1.4 mg/kg/h.
continued at a reduced infusion dose of 0.25 mg/kg/h No change for the bolus dose.
for 4-12h as clinically necessary
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.
Intravenous/Subcutaneous Anticoagulants (Cont.) 8
p.120
Dose
Drug Indications Dose Comments
adjustments
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 < 30ml/min: no LD and MD treatment with LMWH
1 mg/Kg QD s.c. might be helpful in pregnancy,
If > 75 years and CrCl < 30ml/min: extreme body weights and
no LD and 0.75 mg/Kg QD s.c. renal impairment.
STEMI Primary PCI: 0.5 mg/Kg i.v. bolus In patients with CrCl < 30 ml/min:
Enoxaparin
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/Subcutaneous Anticoagulants (Cont.) 8
p.121
Dose
Drug Indications Dose Comments
adjustments
Prevention of VTE 3500 IU s.c. QD (moderate risk) - Monitoring for HIT -
Tinzaparin
Treatment of DVT and PE 200 IU/Kg QD or 100 IU/Kg BID s.c. Anti Xa monitoring if renal kg/24h for 5 months - After
impairment this period, vitamin K antag or
a LMWH should be continued
indefinitely or until the cancer
is considered cured
Anticoagulant in patients Initial i.v. infusion dose: 2 μg/kg/min Renal and hepatic impairment: Monitored using aPTT goal:
Argatroban
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 PCI: ACT goal:
followed by 25 μg/kg/min i.v. 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 8
p.122
Dose
Drug Indications Dose Comments
adjustments
STEMI 1.5 million units over 30-60min i.v. - Absolute contraindications to
Streptokinase (SK)
fibrinolytics:
Treatment of PE Total dose of 100 mg: 10 mg i.v. bolus If weight < 65 Kg: max
followed by 90 mg i.v. for 2h dose < 1.5 mg/kg
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.) 8
p.123
Dose
Drug Indications Dose Comments
adjustments
STEMI 10 units + 10 units i.v. bolus given Renal and hepatic Absolute contraindications to
30 min apart impairment: fibrinolytics:
Reteplase
(rt-PA)
caution advised
Previous intracranial haemorrhage or stroke
of unknown origin at any time
Ischaemic stroke in the preceding 6 months
Central nervous system damage or neoplasms
or atrioventricular malformation
STEMI Over 10 seconds; Single i.v. bolus: -
Recent major trauma/surgery/head injury
30 mg if < 60 kg
(within the preceding 3 weeks)
35 mg if 60 to < 70 kg
Gastrointestinal bleeding within the past month
40 mg if 70 to < 80 kg
Tenecteplase
(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 8
p.124
Dose
Drug Indications Dose Comments
adjustments
Beta-blockers: Preferred over calcium channel blockers - Contraindicated if coronary spasm, severe bradycardia, AV block, severe bronchospasm
CrCl: 15-35ml/min:
STEMI 25-100 mg QD, max dose 50 mg/day;
titrate as tolerated up to 100 mg QD CrCl < 15ml/min:
only if no LVSD or CHF max dose 25 mg/day
NSTE-ACS LD: 3.125-25 mg oral Caution in elderly and Preferred if LVSD/HF
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.
Antiischemic drugs (Cont.) 8
p.125
Dose
Drug Indications Dose Comments
adjustments
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 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.) 8
p.126
Dose
Drug Indications Dose Comments
adjustments
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 Contraindicated if hypotension
Amlodipine
impairment
Nitrates
ACS If intolerant or unresponsive to nitroglycerin - Contraindicated if severe
s.l. 5 μg/min - Increase by 5 mcg/min q3-5min up to 20 hypotension and co-administration
i.v.
up to 3 puff in 15min
Use glass bottles for nitroglycerin
i.v. administration
Angina 0.3 to 0.6 mg s.l. or in the buccal pouch every 5min as -
sublingual
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.) 8
p.127
Dose
Drug Indications Dose Comments
adjustments
Angina 5-10 mg BID with the two doses given 7h apart - Contraindicated if severe
(8am and 3pm) to decrease tolerance development - hypotension and co-administration
mononitrate
Isosorbide
Angina 0.2 to 0.4 mg/h patch applied topically once a day for -
Nitroglycerin
transdermal
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.) 8
p.128
Dose
Drug Indications Dose Comments
adjustments
Other antiishemic drugs
Stable 5-7.5 mg oral BID Caution in elderly and Contraindicated if severe hepatic
Ivabradine
Stable Initial dose: 375 mg oral BID Use with caution in Contraindicated if CrCl < 30ml/
Ranolazine
angina After 2-4 weeks, the dose should be titrated renal and hepatic min, concomitant administration
to 500 mg BID and, according to the patient’s impairment, CHF, of potent CYP3A4 inhibitors,
response, further titrated to a recommended max elderly, low weight moderate or severe hepatic
dose of 750 mg BID 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.
Hypolipidemic drugs 8
p.129
Dose
Drug Indications Dose Comments
adjustments
Statins: Secondary prevention of cardiovascular disease: start with high doses and down titrate if side effects
Target LDL-C levels < 70 mg/dl initiated early after admission
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.
Hypolipidemic drugs (Cont.) 8
p.130
Dose
Drug Indications Dose Comments
adjustments
Others
Hyperlipidemia 10 mg oral QD Avoid use if moderate-severe -
Ezetimibe hepatic impairment
Hyperlipidemia 48-160 mg oral QD CrCl 50-90ml/min: Contraindicated if
Fenofibrate May adjust dose q4-8 weeks start 48-54 mg QD CrCl < 50ml/min or
hepatic impairment
Hyperlipidemia 900-1200 mg/day oral Contraindicated
if severe renal
impairment or hepatic
Gemfibrozil dysfunction
Statins may increase
muscle toxicity: avoid
concomitant use
Evolocumab PCSK9 inhibitor (not yet available). Most common side effects: nasopharyngitis, upper respiratory tract infection, headache and back pain
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 8
p.131
Dose
Drug Indications Dose Comments
adjustments
ACEI
HF Start: 6.25 mg oral TID CrCl > 50 ml/min: 75-100% of the normal dose Check renal function,
Target dose: 50 mg TID CrCl 10-50ml/min: 25-50% electrolytes,
Captopril
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.) 8
p.132
Dose
Drug Indications Dose Comments
adjustments
HF Start: 2.5 mg oral QD CrCl > 60ml/min: start 5 mg/day Check renal function,
Perindopril
pregnancy (risk)
Target dose: 5 mg BID max 5 mg/day
Caution in elderly and 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.
Heart failure & hypertension (Cont.) 8
p.133
Dose
Drug Indications Dose Comments
adjustments
ARB
HF, HTN Start: 4-8 mg oral QD If renal or hepatic impairment: If ACEI is not tolerated.
Candesartan
Major contraindications:
History of angioedema, known
bilateral renal artery stenosis,
HF Start: 50 mg oral QD CrCl < 20ml/min: 25 mg QD pregnancy (risk)
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.) 8
p.134
Dose
Drug Indications Dose Comments
adjustments
Beta-blockers: Check 12- lead ECG
HTN Start: 25 mg oral QD CrCl 10-50ml/min: Major contraindications:
Atenolol
Usual dose: 50-100 mg QD decrease dose 50% asthma, 2nd or 3rd degree
CrCl < 10ml/min: AV block
decrease dose 75%
HF Start: 1.25 mg oral QD CrCl < 20ml/min:
Cardioselective
Bisoprolol
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.) 8
p.135
Dose
Drug Indications Dose Comments
adjustments
Beta-blockers: Check 12- lead ECG
HF Start: 1.25 mg oral QD Renal impairment or elderly: Major contraindications:
Cardioselective
Target dose: 10 mg QD start dose 2.5 mg QD, titrate to 5 mg QD asthma, 2nd or 3rd degree
Nebivolol
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.) 8
p.136
Dose
Drug Indications Dose Comments
adjustments
Other vasodilators
HTN Start: 5 mg oral QD, increase after Elderly or secondary agent: Contraindicated if cardiogenic
Amlodipine
HTN Initiate the IV infusion at 4 ml/h (2 mg/h); The desired therapeutic response for most Hypersensitivity to soy, peanut,
Clevidipine
the dose may be doubled every 90 seconds patients occurs at doses of 8-12 ml/h or egg products
Uptitration until desired BP range (4-6 mg/h) Critical Aortic stenosis, mitral
is achieved The max recommended dose is 64 ml/h stenosis, HOCM
Half life of 1-2min (32 mg/h)
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.) 8
p.137
Dose
Drug Indications Dose Comments
adjustments
Other vasodilators
HTN Immediate-release form: Start 40 mg oral TID in elderly or small Contraindicated if bradycardia,
Verapamil
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.) 8
p.138
Dose
Drug Indications Dose Comments
adjustments
Thiazides
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.) 8
p.139
Dose
Drug Indications Dose Comments
adjustments
Thiazides
HTN Start 1.25 mg PO QAM x4weeks, CrCl < 25 ml/min: avoid use -
Indapamide
Aldosterone-antagonists
HF Start 25 mg oral QD CrCl < 10ml/min, anuria or acute renal Check renal function,
Spironolactone
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.) 8
p.140
Dose
Drug Indications Dose Comments
adjustments
Aldosterone-antagonists
HF Start 25 mg oral QD Elderly: caution advised Check renal function,
Eplerenone
Others
HF 5-7.5 mg oral BID Caution in elderly and CrCl < 15ml/min Contraindicated if severe
Ivabradine
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.
Inotropics & vasopressors 8
p.141
Dose
Drug Indications Dose Comments
adjustments
HF/cardiogenic LD: 6 to 12 µg/kg i.v. over 10 min Avoid use if CrCl < 30ml/min or Calcium sensitizer and ATP-dependent potassium
Levosimendan
shock (given only if immediate effect is severe hepatic impairment channel opener
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 CrCl 50ml/min: start 0.43 μg/kg/min
Milrinone
0.375-0.75 μg/kg/min CrCl 40ml/min: start 0.38 μg/kg/min Caution if atrial flutter
CrCl 30ml/min: start 0.33 μg/kg/min
CrCl 20ml/min: start 0.28 μg/kg/min Hypotensive drug
CrCl 10ml/min: start 0.23 μg/kg/min
CrCl 5ml/min: start 0.20 μg/kg/min
Cardiogenic 0.5-5 µg/min (0.25-2.5 ml of a - ß1, ß2 agonist.
Isoproterenol
Isoprenaline/
shock 2-5 μg/Kg/min i.v. Increases BP, PAP, heart rate, cardiac output and
ß effect : 5-15 μg/Kg/min i.v. pulmonary and systemic VR
a effect : 15-40 μg/Kg/min i.v. More arrhythmogenic than dobutamine and
noradrenaline
Cardiogenic 0.05-0.2 μg/kg/min i.v. titrate to
- a 1, ß1 agonist
Noradrenaline
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 8
p.143
Dose
Drug Indications Dose Comments
adjustments
Group I
AF 15-18 mg/kg i.v. over 60 min, followed by Reduce LD to 12 mg/kg in severe renal Hypotension
Procainamide
Pulseless VT/VF 1-1.5 mg/kg i.v./i.o. bolus (can give additional 1-2 mg/min infusion if liver disease or HF Contraindicated if advanced AV
0.5-0.75 mg/kg i.v./i.o. push every 5-10 min if block, bradycardia,
Lidocaine i.v.
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.) 8
p.144
Dose
Drug Indications Dose Comments
adjustments
Group I
SVT, 2 mg/kg (max 150 mg) i.v. over 30min Severe renal impairment: Contraindicated if cardiogenic
ventricular This may be followed by an infusion at a rate caution advised shock, recent MI, 2nd or 3rd
Flecainide i.v.
PSVT, LD: 0.5-2 mg/kg i.v. direct over a minimum May need to reduce dose in renal or Contraindicated if unstable HF,
Propafenone i.v.
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.) 8
p.145
Dose
Drug Indications Dose Comments
adjustments
Group II
Arrhythmias 2.5 mg i.v. over 2.5 min every 5 min Caution in elderly Contraindicated if cardiogenic shock, bradycardia
Atenolol
(max 10 mg) and/or severe and greater than first-degree block, unstable HF
i.v.
renal impairment
Arrhythmias 2.5-5mg i.v. over 5 min, Caution if Contraindicated if cardiogenic shock, bradycardia
Metoprolol
may repeat every 5 min severe hepatic and greater than first-degree block, unstable HF
(max 15mg) impairment
i.v.
Arrhythmias Initially given as slow i.v. boluses of 1 mg, - Contraindicated if cardiogenic shock, bradycardia
Propranolol
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.) 8
p.146
Dose
Drug Indications Dose Comments
adjustments
Group III
AF (termination) 5 mg/Kg i.v. over 30 min, followed by - Reduce infusion rate if bradycardia, AV block,
infusion of 1 mg/min for 6h, then hypotension
Amiodarone i.v.
0.5 mg/min
Bolus should be avoided if hypotension or severe
Stable VT 150 mg i.v. over 10 min followed by -
LV dysfunction
(with a pulse) infusion of 1 mg/min for 6h, then
0.5 mg/min
Highly vesicant agent
Pulseless VT/VF 300 mg bolus i.v. (can give additional -
150 mg i.v. bolus if VF/VT persists) followed
by infusion of 900 mg over 24h
Paroxysmal or 400 mg oral BID - Contraindicated if severe renal or liver dysfunction,
Dronedarone
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.) 8
p.147
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
Verapamil
(may repeat up to max cumulative dose (except RVOT-VT), fascicular VT, bronchospasm,
i.v.
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.) 8
p.148
Dose
Drug Indications Dose Comments
adjustments
Others
VT-Torsades de Pointes Bolus: 1-2 g i.v./i.o. over 5 min Caution if severe Contraindicated if myasthenia gravis
Magnesium
Acute atrial fibrillation 3 mg/kg i.v. over 10 min. If AF persists, - Contraindicated if ACS within the last 30 days,
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.
Abbreviations
APTT = Activated partial thromboplastin time BNP = Brain natriuretic peptide p.149
AB = Airway and breathing BP = Blood pressure
ABG = Arterial blood gas CABG = Coronary artery bypass grafting
AADs = Antiarrhythmic drugs CAD = Coronary artery disease
AAS = Acute aortic syndrome Cath Lab = Catheterisation laboratory
ACEI = Angiotensin converting enzyme inhibitor CCU = Coronary care unit
ACLS = Advanced cardiovascular life support CHF = Congestive heart failure
ACS = Acute coronary syndrome CMR = Cardiovascular magnetic resonance
ACT = Activated clotting time COPD = Chronic obstructive pulmonary disease
AD = Aortic Dissection CPAP = Continuous positive airway pressure
AED = Automated external defibrillator CPR = Cardiopulmonary resuscitation
AF = Atrial fibrillation CrCI = Creatinine clearance
Ao = Aortic CS = Cardiogenic shock
aPRR = Activated partial thromboplastin time CSM = Carotid sinus massage
ARB = Angiotensin receptor blockers CSNRT = Corrected sinus node recovery time
AS = Aortic stenosis CSS = Carotid sinus syndrome
AV = Atrioventricular CT = Computed tomography
AVN = Atrioventricular node CT-angio = Computed tomography angiography
AVNRT = Atrioventricular nodal re-entrant tachycardia CUS = Compression venous ultrasound
AVNT = Atrioventricular nodal tachycardia CV = Cardiovascular
BID = Twice a day CXR = Chest X-ray
BBB = Bundle branch block DD = Dyastolic dysfunction
BLS = Basic life support DM = Diabetes mellitus
Abbreviations
DVT = Deep vein thrombosis IHD = Ischemic heart disease p.150
ECG = Electrocardiogram IMH = Intramural hematoma
ED = Emergency department ISFC = International Society and Federation of
EG = Electrograms Cardiology
EMB = Endomyocardial biopsy i.o. = Intraosseous
EMS = Emergency medical services IV = Invasive ventilation
EPS = Electrophysiological study i.v. = Intravenous
ERC = European Resuscitation Council KD = Kidney disease
ESR = Erythrocyte sedimentation rate LBBB = Left bundle branch block
ETT = Exercice treadmill testing LD = Loading dose
FMC = First medical contact LGE = Late gadolinium enhancement
GER = Gastroesophageal reflux LMWH = Low-molecular weight heparin
GFR = Glomerular flow rate LOC = Loss of consciousness
GI = Gastrointestinal LV = Left ventricular
GP = Glycoprotein LVD = Left ventricular dysfunction
HF = Heart failure LVEF = Left ventricular ejection fraction
HTN = Hypertension LVH = Left ventricular hypertrophy
HR = Heart rate LVSD = Left ventricular systolic dysfunction
hsTn = High-sensitive troponin MCS = Mechanical circulatory support
IABP = Intra-aortic balloon pump MD = Maintenance dose
ICC = Intensive cardiac care MDCT = Computed tomography with >4 elements
ICCU = Intensive cardiac care unit MI = Myocardial infarction
ICD = Implantable cardioverter defibrillator MRI = Magnetic resonance imaging
Abbreviations
Mvo = Microvascular obstruction QD = Once a day p.151
NIV = Non-invasive ventilation QPM = Every evening
NOAC = New oral anticoagulants rtPA = Recombinant tissue plasminogen
NSAID = Non-steroidal anti-inflammatory drugs activator
NSTEACS = Non-ST-elevation ACS RV = Right ventricular
NSTEMI = Non ST-segment elevation myocardial infarction RVOT-VT = Right ventricular outflow tract ventricular
NTG = Nitroglycerin tachycardia
NT-proBNP = N-terminal pro brain natriuretic peptide SBP = Systemic blood pressure
NVAF = Non-valvular atrial fibrillation s.c = Subcutaneous
NYHA = New York Heart Association SLE = Systemic lupus erythematosus
OH = Orthostatic hypotension SMU = Syncope management units
PAP = Pulmonary arterial pressure STE-ACS = ST-segment elevation acute coronary syndrome
PAU = Penetrating aortic ulcer STEMI = ST-segment elevation myocardial infarction
PCI = Percutaneous coronary intervention SVT = Supraventricular tachycardia
PCM = Physical counter-measures Spo2 = Oxygen saturation
PCP = Pulmonary capillary pressure TEE = Transesophageal echocardiography
PE = Pulmonary embolism TEVAR = Thoracic endovascular aortic aneurysm repair
PEA = Pulmonary endarterectomy TIA = Transient ischemic attack
PEEP = Positive end expiratory pressure TID = Three times a day
PR = Pulmonary regurgitation TLOC = Transient loss of consciousness
ProCT = Procalcitonin Tn = Troponin
PRN = Pro re nata TOE = Transoesopageal echocardiography
PSVT = Paroxysmal supraventricular tachycardia TSH = Thyroid-stimulating hormone
Abbreviations
TTE = Transthoracic echocardiography p.152
UFH = Unfractionated heparin
ULN = Upper limit of normal
VF = Ventricular fibrillation
VR = Vascular resistance
VT = Ventricular tachycardia
VTE = Venous thromboembolism
VVS = Vasovagal syncope
WHO = World Health Organization
WPW = Wolff-Parkinson-White
Notes
p.153
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
Notes
p.154
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
References and copyright acknowledgments Acknowledgements
Reproduced With permission of Oxford University Press (UK) © European Society of Cardiology p.155
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
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 p.156
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
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 Registered 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 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.
The financial support of the sponsors, AstraZeneca and Novartis Pharma AG, made the development of the Toolkit
easier. We appreciate the generous unrestricted educational grants and the independence to develop the Toolkit with no
influence whatsoever in the selection of faculty, topics, clinical or scientific content.
Acute Cardiovascular Care Association
Clinical Decision-Making
TOOLKIT
Acute
flash me www.escardio.org/ACCA Cardiovascular
Care Association
A Registered Branch of the ESC