Síndrome coronario agudo Guía AHA 2025 - Dr Heder Bedoya

[Music]

Today, the intention is to

review a clinical practice guideline

as part of these literature review sessions

. My name is Derbedo,

emergency medicine resident.

So, let's

go, the guide that I had

previously shared with you and that we

intend to review today is this guide that

came out this

year on the management and approach to

patients with

acute coronary syndromes, published in 2025

by the AJA and the AC. CC, which are like the

main associations, but

we see that they include many other

associations, mostly

from North America or the Americas, and this

tells us that this is the

American guide to coronary syndromes,

because we also have a European guide

that came out last year and

that gave us some of what we are

going to see here

next, prior to these guidelines.

as if doing a historical review of how

long it's been since we had a heart-stopping guide

to these associations. So,

we realize that in 2013 the

guide for the management of

patients with ST elevation myocardial infarction was released,

and in 2014 the guide for the management

of patients with

non-ST elevation myocardial infarction was released, sorry.

Uh, this tells us that these

guidelines were previously handled

independently, separating

acute coronary syndromes by with elevation

versus without elevation, and each had its own

independent guideline. This guide

unites those two spectra, but as we will

see later, it's not like we're

going to cover

the entire context of what a

coronary syndrome is.

Prior to this, there was also a

2015 update, more focused on

reperfusion strategies, and all of this contributed

to the development of the guide. So,

let's see that it's been a long time, more

than 10 years, since these guidelines were last

updated, and perhaps we don't realize how long it's been since they were

updated

, because we have the

American guidelines and the

European guidelines, and each one

releases its own guidelines. Besides, it's

no secret that this is a

highly studied topic, and every year new

publications are released regarding the

management of these patients, and

the management has been very

universal. So, this supports us, or

rather helps us, to make the update

persistent even though the guides

take so long to

come out. This is therefore the author listed

as the main author of the guide.

Actually, he is a, he is one, well, his

main role is as editor of this

Circulation magazine, where the

guide was published, but he has

several, well, how to say it? as his

professional qualifications, since he is the director of several

cardiology units and a professor at

faculties of medicine and

cardiology. In addition, he is part of

several cardiology,

hemodynamics, and angiography committees. So, he's

a person who's like the one they

put as the leader of the whole publication,

because as we saw previously, or

as will be mentioned, there are many

people who are part of the

development of this guide, but this is the one

who appears as the main one. Since it

came out, well, this is the report

they leave us, seven citations, it came out

this

year, and we see that from February until

the moment of the review, well, it already had

seven citations in new

publications and more than 300,000

downloads, which implies that we are

all at the forefront of

what is coming out and we are

updating ourselves with this.

cluster. So the group that tried

to clarify this guide, or rather, the group that

produced this guide, so that we

could read it and have the

context, was made up of several

specialties. This includes a

lot of names that, obviously,

due to time constraints and because it's not

the objective, I'm not going to

mention them. But we have to keep in mind

that they include general cardiologists,

interventional cardiologists,

cardiovascular surgeons,

critical care cardiologists,

emergency physicians, cardiac imaging experts

, advanced practice nurses

, clinical pharmacists, and

patient representatives.

So we see that we know the

quality of all these guidelines and the

responsibility they have with

all these guidelines at a universal level, and

they also include multiple

specialties to make the decisions they

have to make. All this on

behalf of several

societies, as I said, all from

America. How did they conduct the search?

So what they did was

publish research on human beings, articles published in

English and

indexed. They conducted a review

from July 2023 to April

2024. But something important is that in the

process of drafting and

editing the

guide, if any new studies came out

that could contribute to those

recommendations, they included them, and if they

considered them relevant, they

included them. The databases they

included were Medline, Enbase, Cokrin, and

this other database. They even

mention others, listing them among others,

but they don't clearly state

which others they searched for. The

fact is that they conduct a broad search

, although it is somewhat

limited due to the

language barrier, as they only include

publications in English, even though it

is an American guide.

This is like the search strategy and

keywords they included

to retrieve as many articles as

possible for all the

recommendations. I'm not going to dwell

on this, I simply want to show you what

they contribute, how they

conducted the search, and where

all those recommendations that we're

going to see from now on came from

. This brings us to the chart that

all guides classically include.

which will define for us the strength

of the recommendation divided into classes and the

level of evidence,

or the quality of the evidence with which

these recommendations are given, being

class one and this is traffic light-shaped, which is

something pleasing to the eye because one

already knows from the outset what

is probably beneficial and what is probably

harmful by seeing the green and the red and

the levels of evidence in a

blue tone that varies between the

recommendations. We always hope to

have the highest possible balance between the strength of the

recommendation and the quality of the

evidence that supports that strength of

recommendation.

So, getting down to business, I wo

n't go into much background on this,

because we've already reviewed the guidelines

in previous contexts and

because it's a very extensive guide.

Uh, and I want to get right to the point

so we can talk completely about the

guide. So, the first thing I did was

in several sections, and the first thing is to

orient ourselves in what we would do

in the

emergency department. It's important to clarify that the

recommendations I'm going to show you

here are not all the recommendations in

the guide; they are the recommendations that I consider

relevant to us in the

emergency department and that may be changes with

respect to the guidelines that I

mentioned previously that we had from

these publishing societies. Perhaps

when one finishes and perhaps when

the review is finished, the

recommendations will not vary much from what we

know, but it is because, well,

last year we had the opportunity to

review the European guide and that already

gives us some very fresh concepts of what is being

recommended, but, well, for

the recommendation of the, well, there is

some variation. So, first,

speaking of the approach, it must be made

clear that they include here

acute coronary syndrome with

ST elevation and without ST elevation, but

they tell us that they will only

include type one infarction based on

the fourth definition of infarction from

2018, that type one infarction is

basically that infarction that occurs because we

normally have some plaques, well,

normally we don't have

atherosclerotic plaques. These plaques can

erode or rupture, leading to

partial or complete thrombosis, which

reduces blood flow through the

coronary arteries and produces ischemia,

known as coronary syndrome.

This is the heart attack we're going to

talk about, and the one they mention in the guide.

Type two, type

three, and type four heart attacks are not included in

this guide, and they are giving a

preview that they will probably

release guides focused on those other

types of heart attacks that have

different considerations. Given that, we are given a

spectrum that we will evaluate:

acute coronary syndrome with ST elevation,

without ST elevation, and unstable angina.

So, starting with the

recommendations, there's something good

that I wanted to bring up, although we'll see that it doesn't

vary much from the next

recommendation, and that is that

they set aside a chapter for

the prehospital setting, and this

seems extremely important to me because even though

we're going to work in

emergencies, we have to be very closely involved

with the

prehospital setting and educate the

doctors. doctors and staff

working in the pre-hospital setting.

What recommendations do they give us? They

tell us,

uh, first in patients in whom you

suspect an acute coronary syndrome.

Oops, sorry, this got moved.

Uh,

well, well, sorry, here

in this part the troponins thing doesn't apply

because obviously we are in the

prehospital setting, but rather that you

should take an electrocardiogram in

the first uh 10 minutes of the of the of the

first approach to

the patients. The second recommendation

is that if you have a patient with

suspected coronary syndrome, and the

initial ECG is not

diagnostic, you should perform

serial ECGs to determine if there are

possible ischemic changes. So,

we know that we

can commonly have an ECG that tells us about

ST elevation or an ECG that does not

give us any diagnostic changes. And in

these they recommend that you should

have those changes, well, or measure

serially, that is, every 15, 20

minutes, they don't give us a

set time, but they tell us that in

search of those ischemic changes.

Also, the other

prehospital recommendation, this here, uh, sorry, is that

I did the translation to

have the image in Spanish and it got

messed up. The other

important recommendation here for

pre-hospital care is that if you

have an ST elevation or if you

have a patient with a very high suspicion

of coronary syndrome, you should

take them to a unit that has

hemodynamics, that has PCI, that

is the highest priority with these

patients, not to take them to the

nearest hospital, but to take them to a hospital

that has PCI.

When it reaches us as

part of that approach, then it doesn't

change much. Here they do give us a

recommendation, which is that we should have an

electrocardiogram within the first 10

minutes for the management of these

patients. And if this electrocardiogram

is not diagnostic, then we

should also perform

serial electrocardiograms, because in some of those

we may see changes that are related

to that ischemia or changes that are

related to high-risk patterns and

that change the urgency with

which we are going to manage those patients.

especially when

clinical suspicion is high, or when

symptoms are persistent, or the patient's

condition is worsening. Well, if we don't

have this, if we don't have any

of these three, then we should do it

within a timeframe that we

establish, but if the patient

is deteriorating or presents any

other alteration, we should immediately

take a new

electrocardiogram. What are we going

to look for? Then they tell us,

you can

look for ST elevation or any

other change that would lead me to believe it is not

ST elevation. So you

can evaluate the patient with

ST elevation, because the

definition remains basically the

same: I have a

new or presumably new elevation of more than

1 mm in more than two

anatomically contiguous leads measured at the

J point. And this is very important because

I am going to measure that change that is at the

J point of the electrocardiogram.

and the adjacent branches. I'm

bringing this up from another article, but

basically it represents

territories that are irrigated by

certain arteries. So, if I have

two contiguous leads in any of

these, I'm already talking about an

ST elevation, with the exception

of B2 and B3, where we already have some

considerations in men and

women, so I'm not going to focus

much on

this. What else

can be seen? So

we can see, and here they said that if you

have symptoms or if you have a

type of clinical presentation that makes you suspect

that the patient has a

posterior wall infarction or has extension to the

right ventricle or a right wall infarction

, you should complete the

electrocardiogram leads by taking

right and

posterior leads, keeping in mind that in

these the ST elevation will not be

1 mm, but 0.5 mm and that you could

find

other findings on the

electrocardiogram that do not necessarily

have to be ST elevation, but

that can be high risk, such as

a left bundle branch block.

Uh, but they make it clear, and this

seems important to me because this guide

mentions that if you have a

new left bundle branch block in a

patient who is asymptomatic, that is not

going to be considered an

ST equivalent, but you should

individualize the patient and see what is

causing it, well, if there is

something else. Obviously, that won't

matter if you don't have a clinical case,

but it's good that they're making that

clear. And what is not ST, well

then we see a

new descent, whether horizontal or downward.

This is very important, horizontal or

descending, more than 0.5-5 mm in two

continuous leads or

T wave inversion more than 1 mm in two continuous leads with

a prominent R wave, an RS ratio

greater than 1 or a transient

ST segment elevation. We can arrive, we see

this from the start and remember that this is

changing and we may see it and

the

occlusion is not persistent, therefore the

elevation is persistent and this already changes the spectrum

of an ST elevation versus one without

ST elevation. For practical purposes and

as a shorthand, from now on we

will refer to

ST elevation as STEMI and non-

ST elevation as STEMI. When you have signs of

right heart failure that you suspect is a

right heart attack, then you should,

as I told you, perform the

extension of the derivatives. And it is very

important that you repeat the electrocardiograms,

and this is based on several literatures.

Here I bring you one

that basically told us, this is

an observational study, 41,000

patients with ST elevation myocardial infarction

. What did they do? They

saw that there was a large

percentage, even

the forgiveness, less than 8% if we look at it here at

10 minutes. This down here is

time. Time from the initial

electrocardiogram to the diagnosis of

ST elevation. And this is the

percentage of diagnoses. So we see

that here this is 6% less than 6% at

8. At 10 minutes, sorry, or if

we include this at 10 minutes, less

than 8% had an ST elevation. But

of those

patients, you can see that 35% had ST

elevation at 30 minutes

, 60% had ST elevation at 60 minutes, that is

, at one hour,

and if we go further, up to

78.6% of the patients at 120 minutes.

This is the importance

they tell us of repeating the electrocardiogram,

because you may have a

normal electrocardiogram initially, but if

you repeat that electrocardiogram at these

time intervals that I'm telling you about, you can

realize that the electrocardiogram is

dynamic and makes

important changes that can change the

diagnosis. What is the purpose of all this? to

define the spectra I was

telling you about. So, the spectra are about

a non-ST elevation, non-

STEMI, and a STEMI, which is

ST elevation. Basically, they here are already

taking the risk of saying, as we've been

talking lately about the change in

nomenclature, that we're orienting it towards

an occlusive or non-occlusive coronary event

. They say here that sememi is

with partial occlusion and stemi with

complete occlusion. And this is going to bring about

some changes. Then the

electrocardiogram will show us

the ST elevation, which we

already talked about. and the non-esic with an

electronormal or with a depression or with

T wave inversion or with some other

electrocardiographic finding. Here they

say, to include this

spectrum you can also rely on

troponins, also on

biomarkers. And if you have a

patient who does not have ST elevation and

has a negative troponin, you

can consider him to be in the unstable angiographic spectrum

. If that troponin is

positive, you can consider it in

the context of a patient with non-

ST elevation. And in the ST, a

troponin is usually always

negative, uh, always positive, sorry.

They clarify that if you

take it in a very short time it may be

negative and not representative.

However, this is basically for

the definition, but let's remember that for

the diagnosis of ST, if I already have

an elevation and a corresponding clinical picture,

I don't need a tropine or

wait for the result to define the

course of action.

Based on this, well, we're going to another

recommendation, this is the recommendation

of not um. I'm putting it on non-stere because of what I just

told you about

troponins. This is a recommendation for

in-hospital management, but what I just

told you about troponins

will be much more useful in non-

ST elevation myocardial infarction. So, he tells us that

I should measure troponins as soon as possible

after the patient's admission

, ideally using

high-sensitivity assays, which are the ones we

should all have already

.

And they also tell us that in patients with

suspected coronary syndrome, with an

initial non-diagnostic troponin,

that troponin should be repeated and repeated

using times that are time

zero and one or two hours for

high sensitivity troponins or 3 to

6 hours for conventional troponin assays

, that is, those that are not

high sensitivity, although they

recommend that we

should not be using those troponins. Well, because

we have better options, but if you

are in a place where you only have

conventional problems, keep in

mind that you cannot apply

algorithms in one to two hours, but rather in three to

six hours.

So, this brings us to

their first algorithm, and it's basically

you give that patient a summary

of the approach, which is what we're

doing. Medical history,

adequate physical examination. You suspect

coronary syndrome, you take the electrocardiogram

in the first 10 minutes, this doesn't

change much, you take a troponin test if you do

n't have a diagnosis. And if he has a

stenosis, then take him to

reperfusion therapy, and if not, take

serial electrocardiograms and take a troponin test and do a

troponin curve in case the

first one is not diagnostic. With this,

with all this that you give here,

define what the risk is for your patient

and that leads us to the second point which is

risk. Regarding risk, they give us

several risk stratification strategies

. Basically the most

well-known ones, grace and timi. It must be

understood that the timi has two scales,

one for unstable angir and

the timi eh for ST elevation. The

Grace treatment is for global coronary syndrome

. So, what's the recommendation?

They tell us, "None is

better than the other." Please note that

you will be able to use Grace in

either context and that it

will clearly define the risk. And for

our population, it must be

understood that the pivotal study of

Grace included a population very close to the

population we manage, that is, it

is very comparable to what

we have at hand. Uh, so it's going to

be easier, or more

accurate, to relate it to Grace than

to the team. It doesn't mean you ca

n't use Timy, or it doesn't mean

you can't use both. The

point is to define the patient's risk

. There are many

calculators on the internet, so you can use them to

keep in mind which

items they ask for.

And depending on the result, it will

give us a mortality risk, which

will tell us about the risk and

define the patient in different

types of risk. It's not just the

grace, it's also the clinical context. And

this leads us to another algorithm that

they propose, and it is that after you

do all this, you define the risk of

your patient and put a patient at low

risk who has low grace or timy scores,

who has no

symptoms, troponins below the 99th percentile,

who has no dynamic changes. What good is this to

us? For you to define

what you are going to do with your patient, and it

tells us that you can carry out a

routine invasive strategy or a

selective one, and you can

define whether you do

non-invasive stratification during

hospitalization and or you do

an invasive strategy within

hospitalization or

selectively recommended after the

patient's discharge. If you have an

intermediate risk, then go for an

invasive strategy. They give us a time here with a

class 2 recommendation of less than 72

hours. If you are at high risk, that is

, if you already have elevated gray scores and

have some dynamic changes or

have some other factors that

lead us to this

high risk, you should take him in the first

24 hours. And if you have a very

high-risk patient, that is, a patient with

cardiogenic shock, patients with

signs of acute heart failure, patients

who are clinically worsening,

patients with refractory angina,

patients with clinical instability or

electrical instability, or

who arrive with

ventricular fibrillation or ventricular tachycardia, they

should be taken as

early and as

quickly as possible to

an invasive strategy. They

set a target time of 2 hours here, which

hasn't changed much in

previous recommendations, and that leads us to the

recommendation for the patient in cardiac arrest.

They put the patient in

cardiac arrest, and I put it in

quotes because if you look at

the recommendations, it's not a

patient in cardiac arrest, it's a patient who has already

come out of arrest, who had a cardiac arrest due to a

heart attack and whom you brought out of arrest so that

you could

transfer him. Here they say, if you don't have

PCI, you should be transferred by an

emergency medical system to a center that

has PCI. If you revived him and he has

PCI, you should take him to PCI.

and take into account your

patient's prognosis and what their neurological status is

after they leave the pair. Because they

tell you, if you have a good state of

consciousness or a good

neurological prognosis and the patient has

ST elevation after the arrest, you should

take him to PCI. If that patient has a

poor prognosis or is in a coma and it is an

ST elevation, the decision should be

more individualized by analyzing the pros and

cons of taking that patient. And for

patients who are in cardiac arrest,

comatose,

hemodynamically stable, and have no evidence

of ST elevation,

immediate PCI is not recommended. They here on

unemployment only talk to us about PCI. One

important thing that I didn't see included, but

should be, is the

fibrinolysis strategy.

There's a section in the European guidelines

that talks about the

fibrinolysis strategy in these cases, especially

when I don't have

PCI available.

They can see the transfer process as very

easy, but we know how complex it is to

transfer a patient after all

this.

But at this time we have no

recommendations from them

regarding

that. The third point brings us to management,

and I've already talked a little about management; it

will actually be the

reperfusion strategy, but there are

several types of medications that

we can use that are part of the

medical management that we will give to these

patients. And so we begin with the

controversial topic of oxygen. We should always

recommend oxygen and they

will tell us it is a grade

one recommendation with a low level of evidence, but it

tells us to only give oxygen to the

patient who is desaturated. For patients

whose saturation is less than 90%, this

can obviously be individualized depending on

the altitude, but for patients who are

saturated, give them oxygen to

increase their saturation. If there is no

oxygen, uh, sorry, if there is no

desaturation, then

oxygen administration is not recommended because it has not

improved outcomes. And we see this

referenced in multiple studies.

Here I bring you this, which is the Detox

Trial, which is a study published

in New England, in fact, in 6000

patients with myocardial infarction.

They were talking about administering oxygen therapy,

although they were giving oxygen therapy

here with a simple mask

at 6 L per minute versus ambient air

in patients without hypoxemia. What happened? There

were no differences in mortality, nor were there any

differences in

any of the other outcomes

they were assessing. So, based on

this, they basically tell us to

follow the same recommendation. You

should not give oxygen to patients who

do not require

oxygen. The other option, or rather the

other recommendation, which is also usually

very controversial and perhaps doubtful in the

decision, especially in the

emergency department, is analgesic management.

Obviously we know that to

improve his pain we have to reperfuse,

that will be essential, but

while we reperfuse him we have

several strategies and they are talking to us

here about nitrates.

Nitrates, because they have

nitroglycerin available to

give in tablets or via sublingual or

spray. And they give us these doses,

always keeping in mind that the

patient has to have

hemodynamic stability, because otherwise this patient

goes into cardiogenic shock and

everything gets worse. The IB option, which

is the one we have, they

give us a recommendation of 10 microg per

minute and it is titrated until the

pain improves or until

the patient is hemodynamically able to tolerate it. If they give us

a warning, it is, watch out,

avoid what we already knew about in

patients. This means that

patients with high

blood pressure or

acute pulmonary edema will benefit greatly from nitrates. But if the

patient has suspected

right ventricular infarction, has a

systolic pressure less than 90, has a

drop in

systolic pressure, has any other finding that makes

me think of that extension to the

right ventricle, I could, uh,

I should avoid it because I

could lead this patient to

worsen their hemodynamic status and they

tell us that tachypnea can occur

up to 24 hours after the

infusion, here they only leave us with

these doses. Let's remember that there are already

much higher dose regimens

in bolus form, but they haven't mentioned

anything about them so far. Morphine, or

morphine and

fentanyl, as in the

opioid group, has the limitation that it

can delay the effect of P2 and P12 and

that it can be detrimental in those

patients also with

right ventricular involvement, but they

tell us, make a dose of morphine between 2

and 4 mg and of fentanyl between 20 and 50

micrograms, maximum so as not to exceed it in

the management of those patients

and use it when you have already used other

pain management strategies and that

was not, that is, the pain does not

improve. Those are the recommendations we

have. They don't really vary much, just

like the previous ones. As for

stress relievers,

these recommendations are slightly increased, with aspirin being a bit

stronger. Yes, to everyone. And here they

clarify that

we should give loads to all

patients, even if the patient is already

receiving aspirin. If the patient has already had

a heart attack previously, and was already

taking aspirin, I

should still give my patient injections while

always taking

aspirin. The other antiplatelet drugs,

like

clopidogrel and

plaugelagrel, are not generally prescribed

. You should take aspirin and

one of these in combination.

Those three should not be

used as premedication in patients.

We'll talk about that a little more

later. So, they tell us,

"Aspirin is always the way to go, yes, uh, clopi is

not left as an option when

neither prasugrel nor ticagrelol is available, when

I don't have them or can't

administer them for some reason, or if I'm going

to take my patient for

systemic thrombectomy. If I'm going to take them for

thrombectomy, the only one with studies

is clopi, and it's a 1A recommendation, and I

should only use that one. There's

a recommendation regarding the harm of prasugrel,

and that's in those patients who have had

previous strokes or TIAs; I shouldn't

use it because the literature says that it

can cause

more harm to these patients. And they

also recommend ticagrelol, very

similarly to prazoline. Although they

recommend it even the same, even though

we know that recent literature

may show it's slightly better

than ticagrelol,

but they tell us that if I'm

going to take them on an

invasive management strategy, I'm simply going to leave it with

the management. This is

the consideration I'm going to

have. And they tell us They ask, how will

you choose? And here's another

algorithm. This will depend

on where I'm taking my

patient. Keep in mind that this is for the patients

I'm treating, that is,

after the intervention. For example, if I'm

going to perform PCI on a patient,

they recommend ticagrelor or

clopidogrel, and they don't mention

clopidogrel here. They say below, clopidogrel is used when the

previous ones are unavailable or not

tolerated. If I'm going to take them for a

bypass, ticagrelor or clopidogrel. Here,

clopidogrel is associated with worse

outcomes, so they don't

include it.

If I don't plan to take the patient for

invasive staging, which is what I

was

talking about, then the option

of considering ticagrelor or clopidogrel can be left open when

ticagrelor is unavailable or not

tolerated. And if I'm going to thrombolyze

an ST-segment elevation, then only

clopidogrel. Okay?

That's as

preparation, then. We'll see

that there isn't strong evidence

that I should use it. These aren't presented

as studies that basically say I

should, my patient should be discharged with

it, or that at the time of

the intervention or

invasive stratification, they should be

given that combination. But for

us in the ER, there are already several

studies. This is, for example, one: the

Acost study included 4,000 patients with

ST-segment elevation myocardial infarction (STEMI)

. Some received prasugel and others

received a placebo. And no benefit was shown

in terms of mortality and the other

critical outcomes of the

study, mainly mortality,

but there was a difference in the

patients in terms of bleeding.

So, basically, we

don't use prasugel for pretreatment. Ticagrelol, the

same. Ticagrelol, this is the

Atlantis study from 2014. It included about

1,800 patients and compared

patients who received ticagrelol

prehospitally. And others who were already being tested

in the

hemodynamics lab and were evaluating the resolution

of ST-segment elevation, which showed

no difference. The rate of

major cardiovascular events also

showed no difference, and the only thing they

told us was that there was a difference in

the patients who were discharged with this

management and who presented with

stent thrombosis. Perhaps those who were started

pre-hospital had less

stent thrombosis than those who were

started in the hospital.

However, as I said, we

probably won't use aspirin as pre-treatment in the

emergency department,

and none of these. We'll

leave that to the lab.

Anticoagulation is another

fundamental pillar in order to reduce

all the thrombotic complications that

can arise from the

interventions I'm going to perform.

Unfractionated aspirin

has classically been the preferred option,

right?

Especially in patients without

ST-segment elevation. However, the literature

and what they told us They mention here, and what I'm

going to show you next,

that perhaps enoxaparin is more

feasible. Why? Because those

recommendations for unfractionated enoxaparin

come from previous studies,

older studies. This recommendation was already

included in the guidelines. The problem is

that this requires

infusion,

and the response can be unpredictable, and there

may be a risk of

heparin-induced thrombocytopenia.

However, they give us

a conclusion based on the stress test, and

basically, if you're going to have the patient undergo

thrombolysis, then the most

studied and supported option is enoxaparin.

Keep in mind that with enoxaparin, if you're going to have the patient

undergo thrombolysis, you have a

change in dosage, and you have an

intravenous bolus for those under 75

years old,

and then continue with a

subcutaneous regimen.

In the case of thrombolysis, if you're going to have the patient

undergo PCI, or rather, if you

have a patient who is

going to undergo a

PCI strategy, consider the more fractionated enoxaparin

if available. Available, even this is

more like at the time of PCI,

so it might be more related to

use in hemodynamics. And use the

option if you see fit, well, if you consider it

difficult,

vivariludin, uh, or enoxaparin also

don't leave it as a contraindication. And if you are going to

give medical management, well, fondaparinox

can be an

option for those patients. How

long are we going to leave it? Well, if you

thrombolyzed the patient, what they tell us

is basically that this

anticoagulation should last at least

8 days or until the patient's discharge,

which is generally completed within

that time or whichever comes

first. And if you took the patient to

PCI, that's why the unfractionated heparin,

if you took them, you gave them unfractionated heparin

, when they come out of the

procedure, they are transferred to the ICU for

monitoring, uh, if they don't have any other

indication to continue

anticoagulation, it can be

discontinued. This is what I was telling you,

this is the ATOL study, a study of

900 patients. They basically evaluated

how they fared with heparin and how they fared

with enoxaparin and saw that the

patients fared better with

enoxaparin than

with

unfractionated heparin.

Another important debate in the literature is

the beta-blocker. And here they go so far as

to tell us, there is a

recommendation to give

beta-blockers to these patients early,

in the first 24 hours,

to reduce the risk of reinfarction and

ventricular arrhythmias. Why do I say this? Well,

this has a

pathophysiological context, and it is that they will decrease

the oxygen demand of the myocardium,

reduce heart rate,

blood pressure, and improve

contractility. Very useful in

patients with heart failure and

decreased bronchopulmonary edema. The thing is,

we had a debate because we

previously had these studies,

this is A 2014 meta-analysis by

Dr. Bangalore, which basically

evaluated the outcomes of patients

receiving beta-blockers, said there

was no difference in mortality

, but that these patients

developed more

cardiogenic shock. So, that was

the reason for not using them.

However, studies have come out

that also say there probably isn't a

difference in mortality,

but what we want to evaluate are

other things, and they tell us that there wo

n't be a

significant difference in infarct size.

Nor in ejection fraction, but in the incidence

of malignant arrhythmias—

I mean,

ventricular arrhythmias—well, it will be

favorable. So they tell us,

use it. Obviously, if the patient is at

risk of cardiogenic shock, don't

use it. But they tell us, if in those

first 24 hours you

couldn't administer it, re-evaluate in the next 24

hours. Come on, will the patient have

recovered? That risk he had of

developing shock, and can I already give him

the beta-blocker? And they recommend

giving it to him. So, it's a

recommendation that seems novel to me

and that somewhat addresses that debate that

existed, and with the strength they

give it, well, we should

consider it. The other thing is the

reperfusion strategy here within the management,

well, PCI and thrombolysis. Ideally, it

says if you have PCI, you have

availability within your hospital in

less than 90 minutes. This doesn't change. If

you don't have availability in less

than 120

minutes, patients with

cardiogenic shock should be taken to the

strategy, and if it's within 12 to 24

hours, or as time goes on,

you'll see that the recommendation

decreases. Thrombolysis, basically, if

you, the first recommendation for

thrombolysis is if you have the option of

taking him to a center that has PCI,

take him there. If not, thrombolyze him, and hopefully that

patient is within the first 12

hours, because otherwise it won't help.

If that patient is more than 12 hours away, it's

better to transfer him A center that has PCI and

that performs PCI. Where does this come from?

Well, we've known this for a

long time. These studies that first

compared PCI versus fibrinolysis,

obviously PCI performed much better,

so that's why we prefer PCI. And in

the studies of thrombolysis timing,

as we see, when a

patient has been waiting for more than 12 hours, there's no

difference compared to the

placebo, and hopefully, those patients will see more

difference if we take them to

reperfusion in less than 3 hours when we're

going to

thrombolyze them. Every minute I delay

taking my patient to PCI is

an increase in mortality. This is

a study that showed us that for every

10 minutes of delay in

PCI, after one hour from the first

medical contact, there were four deaths

per 100 patients. And that revealed

several factors related to

mortality, including my

taking too long and my patient

having some other type of

complication, such as

cardiogenic shock. The other recommendation,

which is also number one, is the recommendation

for the disease. Multivessel disease. And here they

tell us that you should prefer, this

is in terms of preferring surgery

versus PCI, multivessel disease. You

should prefer those patients who

have complex multivessel disease

, who have

significant stenosis of the left main coronary artery with

complex disease, who have

diabetes and multivessel disease with

involvement of the left anterior descending artery,

who have

multivessel disease with a

complex lesion of a coronary trunk and

left ventricular dysfunction,

they should undergo this strategy. And the

recommendation here, based on this

study, is also that if you are going to take

these patients for

revascularization, intervene in all

the vessels and not just the

culprit vessel, which was also a debate to

consider.

They said that the recommendation in this

study is that if you revascularize

everything completely, you will decrease

mortality from cardiovascular causes and

the rate of reinfarction. Finally, the

complications, which must be taken into

account. Basically, this:

papillary muscle rupture,

contained rupture, ventricular septal rupture

, rupture of a

free wall of the free wall of the Ventricular failure should

always be suspected in patients with

recurrent or refractory chest pain

,

accompanied by murmurs,

disproportionate heart failure, cardiogenic shock, or

sudden cardiac death,

especially upon admission

or within a week of the

infarction. Electrical complications can also occur

. An

important recommendation is that

these patients

with heart failure, who are left

with heart failure, decreased fever,

decreased functional class, and who

may be at high risk of

arrhythmias, should have a

cardioverter-defibrillator (CDI). In patients

with any type of heart block,

the appropriateness of

implanting a pacemaker should also be considered. Finally, for

safe discharge,

these recommendations are essential

. It's

basically about managing anything that

could increase cardiovascular risk,

and ensuring that whenever a patient

presents to the emergency department,

regardless of the reason for their visit, we are prepared to monitor their condition. When consulting,

we should consider what aspects of

my patient's care are not currently being managed, what they are

lacking, and how I can make an

impact.

Finally, to

rate the guideline, I basically

used this strategy, which is the GR (Graphic Reference Guide).

Basically, they tell us about the

recommendations and

the quality of the guideline. I give it a

six because there are some

recommendations that we already know from other

articles and that they don't dare to

mention. The quality of the

guideline's presentation seems good to me. The

European guideline is perhaps a little more

visually appealing, but this is

a good guideline, and the

recommendations are very easy to find

and understand.

The

reports in the guideline are

transparent and adequate; the

information is complete for

decision-making. I believe it is of

high quality in the

decisions they mention.

And the quality of

the recommendations, to

reiterate,

is also high because the recommendations... As I

showed you, they're based on a lot of

evidence, even though we might consider it as

nothing new, given that we

already have another one with a

six overall rating because not

everything was a seven. If I were to use the guide

in practice, I think we

have the option of choosing

several guides and articles and

making decisions based on that. So, I

agree, and I would

recommend it to someone, or would I

use it for... well, it was the other way around. I would

recommend this one to

someone, and this is the one I would use to make

decisions. I think so, because that's why I

brought up the review. That's

all. Thank you very much. I'll be waiting for

the discussion.