European Resuscitation Council Guidelines for Resuscitation ... - CPR

Resuscitation 81 (2010) 1353–136318 de 0ctubre de 2010 www.elsuapdetodos.comContents lists available at ScienceDirectResuscitationjournal homepage: www.elsevier.com/locate/resuscitationEuropean Resuscitation Council Guidelines for Resuscitation 2010Section 5. Initial management of acute coronary syndromesHans-Richard Arntz a,1 , Leo L. Bossaert b,∗,1 , Nicolas Danchin c , Nikolaos I. Nikolaou da Department of Cardiology, Campus Benjamin Franklin, Charite, Berlin, Germanyb Department of Critical Care, University of Antwerp, Antwerp, Belgiumc Department of Coronary Artery Disease and Intensive Cardiac Care, Hôpital Européen Georges Pompidou, Paris, Franced Constantopouleio General Hospital, Athens, GreeceSummary of main changes since 2005 GuidelinesChanges in the management of acute coronary syndrome sincethe 2005 guidelines include:DefinitionsThe term non-ST-elevation myocardial infarction-acute coronarysyndrome (non-STEMI-ACS) has been introduced for bothNSTEMI and unstable angina pectoris because the differential diagnosisis dependent on biomarkers that may be detectable only afterhours, whereas decisions on treatment are dependent on the clinicalsigns at presentation.Chest pain units and decision rules for early discharge• History, clinical examinations, biomarkers, ECG criteria and riskscores are unreliable for the identification of patients who maybe safely discharged early.• The role of chest pain observation units (CPUs) is to identify, byusing repeated clinical examinations, ECG and biomarker testing,those patients who require admission for invasive procedures.This may include provocative testing and, in selected patients,imaging procedures as cardiac computed tomography, magneticresonance imaging, etc.Symptomatic treatment• Non-steroidal anti-inflammatory drugs (NSAIDs) should beavoided.• Nitrates should not be used for diagnostic purposes.• Supplementary oxygen to be given only to those patients withhypoxaemia, breathlessness or pulmonary congestion. Hyperoxaemiamay be harmful in uncomplicated infarction.Causal treatment• Guidelines for treatment with acetyl salicylic acid (ASA) havebeen made more liberal and it may now be given by bystanderswith or without dispatchers assistance.• Revised guidance for new antiplatelet and antithrombin treatmentfor patients with ST elevation myocardial infarction (STEMI)and non-STEMI-ACS based on therapeutic strategy.• Gp IIb/IIIa inhibitors before angiography/percutaneous coronaryintervention (PCI) are discouraged.Reperfusion strategy in STEMI• Primary PCI (PPCI) is the preferred reperfusion strategy providedit is performed in a timely manner by an experienced team.• A nearby hospital may be bypassed by emergency medical services(EMS) provided PPCI can be achieved without too muchdelay.• The acceptable delay between start of fibrinolysis and first ballooninflation varies widely between about 45 and 180 mindepending on infarct localisation, age of the patient, and durationof symptoms.• ‘Rescue PCI’ should be undertaken if fibrinolysis fails.• The strategy of routine PCI immediately after fibrinolysis (‘facilitatedPCI’) is discouraged.• Patients with successful fibrinolysis but not in a PCI-capable hospitalshould be transferred for angiography and eventual PCI,performed optimally 6–24 h after fibrinolysis (the ‘pharmacoinvasive’approach).• Angiography and, if necessary, PCI may be reasonable in patientswith return of spontaneous circulation (ROSC) after cardiac arrestand may be part of a standardised post-cardiac arrest protocol.• To achieve these goals, the creation of networks including EMS,non-PCI capable hospitals and PCI hospitals is useful.www.elsuapdetodos.comPrimary and secondary prevention∗ Corresponding author.E-mail address: leo.bossaert@ua.ac.be (L.L. Bossaert).1 These individuals contributed equally to this manuscript and are equal first coauthors.• Recommendations for the use of beta-blockers are morerestricted: there is no evidence for routine intravenous betablockersexcept in specific circumstances such as for the0300-9572/$ – see front matter © 2010 European Resuscitation Council. Published by Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.resuscitation.2010.08.016