Vol 25, No 3 (2018)
Review articles — Clinical cardiology
Published online: 2018-04-17

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Treatment of patients with acute coronary syndrome: Recommendations for medical emergency teams: Focus on antiplatelet therapies. Updated experts’ standpoint

Jacek Kubica1, Piotr Adamski1, Przemysław Paciorek12, Jerzy R. Ładny3, Zbigniew Kalarus4, Waldemar Banasiak5, Wacław Kochman6, Jarosław Gorący7, Beata Wożakowska-Kapłon8, Eliano Pio Navarese1, Andrzej Kleinrok9, Robert Gil10, Maciej Lesiak11, Jarosław Drożdż12, Aldona Kubica1, Krzysztof J. Filipiak13, Jarosław Kaźmierczak7, Aleksander Goch1, Stefan Grajek11, Andrzej Basiński6, Łukasz Szarpak13, Grzegorz Grześk1, Piotr Hoffman14, Wojciech Wojakowski15, Zbigniew Gąsior16, Sławomir Dobrzycki3, Jolanta M. Siller-Matula17, Adam Witkowski14, Wiktor Kuliczkowski18, Marcin Gruchała6, Dariusz Timler12, Grzegorz Opolski13, Dariusz Dudek19, Jacek Legutko19, Marzenna Zielińska12, Jarosław Wójcik20
Pubmed: 29671864
Cardiol J 2018;25(3):291-300.


A group of Polish experts in cardiology and emergency medicine, encouraged by the European Society of Cardiology (ESC) guidelines, have recently published common recommendations for medical emergency teams regarding the pre-hospital management of patients with acute coronary syndrome. Due to the recent publication of the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation and 2017 focused update on dual antiplatelet therapy in coronary artery disease the current panel of experts decided to update the previous standpoint. Moreover, new data coming from studies presented after the previous document was issued were also taken into consideration.

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  1. Kubica J, Adamski P, Paciorek P, et al. Anti-aggregation therapy in patients with acute coronary syndrome - recommendations for medical emergency teams. Experts' standpoint. Kardiol Pol. 2017; 75(4): 399–408.
  2. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39(2): 119–177.
  3. Valgimigli M, Bueno H, Byrne RA, et al. 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease developed in collaboration with EACTS: The Task Force for dual antiplatelet therapy in coronary artery disease of the European Society of Cardiology (ESC) and of the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2018; 39(3): 213–260.
  4. Gierlotka M, Zdrojewski T, Wojtyniak B, et al. Incidence, treatment, in-hospital mortality and one-year outcomes of acute myocardial infarction in Poland in 2009-2012--nationwide AMI-PL database. Kardiol Pol. 2015; 73(3): 142–158.
  5. Terkelsen CJ, Sørensen JT, Maeng M, et al. System delay and mortality among patients with STEMI treated with primary percutaneous coronary intervention. JAMA. 2010; 304(7): 763–771.
  6. Huber K, De Caterina R, Kristensen SD, et al. Pre-hospital reperfusion therapy: a strategy to improve therapeutic outcome in patients with ST-elevation myocardial infarction. Eur Heart J. 2005; 26(19): 2063–2074.
  7. Lopes RD, Siha H, Fu Y, et al. Diagnosing acute myocardial infarction in patients with left bundle branch block. Am J Cardiol. 2011; 108(6): 782–788.
  8. Chan AW, Kornder J, Elliott H, et al. Improved survival associated with pre-hospital triage strategy in a large regional ST-segment elevation myocardial infarction program. JACC Cardiovasc Interv. 2012; 5(12): 1239–1246.
  9. Widimsky P, Rohác F, Stásek J, et al. Primary angioplasty in acute myocardial infarction with right bundle branch block: should new onset right bundle branch block be added to future guidelines as an indication for reperfusion therapy? Eur Heart J. 2012; 33(1): 86–95.
  10. Roffi M, Patrono C, Collet JP, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016; 37(3): 267–315.
  11. Dhruva VN, Abdelhadi SI, Anis A, et al. ST-Segment Analysis Using Wireless Technology in Acute Myocardial Infarction (STAT-MI) trial. J Am Coll Cardiol. 2007; 50(6): 509–513.
  12. Fordyce CB, Al-Khalidi HR, Jollis JG, et al. Association of Rapid Care Process Implementation on Reperfusion Times Across Multiple ST-Segment-Elevation Myocardial Infarction Networks. Circ Cardiovasc Interv. 2017; 10(1).
  13. Stowens JC, Sonnad SS, Rosenbaum RA. Using EMS Dispatch to Trigger STEMI Alerts Decreases Door-to-Balloon Times. West J Emerg Med. 2015; 16(3): 472–480.
  14. Squire BT, Tamayo-Sarver JH, Rashi P, et al. Effect of prehospital cardiac catheterization lab activation on door-to-balloon time, mortality, and false-positive activation. Prehosp Emerg Care. 2014; 18(1): 1–8.
  15. Nallamothu BK, Normand SLT, Wang Y, et al. Relation between door-to-balloon times and mortality after primary percutaneous coronary intervention over time: a retrospective study. Lancet. 2015; 385(9973): 1114–1122.
  16. Bagai A, Jollis JG, Dauerman HL, et al. Emergency department bypass for ST-Segment-elevation myocardial infarction patients identified with a prehospital electrocardiogram: a report from the American Heart Association Mission: Lifeline program. Circulation. 2013; 128(4): 352–359.
  17. Welsh RC, Chang W, Goldstein P, et al. Time to treatment and the impact of a physician on prehospital management of acute ST elevation myocardial infarction: insights from the ASSENT-3 PLUS trial. Heart. 2005; 91(11): 1400–1406.
  18. Parodi G. Editor's Choice-Chest pain relief in patients with acute myocardial infarction. Eur Heart J Acute Cardiovasc Care. 2016; 5(3): 277–281.
  19. Kubica J, Kubica A, Jilma B, et al. Impact of morphine on antiplatelet effects of oral P2Y12 receptor inhibitors. Int J Cardiol. 2016; 215: 201–208.
  20. Kubica J, Adamski P, Ostrowska M, et al. Morphine delays and attenuates ticagrelor exposure and action in patients with myocardial infarction: the randomized, double-blind, placebo-controlled IMPRESSION trial. Eur Heart J. 2016; 37(3): 245–252.
  21. Hobl EL, Stimpfl T, Ebner J, et al. Morphine decreases clopidogrel concentrations and effects: a randomized, double-blind, placebo-controlled trial. J Am Coll Cardiol. 2014; 63(7): 630–635.
  22. Parodi G, Bellandi B, Xanthopoulou I, et al. Morphine is associated with a delayed activity of oral antiplatelet agents in patients with ST-elevation acute myocardial infarction undergoing primary percutaneous coronary intervention. Circ Cardiovasc Interv. 2015; 8(1).
  23. Kubica J, Adamski P, Ostrowska M, et al. Influence of morphine on pharmacokinetics and pharmacodynamics of ticagrelor in patients with acute myocardial infarction (IMPRESSION): study protocol for a randomized controlled trial. Trials. 2015; 16: 198.
  24. Puymirat E, Lamhaut L, Bonnet N, et al. Correlates of pre-hospital morphine use in ST-elevation myocardial infarction patients and its association with in-hospital outcomes and long-term mortality: the FAST-MI (French Registry of Acute ST-elevation and non-ST-elevation Myocardial Infarction) programme. Eur Heart J. 2016; 37(13): 1063–1071.
  25. Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J. 2005; 149(6): 1043–1049.
  26. Iakobishvili Z, Porter A, Battler A, et al. Effect of narcotic treatment on outcomes of acute coronary syndromes. Am J Cardiol. 2010; 105(7): 912–916.
  27. de Waha S, Eitel I, Desch S, et al. Intravenous morphine administration and reperfusion success in ST-elevation myocardial infarction: insights from cardiac magnetic resonance imaging. Clin Res Cardiol. 2015; 104(9): 727–734.
  28. Steg PhG, James SK, Atar D, et al. ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20): 2569–2619.
  29. Alexopoulos D, Barampoutis N, Gkizas V, et al. Crushed versus integral tablets of ticagrelor in ST-segment elevation myocardial infarction patients: a randomized pharmacokinetic/pharmacodynamic study. Clin Pharmacokinet. 2016; 55(3): 359–367.
  30. Parodi G, Xanthopoulou I, Bellandi B, et al. Ticagrelor crushed tablets administration in STEMI patients: the MOJITO study. J Am Coll Cardiol. 2015; 65(5): 511–512.
  31. Rollini F, Franchi F, Angiolillo DJ, et al. Crushed Prasugrel Tablets in Patients With STEMI Undergoing Primary Percutaneous Coronary Intervention: The CRUSH Study. J Am Coll Cardiol. 2016; 67(17): 1994–2004.
  32. Niezgoda P, Sikora J, Barańska M, et al. Crushed sublingual versus oral ticagrelor administration strategies in patients with unstable angina. A pharmacokinetic/pharmacodynamic study. Thromb Haemost. 2017; 117(4): 718–726.
  33. Stub D, Smith K, Bernard S, et al. AVOID Investigators. Air Versus Oxygen in ST-Segment-Elevation Myocardial Infarction. Circulation. 2015; 131(24): 2143–2150.
  34. Thygesen K, Alpert J, Jaffe A, et al. Third universal definition of myocardial infarction. Eur Heart J. 2012; 33(20): 2551–2567.
  35. Lange RA, Hillis LD. Antiplatelet therapy for ischemic heart disease. N Engl J Med. 2004; 350(3): 277–280.
  36. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2014; 35(37): 2541–2619.
  37. Sheyin O, Perez X, Pierre-Louis B, et al. The optimal duration of dual antiplatelet therapy in patients receiving percutaneous coronary intervention with drug-eluting stents. Cardiol J. 2016; 23(3): 307–316.
  38. Kubica A, Kasprzak M, Siller-Matula J, et al. Time-related changes in determinants of antiplatelet effect of clopidogrel in patients after myocardial infarction. Eur J Pharmacol. 2014; 742: 47–54.
  39. Serebruany VL, Midei MG, Meilman H, et al. Platelet inhibition with prasugrel (CS-747) compared with clopidogrel in patients undergoing coronary stenting: the subset from the JUMBO study. Postgrad Med J. 2006; 82(968): 404–410.
  40. Wiviott SD, Trenk D, Frelinger AL, et al. PRINCIPLE-TIMI 44 Investigators. Prasugrel compared with high loading- and maintenance-dose clopidogrel in patients with planned percutaneous coronary intervention: the Prasugrel in Comparison to Clopidogrel for Inhibition of Platelet Activation and Aggregation-Thrombolysis in Myocardial Infarction 44 trial. Circulation. 2007; 116(25): 2923–2932.
  41. Husted SE, Storey RF, Bliden K, et al. Pharmacokinetics and pharmacodynamics of ticagrelor in patients with stable coronary artery disease: results from the ONSET-OFFSET and RESPOND studies. Clin Pharmacokinet. 2012; 51(6): 397–409.
  42. Steg PG, James S, Harrington RA, et al. Inhibition of platelet aggregation by AZD6140, a reversible oral P2Y12 receptor antagonist, compared with clopidogrel in patients with acute coronary syndromes. J Am Coll Cardiol. 2007; 50(19): 1852–1856.
  43. Mehta SR, Tanguay JF, Eikelboom JW, et al. Double-dose versus standard-dose clopidogrel and high-dose versus low-dose aspirin in individuals undergoing percutaneous coronary intervention for acute coronary syndromes (CURRENT-OASIS 7): a randomised factorial trial. Lancet. 2010; 376(9748): 1233–1243.
  44. Dans AL, Connolly SJ, Wallentin L, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) trial. Circulation. 2013; 127(5): 634–640.
  45. Sørensen R, Hansen ML, Abildstrom SZ, et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009; 374(9706): 1967–1974.
  46. Hansen ML, Sørensen R, Clausen MT, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010; 170(16): 1433–1441.
  47. Oldgren J, Budaj A, Granger CB, et al. RE-DEEM Investigators. Dabigatran vs. placebo in patients with acute coronary syndromes on dual antiplatelet therapy: a randomized, double-blind, phase II trial. Eur Heart J. 2011; 32(22): 2781–2789.
  48. Kubica J, Kozinski M, Navarese EP, et al. Cangrelor: an emerging therapeutic option for patients with coronary artery disease. Curr Med Res Opin. 2014; 30(5): 813–828.
  49. Bhatt D, Stone G, Mahaffey K, et al. Effect of Platelet Inhibition with Cangrelor during PCI on Ischemic Events. N Engl J Med. 2013; 368(14): 1303–1313.
  50. Kubica J, Pstrągowski K, Adamski P, et al. Mild therapeutic hypothermia for patients with acute coronary syndrome and cardiac arrest treated with percutaneous coronary intervention (UNICORN). The design and rationale for the prospective, observational, multicenter study. Med Res J. 2016; 1(1): 23–27.
  51. Klimczuk T, Kubica J, Kasprzak M, et al. Łagodna hipotermia terapeutyczna po nagłym zatrzymaniu krążenia w przebiegu ostrego zespołu wieńcowego – doświadczenia z wdrażania metody. Folia Cardiol. 2015; 10(1): 19–24.
  52. Wiviott SD, Braunwald E, McCabe CH, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007; 357(20): 2001–2015.
  53. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361(11): 1045–1057.
  54. Adamski P, Adamska U, Ostrowska M, et al. New directions for pharmacotherapy in the treatment of acute coronary syndrome. Expert Opin Pharmacother. 2016; 17(17): 2291–2306.
  55. Held C, Asenblad N, Bassand JP, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol. 2011; 57(6): 672–684.
  56. Directive of the Minister of Health dated 20 April 2016 on medical rescue procedures and health services different than medical rescue procedures, which can be performed by paramedic.
  57. Kleinrok A, Płaczkiewicz DT, Puźniak M, et al. Electrocardiogram teletransmission and teleconsultation: essential elements of the organisation of medical care for patients with ST segment elevation myocardial infarction: a single centre experience. Kardiol Pol. 2014; 72(4): 345–354.
  58. Abraham NS, Hlatky MA, Antman EM, et al. ACCF/ACG/AHA 2010 expert consensus document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use. A Report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol. 2010; 56(24): 2051–2066.
  59. Rakowski T, Siudak Z, Dziewierz A, et al. Contemporary use of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction referred to primary percutaneous coronary interventions in Poland: Data from ORPKI national registry. J Thromb Thrombolysis. 2018; 45(1): 151–157.