Perspectives about the 2020 ESC Guidelines

For the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

The content given in the videos reflects the opinion and scientific knowledge of the healthcare professionals.

In this video, Prof. Evangelos Giannitsis from University of Heidelberg, Germany discusses the biomarker section of the new ESC Guidelines in the light of current evidence.

Main messages:

  • "…the new ESC Guidelines now emphasize hs troponin assays and the 0-1 algorithm for diagnosis of non-ST elevated myocardial infarction. With that the standard 0-3 algorithm has been downgraded. That means we move away from the 99,9 percentile as decision cutoff for the diagnosis of infarction…I think there is not enough evidence for the 0-1 algorithm…"
  • "Usefulness of other biomarkers has been downgraded…that’s why the current guidelines cannot be easily understood…"

Concerned about safety of discharging patients with ACS suggestive symptoms despite full MI workup in ED? Learn from Prof. Evangelos Giannitsis, University of Heidelberg, Germany how the biomarkers copeptin and troponin can give you confidence.

Main messages:

  • "…we like to discharge patients abased on any algorithm…also on the ESC suggested 0-1 algorithm…but evidence for a safe discharge is very limited… there is no randomized clinical trial available currently…However, the BIC-8 trial showed that by using copeptin and troponin you can discharge patients more often with a death rate of zero after 30 days. This was confirmed by real world evidence from 18 countries (registry procure)…"

Not sure how to rule out of ACS in emergency cases? In this video, Prof. Martin Moeckel from Charité University, Berlin explains his view on the current ESC Guidelines and which algorithm he uses in clinical practice.

Main messages:

  • "…Copeptin has been challenged by the new recommendation but not by new data…"
  • "…guidelines have left out some fields of diagnostic purposes in ACS which require a more differentiated approach in clinical practice…they focus very much on a definite ACS population with typical symptoms, and not on the undifferentiated broad spectrum of presentation what we see in emergency medicine…"

Not possible to follow the new ESC Guidelines with hs-Tn for NSTE-ACS? Listen to Prof. Evangelos Giannitsis, University of Heidelberg, Germany who talks about current biomarker evidence.

Main messages:

  • "…evidence on all available 0-1 and 0-2 algorithms are not fully displayed in the new ESC Guidelines…not all high sensitive troponins can be used for these two algorithms as they have not been fully validated…"

Need help in grey zones with a 0-1 algorithm using hsTn only? Prof. Kurt Huber, Medical School Vienna, Austria explains his view on the effects from the ESC Guidelines 2020 and where he prefers a dual marker strategy with copeptin.

Main messages:

    What’s your opinion on the diagnostics chapter in the new ESC Guidelines 2020?
  • "…not all centers can use just high sensitive troponin…we have relatively good experience with a dual assay system using copeptin in combination with troponin to exclude ACS patients, especially with a non-high troponin…"
  • "…we have several markers with very important prognostic value, including copeptin. It’s not true to say you should not use these biomarkers any longer. It depends on your individual decision in your hospital and in your lab to be used in clinical routine…"

In this video Prof. Hüseyin Ince from Rostock Medical University, Germany explains you his opinion on the diagnostics chapter of the new ESC Guidelines.

Main messages:

    What’s your opinion on the diagnostics chapter in the new ESC Guidelines 2020?
  • "…biomarkers are very important, to focus only on the troponin is not the right way to go…I think there is valuable information you can get out of other biomarkers…"

How do the new ESC Guidelines change the clinical practice? Learn from Prof. Martin Moeckel from Charité University, Berlin how he will react and he sees the evidence for the IIIB recommendation.

Main messages:

    What do you think about the group of biomarkers stated with the recommendation level IIIB (not recommended)?
  • "…I reviewed the six citations of the IIIB recommendation, none support any part of the recommendation…maybe this is a mistake…"

In this video, learn from Prof. Evangelos Giannitsis, University of Heidelberg, Germany how he sees current biomarker practice in NSTE-ACS for the safety of patients and effectiveness of monitoring.

Main messages:

  • "…my major challenge is to have decongestion of my chest pain unit, so l like all fast protocols but I need flexibility…instant rule out with hs-Tn, dual marker strategy with Copeptin…if we cannot keep the interval for blood draw in two hour +/- 90 minutes, then I can flexibly switch to 0-1 or 0-3 protocols.…sometimes is necessary to perform…"

No further intermediate-risk group in NSTE-ACS patients? Listen to Prof. Martin Moeckel from Charité University, Berlin who critically talks about the two risk categories in the ESC Guidelines as there is no new studies supporting this.

Main messages:

    What do you think about the group of biomarkers stated with the recommendation level IIIB (not recommended)?
  • "…use of prognostic markers in ACS is no definite standard of routine care…you primarily look for the diagnostic aspect to decide on the further direction of the patient. Nobody knows at the moment what to do with prognostic information…this may change in the future…"
  • "…risk stratification in new Guidelines may be too simple: high-risk and normal risk…but it must not be oversimplified… we do have an intermediate risk category which is challenging and many patients are in…"

 

Intended use for B·R·A·H·M·S Copeptin proAVP KRYPTOR is:

The B·R·A·H·M·S Copeptin proAVP KRYPTOR assay measures the C-Terminal precursor fragment of Vasopressin (AVP or ADH). Vasopressin is a key regulator of water balance, has haemodynamic effects and plays a critical role in the regulation of hypothalamo-pituitary-adrenal axis reflecting the individual stress response. Copeptin and vasopressin (AVP, ADH) are released from the same precursor hormone in equimolar amounts into the bloodstream, hence Copeptin can be used as a surrogate marker for vasopressin. B·R·A·H·M·S Copeptin proAVP KRYPTOR is indicated in conjunction with Troponin as an aid in ruling out acute myocardial infarction in patients presenting with chest pain or equivalent symptoms of cardiac origin. B·R·A·H·M·S Copeptin proAVP KRYPTOR is indicated in conjunction with other clinical data (e.g. osmolality and hydration status) as an aid in the differential diagnosis of patients with water balance disorders, e.g. Polyuria-Polydipsia Syndrome and Syndrome of Inappropriate ADH secretion (SIADH).

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