ST-Elevation Myocardial Infarction (STEMI)

Publication Date: January 1, 2013

Key Points

Key Points

  • Systems of care should be established in each community to care for patients with ST-Elevation Myocardial Infarction (STEMI) with the ultimate goal of reducing total ischemic time between symptom onset and reperfusion.
  • Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients with STEMI when it can be done in a timely fashion (ie, within 2 hours of first medical contact) by expert operators.
  • Following delivery of fibrinolytic therapy when indicated, patients should be transferred to a PCI-capable center, even if clinically stable with signs of successful reperfusion.
  • Non-infarct artery PCI, when indicated, should be deferred to a time remote from primary PCI in the absence of shock or severe heart failure.

Treatment

...Treatment...

...Onset of Myocard...

...Regional Systems...

...should create and maintain a regional system...

...ance of a 12-lead electrocardiogram (ECG) b...

Reperfusion therapy should be administered to...

...ommended method of reperfusion when it...

...hospital for primary PCI is the reco...

...ate transfer to a PCI-capable hospi...

...nce of contraindications, fibrinolytic...

...brinolytic therapy is indicated or chosen as t...

...erfusion therapy is reasonable for patients with...

...Evaluation and Man...

...ypothermia should be started as soon as possib...

...ediate angiography and PCI when indicated sh...

...ed time windows are system goals. For any indi...


.... Improving Door-to-Balloon (D2B) TimesHaving tro...


...rfusion Therapy for Patients with STEMI...


...Reperfus...

...hould be performed in patients with STEMI...

...I should be performed in patients wit...

...ld be performed in patients with STEMI and...

...ary PCI is reasonable in patients with STEMI if...

...NOT be performed in a noninfarct artery at the ti...


...Table 2. Primary...

...ic symptoms...

...hemic sympto...

...shock or acute severe HF irrespective of tim...

...ing ischemia 12-24 h after symptom onset...

...I of a noninfarct artery at the time of pr...

...Aspiration...

...ation thrombectomy is reasonable for patie...

...Use...

...of a stent (bare-metal stent [BMS] or drug-el...

...used in patients with high bleeding risk, in...

...NOT be used in primary PCI for patients w...

...lasty without stent placement may be us...

...Adjunctive Ant...

...Antiplatelet Therap...

...25 mg should be given before primary PCI. ( B...

...spirin should be continued indefinitel...

...ogrel 600 mg (I-B) or ( B , I...

...l 60 mg (I-B) or (B, I)701...

Ticagrelor 180 mg (B...

...pidogrel 75 mg daily or ( B , I )701...

...10 mg daily or ( B , I )701...

...agrelor 90 mg bida ( B ,...

...The recommended maintenance dose of aspir...

...nable to use 81 mg of aspirin per day in...

...ximab ( A , IIa...

high-bolus-dose tirofiban ( B , II...

...double-bolus eptifibatide ( B , IIa )...

...nable to administer intravenous GP IIb...

...ay be reasonable to administer intr...

...ntinuation of a P2Y inhibitor beyond 1 year may...

...sugrel should NOT be administered to pa...

...Anti...

...with additional boluses administered...

...h or without prior treatment with UFH. ( B , I...

...nts with STEMI undergoing PCI who are at hig...

Fondaparinux should NOT be used as th...

...with additional boluses administered as needed...

...udin with or without prior treatment with UFH...


...T...

...Antiplatelet therap...

...Aspir...

...2-325 mg load before procedure (B)701...

...325 mg daily maintenance dose (indefinite)a (...

...g daily is the preferred maintenanc...

...P2Y12 ...

...ogrel: 600 mg as early as possible or at...

...ugrel: 60 mg as early as possible or at...

...0 mg as early as possible or at time of...

...Mai...

...el: 75 mg daily or ( B , I...

...10 mg daily or ( B , I )70...

...or: 90 mg bida ( B , I )701...

...idogrel: 75 mg daily or ( B , I )70...

...ugrel: 10 mg daily or ( B ,...

...: 90 mg bida ( B , I )701...

...Clopidogrel, prasugrel, or ticagre...

...Patients with STEMI with prior stroke or...

...IV GP IIb/IIIa receptor a...

...ximab: 0.25-mg/kg IV bolus, then 0.125...

...ban: (high-bolus dose): 25-mcg/kg IV bolus, then...

...patients with creatinine clearance...

...Eptifibatide: (double bolus): 180-...

...ents with CrCl...

...void in patients on hemodialysis ( B...

...re-catheterization laboratory administratio...

Intracoronary abciximab 0.25-mg/kg bolus ( B...

...Anticoagulan...

...UFH:...

.../IIIa receptor antagonist planned: 5...

...GP IIb/IIIa receptor antagonist pl...

...lirudin: 0.75-mg/kg IV bolus, then 1.7...

...usion to 1 mg/kg/h with estimated CrCl...

...UFH with GP IIb/IIIa receptor anta...

Fondaparinux: not recommended as sol...

...a The recommended maintenance dose of as...


...Reperfusion at a...

...Fibrinol...

...bsence of contraindications, fibrinolyt...

In the absence of contraindications...

...erapy should NOT be administered to pati...


...Tabl...

...hemic symptom...

...dence of ongoing ischemia 12-24 h after sympt...

...sion, except if true posterior (inferobasa...


Table 5. Fibrinolytic Agents 

...brinolytic Agents Having trouble viewing tabl...

...aindications and Cautions for Fibrinolytic Therapy...

...Adjunctive...

...Antipla...

Aspirin(162-325 mg loading dose) a...

...e continued indefinitely. ( A , I )701...

...grel (75 mg daily) should be continu...

...d up to 1 year ( C , I )701...

...onable to use aspirin 81 mg per day in prefer...

...ts with STEMI undergoing reperfusion with f...

Recommended regimen...

...ministered as a weight-adjusted intravenous...

...istered according to age, weight, and CrCl, g...

...ux administered with initial intravenous dose,...


...Table 7. Adjunctive Anti...

...Antiplatelet therapy...

...mg loading dose ( A , I )701

...-325 mg daily maintenance dose (indefinite) ( A ,...

...ily is the preferred maintenance dose ( A , I...

...P...

...Clopidogrel

...75 y: 300 mg loading dose ( A ,...

...14 d) ( A , I...

...y) ( C , I )701...

...ge >75 y: no loading dose, give 75 mg ( A...

...4 d) ( A , I )7...

...1 y) ( C , I )701

...Anticoagulant...

...-based IV bolus and infusion adjust...

...Enox...

...If age...

...Fondaparinux...

...itial dose 2.5 mg IV, then 2.5 mg sub...

...Transfer of Patient...

...mmediate transfer to a PCI-capable hospital f...

...gent transfer to a PCI-capable hospital for corona...

...r to a PCI-capable hospital for coronary angiograp...

...Although individual circumstances will vary, clin...


...Table 8. Indi...

...ransfer for cardiogenic shock or sever...

...ent transfer for failed reperfusion or r...

...art of an invasive strategy in stable pati...

...ndividual circumstances will vary, clinical...


...Delayed Invasi...

...Coro...

...rdiogenic shock or acute severe HF that de...

...ntermediate- or high-risk findings o...

...rdial ischemia that is spontaneous...

...graphy with intent to perform revascularizat...

...onary angiography is reasonable before hospit...

...idual circumstances will vary, clinical s...


T...

...genic shock or acute severe HF that develo...

...high-risk findings on pre-discharge noninv...

...r easily provoked myocardial ischemia ( C , I...

...rfusion or reocclusion after fibrinolytic thera...

...ients after successful fibrinolysis,...

...dividual circumstances will vary, clini...

...PCI of an Infarct Ar...

...hock or acute severe HF or (B, I)701...

...te- or high-risk findings on predi...

...ial ischemia that is spontaneous or provoked by mi...

...ed PCI is reasonable in patients with ST...

...a significant stenosis in a patent i...

...of a significant stenosis in a patent infar...

Delayed PCI of a totally occluded infarct artery >...

...ough individual circumstances will var...


...Table 10. Indi...

...ock or acute severe HF ( B , I )701...

...or high-risk findings on predischarge noninv...

...easily provoked myocardial ischemia ( C ,...

...tients with evidence of failed reperfusio...

...nts after successful fibrinolysis,...

...lea patients >24 h after successful fibrinolysis...

...of a totally occluded infarct artery >...

...ndividual circumstances will vary, clinical stabil...

...PCI of a Noninfarct A...

PCI is indicated in a noninfarct artery...

...s reasonable in a noninfarct artery at a...

...Adjuncti...

...Antiplatelet Ther...

...pirin should be continued indefinitely. ( A...

...0 mg loading dose should be given before or at...

...ading dose should be given before or...

...daily should be given after PCI. ( C ,...

...er PCI, it is reasonable to use 81 mg of aspi...

Prasugrel, in a 60 mg loading dose, is re...

...10 mg daily maintenance dose, is reasonable a...

...hould NOT be administered to patients with a his...

...Anticoagulant...

...nts with STEMI undergoing PCI after recei...

...r patients with STEMI undergoing PCI afte...

...inux should NOT be used as the sole...


...Table 11....

Anti...

...-325 mg loading dose given with fibrinoly...

...-325 mg daily maintenance dose after PCI (indefin...

...the preferred daily maintenance dose (...

...P2Y12 i...

...Loadi...

...ho received a loading dose of clopid...

...ents who have not received a loading dose of c...

...is performed ≤24 h after fibrinolytic...

...f PCI is performed >24 h after fibrinolytic therap...

...ormed >24 h after treatment with a...

...h prior stroke/TIA: prasugrel ( B , III (har...

...Maintenance Doses...

...tinue therapy for ≥30 d and up to 1 y with...

Clopidogrel: 75 mg daily OR (...

...rasugrel: 10 mg daily ( B , I...

Clopidogrel: 75 mg daily or ( C ,...

...l: 10 mg daily ( B , IIa )701...

...Anticoagulant...

...tinue UFH through PCI, administerin...

...xaparin through PCI: No additiona...

...daparinux as sole anticoagulant for PC...

...aACT with no planned GP IIb/IIIa receptor an...


...Coron...

...CABG in Pati...

...gent CABG is indicated in patients with STEMI...

...ended in patients with STEMI at time of op...

...mechanical circulatory support is r...

Emergency CABG within 6 hours of sym...

...rin should not be withheld before urgent...

...pidogrel or ticagrelor should be discontinued...

...ort-acting intravenous GP IIb/IIIa...

...be discontinued at least 12 hours befo...

Urgent off-pump CABG within 24 hours of...

...ent CABG within 5 days of clopidogrel or ticagrel...


...Routine Medical T...

...Oral beta blockers should be init...

...ould be continued during and after...

...tients with initial contraindications to the use...

...reasonable to administer intravenous b...

...Renin-An...

...in-converting enzyme (ACE) inhibitor...

...iotensin receptor blocker (ARB) should be gi...

...ne antagonist should be given to patients with...

...re reasonable for all patients with S...

...Lipid Manage...

...igh-intensity statin therapy should be initiate...

...is reasonable to obtain a fasting...

...lected Routine Medical TherapiesHaving tro...


...Compl...

...Cardiogenic Shock...

...ergency revascularization with either PCI or CA...

...of contraindications, fibrinolytic therapy...

...a-aortic balloon pump (IABP) counterpuls...

...rnative LV assist devices for circulatory supp...

...Implanta...

...able cardioverter-defibrillator (ICD) therapy is...

...Bradycardia, AV...

...Pacing in STEMI...

...rary pacing is indicated for symptomatic...

...Pericarditis...

...ecommended for treatment of pericarditis...

...dministration of acetaminophen, colchicine, or n...

...icoids and nonsteroidal anti-inflammatory drugs...


Table 13. Selected Risk Factors for...

...Thromboemb...

...nticoagulant therapy with a vitamin...

...tion of triple antithrombotic therapy wi...

...gulant therapy with a vitamin K antagonist...

...gulant therapy may be considered fo...

...n K antagonist therapy to a lower international...

...riteriaHaving trouble viewing table? Expand...


...Use of Noninvasive Testing...

...sive testing for ischemia should be per...

...oninvasive testing for ischemia might be con...

...ing for ischemia might be considered before d...

...Asse...

...cular ejection fraction (LVEF) should be measured...

...Assessment of...

Patients with an initially reduced LVEF who...


...Posthospitalization Plan...

...ital systems of care designed to prevent h...

...cise-based cardiac rehabilitation/secon...

...r, detailed, and evidence-based plan of care tha...

...ent and advice to stop smoking and t...