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

...reatmen...

...et of Myocardial Infarction (MI)...

Regional Systems of STEMI Care, Reperfusion Therap...

...l communities should create and maintain a reg...

...of a 12-lead electrocardiogram (ECG...

...apy should be administered to all eligible pat...

...s the recommended method of reperfusion...

...le hospital for primary PCI is the recommended...

...sfer to a PCI-capable hospital for prim...

...ence of contraindications, fibrinolytic therapy...

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

...erapy is reasonable for patients with STEM...

...Management of Patients With STEMI and Out-...

...hypothermia should be started as soon...

...mediate angiography and PCI when indicated...

...oposed time windows are system goals. For...


...proving Door-to-Balloon (D2B) TimesHaving tr...


...fusion Therapy for Patients with STEMI...


...perfusion At a PCI-Capable Hospital...

...CI should be performed in patients with STEMI...

Primary PCI should be performed in patients with...

...imary PCI should be performed in patients with...

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

PCI should NOT be performed in a noninfarc...


...Primary PCI in STEMI...

Ischemic sym...

...emic symptoms...

...ogenic shock or acute severe HF irr...

...of ongoing ischemia 12-24 h after symptom onset...

...a noninfarct artery at the time of primary P...

Aspiration Thrombect...

...iration thrombectomy is reasonable for patients...

...f Stents in Primary...

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

...sed in patients with high bleeding risk, inab...

...hould NOT be used in primary PCI for patients wi...

...oplasty without stent placement may be us...

Adjunctive Antithrombotic Therapy for Primary PC...

...atelet Therapy

...rin 162-325 mg should be given before...

...r PCI, aspirin should be continued indefi...

...00 mg (I-B) or ( B , I )701...

...0 mg (I-B) or (B, I)701...

...icagrelor 180 mg (B, I)701...

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

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

...elor 90 mg bida ( B , I...

...nded maintenance dose of aspirin to...

...onable to use 81 mg of aspirin per d...

...iximab ( A , IIa...

...h-bolus-dose tirofiban ( B ,...

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

...be reasonable to administer intravenous GP IIb/...

...t may be reasonable to administer intracoronary ab...

...ation of a P2Y inhibitor beyond 1 year ma...

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

...gulant Therapy

...onal boluses administered as needed to ma...

...din with or without prior treatment with...

...ents with STEMI undergoing PCI who are at hi...

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

...additional boluses administered as needed to m...

...ith or without prior treatment with U...


...3. Adjunctive Antithrombotic Therapy to Sup...

...atelet therapy...

Aspir...

...g load before procedure (B)7...

...daily maintenance dose (indefinite)...

...daily is the preferred maintenance dosea...

... inhibitors

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

...as early as possible or at time of PCI or ( B...

...180 mg as early as possible or at time of PCI...

Maintenance Doses and Duration o...

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

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

...elor: 90 mg bida ( B , I...

Clopidogrel: 75 mg daily or ( B , I )...

...asugrel: 10 mg daily or ( B...

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

...el, prasugrel, or ticagrelor a conti...

...STEMI with prior stroke or TIA: prasugrel ( B...

...a receptor antagonists in conjunction w...

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

...(high-bolus dose): 25-mcg/kg IV bolus, then 0.15...

...ients with creatinine clearance (CrC...

...(double bolus): 180-mcg/kg IV bolus, then 2...

In patients with CrC...

...ents on hemodialysis ( B , IIa )701...

...re-catheterization laboratory administration of I...

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

Anticoagulant...

UFH...

...IIa receptor antagonist planned: 50-70-U/...

With no GP IIb/IIIa receptor antagonist planned:...

...lirudin: 0.75-mg/kg IV bolus, then 1.75 mg/kg/h i...

Reduce infusion to 1 mg/kg/h with estimat...

...ver UFH with GP IIb/IIIa receptor antagonist in pa...

...not recommended as sole anticoagulant for p...

...a The recommended maintenance dose...


...erfusion at a Non–PCI-Capable H...

...brinolytic Therapy When There Is An Anticipat...

...ence of contraindications, fibrinolytic the...

...e of contraindications and when PCI...

...olytic therapy should NOT be administered to pa...


...cations for Fibrinolytic Therapy When There...

...schemic symptoms...

...ce of ongoing ischemia 12-24 h after symp...

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


Table 5. Fibrinolytic Agents 

...ble 5. Fibrinolytic Agents Having troub...

...ontraindications and Cautions for Fibrinolyt...

Adjunctive Antithrombotic Therapy With Fibrino...

...latelet Therapy...

...rin(162-325 mg loading dose) and clopido...

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

...clopidogrel (75 mg daily) should be continue...

...to 1 year ( C , I )7...

...is reasonable to use aspirin 81 mg per...

...agulant Therapy...

...with STEMI undergoing reperfusion with fibrinolyt...

...ended regimens includ...

...dministered as a weight-adjusted in...

...in administered according to age,...

...dministered with initial intravenous dose, f...


...unctive Antithrombotic Therapy to Support...

...tiplatelet ther...

Aspiri...

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

81-325 mg daily maintenance dose (ind...

...aily is the preferred maintenance dose (...

...Y12 inhibitor...

...opidogrel...

...75 y: 300 mg loading dose ( A , I )701...

...( A , I )701...

...≤1 y) ( C , I...

...no loading dose, give 75 mg ( A , I )701...

...( A , I )701...

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

...icoagulant therapy...

...FH...

...ht-based IV bolus and infusion adjuste...

...xaparin...

...If age...

...aparinux ...

...ose 2.5 mg IV, then 2.5 mg subcutaneously daily...

...atients With STEMI to a PCI-Capable Hospital for C...

Immediate transfer to a PCI-capable hospita...

...gent transfer to a PCI-capable hosp...

...fer to a PCI-capable hospital for coro...

a Although individual circumstances will var...


...ndications for Transfer for Angiography After Fibr...

Immediate transfer for cardiogenic s...

...fer for failed reperfusion or reocclus...

...invasive strategy in stable patients with aPCI...

...dividual circumstances will vary, clin...


...ed Invasive Manage...

...oronary Angiography in Patients Who Initially...

...shock or acute severe HF that develops a...

...mediate- or high-risk findings on pr...

...yocardial ischemia that is spontaneous or prov...

...raphy with intent to perform revascul...

...angiography is reasonable before ho...

...gh individual circumstances will vary, clinic...


...9. Indications for Coronary Angiogr...

...c shock or acute severe HF that dev...

...diate-or high-risk findings on pre-discharge nonin...

...ous or easily provoked myocardial ischemia ( C...

...eperfusion or reocclusion after fibrinol...

...blea patients after successful fibrinolysis, befo...

...idual circumstances will vary, clinical st...

...an Infarct Artery in Patients Who Initia...

...ic shock or acute severe HF or (B,...

...or high-risk findings on predischar...

...ial ischemia that is spontaneous or p...

...s reasonable in patients with STEMI and evidence...

...a of a significant stenosis in a pa...

...ayed PCI of a significant stenosis in a patent i...

...layed PCI of a totally occluded infarct a...

a Although individual circumstances will vary,...


Table 10. Indications for PCI of a...

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

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

Spontaneous or easily provoked myocardial ischemi...

...h evidence of failed reperfusion or reocclus...

...lea patients after successful fibrinolysis, idea...

...atients >24 h after successful fibrinolysis ( B...

...d PCI of a totally occluded infarct...

...Although individual circumstances will v...

...Noninfarct Artery Before Hospital...

...CI is indicated in a noninfarct arter...

...is reasonable in a noninfarct artery...

Adjunctive Antithrombotic Therapy to S...

...tiplatelet The...

...spirin should be continued indefinitely. ( A , I...

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

...ding dose should be given before or at the time o...

...daily should be given after PCI. ( C , I )70...

...fter PCI, it is reasonable to use 81 mg of aspir...

...a 60 mg loading dose, is reasonable once...

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

...ugrel should NOT be administered to patien...

...gulant Therapy...

...s with STEMI undergoing PCI after re...

...tients with STEMI undergoing PCI after...

...x should NOT be used as the sole anti...


...junctive Antithrombotic Therapy to Support PCI Aft...

...iplatelet therapy...

Aspiri...

...mg loading dose given with fibrinol...

...-325 mg daily maintenance dose after...

...mg daily is the preferred daily maintena...

P2Y12 inhibitor...

...oading Dose...

...ho received a loading dose of clopidogrel wi...

...nts who have not received a loading dose of clopi...

...rformed ≤24 h after fibrinolytic therapy:...

...formed >24 h after fibrinolytic therapy:...

...CI is performed >24 h after treatment with a f...

...atients with prior stroke/TIA: pra...

...ntenance Doses and Duration of Th...

...placed: Continue therapy for ≥3...

...dogrel: 75 mg daily OR ( C , I )701...

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

...l: 75 mg daily or ( C , I )701...

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

...coagulant therapy...

...e UFH through PCI, administering additional IV bo...

...enoxaparin through PCI: No additi...

...aparinux as sole anticoagulant for PCI ( C ,...

...mmended aACT with no planned GP IIb/I...


...rtery Bypass Graft Surgery (CABG)...

...atients With STEMI...

...ndicated in patients with STEMI and coro...

...commended in patients with STEMI at time of...

...use of mechanical circulatory suppor...

...ency CABG within 6 hours of symptom on...

...ng of Urgent CABG in Patients With STEMI in Rel...

Aspirin should not be withheld before urgen...

...or ticagrelor should be discontinued at least 24...

Short-acting intravenous GP IIb/IIIa receptor anta...

...iximab should be discontinued at least 12...

...ff-pump CABG within 24 hours of clo...

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


...outine Medical Therapies...

...eta Blockers Oral beta blockers s...

...s should be continued during and after hos...

...initial contraindications to the use of bet...

It is reasonable to administer intra...

...otensin-Aldosterone System Inhibitors...

...otensin-converting enzyme (ACE) inhibitor should...

...nsin receptor blocker (ARB) should be...

...sterone antagonist should be given to...

...ors are reasonable for all patients with STEM...

...pid Managemen...

...h-intensity statin therapy should be initiated...

...le to obtain a fasting lipid profile in patie...

...Selected Routine Medical TherapiesHaving trou...


...ications After STE...

Cardiogenic Shoc...

...ency revascularization with either PCI or CA...

In the absence of contraindications,...

...ra-aortic balloon pump (IABP) counterpul...

...rnative LV assist devices for circulatory support...

...ntable Cardioverter-Defibrillator Therap...

...ardioverter-defibrillator (ICD) therapy...

...radycardia, AV Block, and Intraventricular Cond...

...g in STEMI

...y pacing is indicated for symptomatic bradyarrhyth...

Pericardit...

...n is recommended for treatment of pericardit...

...of acetaminophen, colchicine, or narcoti...

...lucocorticoids and nonsteroidal an...


...13. Selected Risk Factors for Bleeding i...

...ic and Bleeding Complications...

...nticoagulant therapy with a vitamin K an...

...tion of triple antithrombotic therapy with a v...

...agulant therapy with a vitamin K antagonist...

...nticoagulant therapy may be consider...

...ting vitamin K antagonist therapy to a lo...

...2 Risk CriteriaHaving trouble viewing table? E...


...sk Assessment Afte...

...nvasive Testing for Ischemia Before Discharge...

...sive testing for ischemia should be performed...

...sting for ischemia might be considered...

...ninvasive testing for ischemia might...

...ent of LV Function...

...ntricular ejection fraction (LVEF) should be me...

Assessment of Risk for Sudden Cardiac Death (...

...ith an initially reduced LVEF who are possib...


...spitalization Plan Of Care...

...sthospital systems of care designed to preve...

...e-based cardiac rehabilitation/secondar...

...ar, detailed, and evidence-based plan of...

...and advice to stop smoking and to avo...