ST-Elevation Myocardial Infarction (STEMI)
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
...Myocardial Infarction (MI)...
...tems of STEMI Care, Reperfusion Therapy...
...communities should create and maint...
Performance of a 12-lead electrocardiogram (E...
...ion therapy should be administered to a...
...s the recommended method of reperfusion when it ca...
...apable hospital for primary PCI is the recom...
...iate transfer to a PCI-capable hospital f...
...he absence of contraindications, fibrinolyti...
...lytic therapy is indicated or chosen as the pr...
...therapy is reasonable for patients wit...
...Management of Patients With STEMI andÂ...
...rapeutic hypothermia should be star...
...iate angiography and PCI when indica...
...proposed time windows are system goals....
...ving Door-to-Balloon (D2B) TimesHaving tro...
...igure 1. Reperfusion Therapy for Patie...
...erfusion At a PCI-Capable H...
Primary PCI should be performed in patient...
...mary PCI should be performed in patients with STE...
...ld be performed in patients with STEMI and c...
...rimary PCI is reasonable in patients with STEMI...
...uld NOT be performed in a noninfarct arter...
.... Primary PCI in STEMI...
...mic symptoms...
...mic symptoms
Cardiogenic shock or acute severe HF i...
...oing ischemia 12-24 h after symptom o...
...f a noninfarct artery at the time of primary PC...
...spiration Thrombect...
...l aspiration thrombectomy is reasonable for...
...Stents in Primary PC...
...stent (bare-metal stent [BMS] or...
...ld be used in patients with high bleeding ri...
...NOT be used in primary PCI for patien...
...Balloon angioplasty without stent placement...
...ve Antithrombotic Therapy for Primary...
Antiplatelet Th...
...25 mg should be given before primary P...
...CI, aspirin should be continued indefinitely....
...grel 600 mg (I-B) or ( B , I )701...
...60 mg (I-B) or (B, I)701...
...agrelor 180 mg (B, I)701...
...ogrel 75 mg daily or ( B , I )701...
...mg daily or ( B , I )701...
...or 90 mg bida ( B , I )701...
...recommended maintenance dose of as...
...is reasonable to use 81 mg of aspirin per d...
abciximab ( A , IIa...
...gh-bolus-dose tirofiban ( B , IIa )...
...double-bolus eptifibatide ( B , I...
...onable to administer intravenous GP IIb/...
...t may be reasonable to administer intracoronary ab...
...ion of a P2Y inhibitor beyond 1 year may be c...
...rel should NOT be administered to pa...
...oagulant Therapy...
...th additional boluses administered as neede...
...with or without prior treatment with UFH...
...th STEMI undergoing PCI who are at high risk o...
...parinux should NOT be used as the sole anti...
...additional boluses administered as needed...
...ivalirudin with or without prior treatment with U...
...unctive Antithrombotic Therapy to Support...
...latelet therapy...
...spirin...
...5 mg load before procedure (B)701...
...ily maintenance dose (indefinite)a ( A ,...
...aily is the preferred maintenance dosea...
...12Â inhibitors
...mg as early as possible or at time of PCI or (...
Prasugrel: 60 mg as early as possible or at time o...
...elor: 180 mg as early as possible or at...
...intenance Doses and Duration of...
...el: 75 mg daily or ( B , I...
...10 mg daily or ( B , I )701...
...: 90 mg bida ( B , I )701...
Clopidogrel: 75 mg daily or (...
...asugrel: 10 mg daily or ( B , I...
...icagrelor: 90 mg bida ( B , I )70...
...Clopidogrel, prasugrel, or ticagr...
...th STEMI with prior stroke or TIA: pr...
...IIIa receptor antagonists in conjunction withÂ...
...mab: 0.25-mg/kg IV bolus, then 0.125 mcg/kg/mi...
...Tirofiban: (high-bolus dose): 25-mcg/kg...
...atients with creatinine clearanc...
...Eptifibatide: (double bolus): 180-mcg/kg IV bolu...
...ents with CrCl
...ents on hemodialysis ( B , IIa )701...
...atheterization laboratory administr...
...ronary abciximab 0.25-mg/kg bolus...
...nticoagulant therap...
...FH:
...IIa receptor antagonist planned: 50-70-U/kg IV bo...
...ith no GP IIb/IIIa receptor antagonist planned: 70...
...0.75-mg/kg IV bolus, then 1.75 mg/kg/h infusio...
...sion to 1 mg/kg/h with estimated...
...er UFH with GP IIb/IIIa receptor an...
...: not recommended as sole anticoagulant for prim...
...a The recommended maintenance dose of as...
...usion at a Non–PCI-Capable Hospit...
...Therapy When There Is An Anticipa...
...absence of contraindications, fibrinolytic t...
...sence of contraindications and when...
...rinolytic therapy should NOT be adminis...
...cations for Fibrinolytic Therapy When T...
Ischemic symptom...
...ngoing ischemia 12-24 h after symp...
...T depression, except if true posterior (inferob...
Table 5. Fibrinolytic Agents
...ble 5. Fibrinolytic Agents Having trou...
...e 6. Contraindications and Cautions for Fibri...
...ntithrombotic Therapy With Fibrinolysi...
Antiplatelet Th...
...spirin(162-325 mg loading dose) and clopid...
...be continued indefinitely. ( A , I )701...
...grel (75 mg daily) should be continued for â...
...nd up to 1 year ( C ,...
...is reasonable to use aspirin 81 mg...
...coagulant Therapy...
...with STEMI undergoing reperfusion...
...ommended regimens include:...
...red as a weight-adjusted intravenous bolus...
...in administered according to age,...
...parinux administered with initial intravenous...
.... Adjunctive Antithrombotic Therapy to...
...atelet therapy...
Aspiri...
...loading dose ( A , I )701...
...mg daily maintenance dose (indefin...
...mg daily is the preferred maintenance dose (...
...12 inhibitors...
...opidogrel...
...≤75 y: 300 mg loading dose ( A , I )701...
...d) ( A , I )70...
...¤1 y) ( C , I )701...
...: no loading dose, give 75 mg ( A , I )701...
...14 d) ( A , I...
...‰¤1 y) ( C , I...
...gulant therapy
UFH
...d IV bolus and infusion adjusted to obtai...
...xaparin
...If age...
...aparinux ...
...dose 2.5 mg IV, then 2.5 mg subcutaneously dai...
...ansfer of Patients With STEMI to a PCI-Capab...
...e transfer to a PCI-capable hospital for coron...
Urgent transfer to a PCI-capable hospi...
...fer to a PCI-capable hospital for c...
...h individual circumstances will vary, clini...
Table 8. Indications for Transfer for An...
...e transfer for cardiogenic shock or seve...
...t transfer for failed reperfusion or reoccl...
...invasive strategy in stable patients with aPCI 3-...
...ugh individual circumstances will vary, c...
...layed Invasive Management...
...ography in Patients Who Initially Were Managed W...
...nic shock or acute severe HF that de...
...te- or high-risk findings on predisc...
...ocardial ischemia that is spontaneous or provo...
...iography with intent to perform revascularizatio...
...giography is reasonable before hosp...
...ndividual circumstances will vary, cli...
...Indications for Coronary Angiography in Pati...
...ck or acute severe HF that develops after...
...te-or high-risk findings on pre-discharge noni...
...aneous or easily provoked myocardial isch...
...d reperfusion or reocclusion after...
...patients after successful fibrinolysis,...
...vidual circumstances will vary, clinical stabi...
...nfarct Artery in Patients Who Initial...
...genic shock or acute severe HF or (B, I)7...
...or high-risk findings on predischar...
...al ischemia that is spontaneous or provoke...
...is reasonable in patients with STEMI an...
...elayed PCIa of a significant stenosis i...
Delayed PCI of a significant stenosis in a patent...
...f a totally occluded infarct artery >24 hours...
...lthough individual circumstances will vary, clinic...
...e 10. Indications for PCI of an Infarct Artery i...
...ck or acute severe HF ( B , I )701...
...iate-or high-risk findings on predischarge n...
...or easily provoked myocardial ischemia (...
...ents with evidence of failed reperfusi...
...tablea patients after successful fibrinolysi...
...>24 h after successful fibrinolysis ( B ,...
...d PCI of a totally occluded infarct artery...
...gh individual circumstances will vary, c...
...farct Artery Before Hospital Discharge...
...indicated in a noninfarct artery at...
...nable in a noninfarct artery at a ti...
...tive Antithrombotic Therapy to Suppo...
...tiplatelet Therapy
...PCI, aspirin should be continued indefinitel...
...oading dose should be given before or at the...
...ing dose should be given before or at t...
...se of 75 mg daily should be given after PCI....
...it is reasonable to use 81 mg of asp...
...rel, in a 60 mg loading dose, is rea...
...n a 10 mg daily maintenance dose, is reasonable af...
...el should NOT be administered to pa...
...nticoagulant Therapy...
...atients with STEMI undergoing PCI after receivi...
...ents with STEMI undergoing PCI after receivi...
...rinux should NOT be used as the sole anticoagulant...
...11. Adjunctive Antithrombotic Thera...
...ntiplatelet ther...
Aspirin
...5 mg loading dose given with fibrin...
...maintenance dose after PCI (indefinite) (...
...mg daily is the preferred daily maintenance dose...
...Y12Â inhibitor...
...ding Doses...
...ents who received a loading dose of clopidogre...
...who have not received a loading dose of...
...PCI is performed ≤24 h after fibrinolytic thera...
If PCI is performed >24 h after fibrinolytic th...
...performed >24 h after treatment wi...
...ients with prior stroke/TIA: prasugrel ( B ,...
...Doses and Duration of Therap...
...aced: Continue therapy for ≥30 d...
...75 mg daily OR ( C , I )701...
...grel: 10 mg daily ( B , II...
...opidogrel: 75 mg daily or ( C ,...
...l: 10 mg daily ( B , IIa...
...ticoagulant therapy...
...ue UFH through PCI, administering addi...
...noxaparin through PCI: No additional drug...
...aparinux as sole anticoagulant for P...
...nded aACT with no planned GP IIb/IIIa re...
Coronary Artery Bypass Graft Surgery (CAB...
...n Patients With STE...
...indicated in patients with STEMI a...
...BG is recommended in patients with S...
The use of mechanical circulatory supp...
...ithin 6 hours of symptom onset may b...
...ent CABG in Patients With STEMI in Relation t...
...not be withheld before urgent CABG. ( C , I )7...
...rel or ticagrelor should be discontinued at least...
...ting intravenous GP IIb/IIIa recept...
Abciximab should be discontinued at...
...CABG within 24 hours of clopidogre...
Urgent CABG within 5 days of clopidogrel or ticagr...
...Medical Therapies (Table 1...
...s Oral beta blockers should be initiated in the...
...ta blockers should be continued during and...
...nitial contraindications to the use of beta block...
...is reasonable to administer intrave...
...ngiotensin-Aldosterone System In...
...ngiotensin-converting enzyme (ACE)...
...n angiotensin receptor blocker (ARB) should be g...
...aldosterone antagonist should be giv...
...nhibitors are reasonable for all p...
...id Management...
...ity statin therapy should be initiated or c...
...asonable to obtain a fasting lipid profil...
...ted Routine Medical TherapiesHaving t...
Complications Aft...
Cardiogenic Shoc...
...rgency revascularization with eithe...
...ce of contraindications, fibrinolytic therapy...
...use of intra-aortic balloon pump (IABP) counter...
...V assist devices for circulatory support may...
...Cardioverter-Defibrillator Therapy...
...lantable cardioverter-defibrillator (ICD) thera...
...ia, AV Block, and Intraventricular Condu...
...g in STEMI...
...orary pacing is indicated for symptoma...
Pericarditi...
...pirin is recommended for treatment...
...tration of acetaminophen, colchicine, or nar...
...ticoids and nonsteroidal anti-inflammatory...
...ed Risk Factors for Bleeding in Pa...
...hromboembolic and Bleeding C...
...icoagulant therapy with a vitamin K anta...
...he duration of triple antithrombotic...
Anticoagulant therapy with a vitamin K antago...
Anticoagulant therapy may be considered for pa...
...min K antagonist therapy to a lower internati...
...k CriteriaHaving trouble viewing ta...
...isk Assessment After STEMI...
...se of Noninvasive Testing for Ischemia Before...
...oninvasive testing for ischemia should be...
Noninvasive testing for ischemia might...
...e testing for ischemia might be considered b...
...ent of LV Functio...
...lar ejection fraction (LVEF) should be...
...of Risk for Sudden Cardiac Death (SCD)...
...ients with an initially reduced LVEF who are p...
...pitalization Plan Of Care...
...systems of care designed to prevent hospita...
...-based cardiac rehabilitation/secondar...
...tailed, and evidence-based plan of care that pr...
...d advice to stop smoking and to avoid secondh...