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
...atment...
...t of Myocardial Infarcti...
...of STEMI Care, Reperfusion Therapy, and Tim...
...communities should create and maint...
...erformance of a 12-lead electrocardio...
...rfusion therapy should be administer...
...ecommended method of reperfusion when...
...capable hospital for primary PCI is the reco...
...mmediate transfer to a PCI-capable hospital...
...absence of contraindications, fibrinolytic therap...
...lytic therapy is indicated or chosen as th...
...herapy is reasonable for patients with STEMI...
...tion and Management of Patients With...
...peutic hypothermia should be started as soon as p...
Immediate angiography and PCI when indic...
...ed time windows are system goals. F...
...mproving Door-to-Balloon (D2B) TimesHaving troubl...
...fusion Therapy for Patients with STEMI...
...fusion At a PCI-Capable H...
...should be performed in patients with STEMI...
...should be performed in patients with ST...
...PCI should be performed in patients w...
...mary PCI is reasonable in patients wi...
...uld NOT be performed in a noninfarct ar...
...ble 2. Primary PCI i...
...chemic symptom...
...ic symptoms...
...ardiogenic shock or acute severe HF irrespecti...
...ce of ongoing ischemia 12-24 h after sym...
...of a noninfarct artery at the time of...
...spiration Thrombe...
...al aspiration thrombectomy is reasonable for...
...Stents in Primary PCI...
Placement of a stent (bare-metal ste...
...be used in patients with high bleeding risk,...
...ld NOT be used in primary PCI for patients...
a Balloon angioplasty without stent placemen...
...ive Antithrombotic Therapy for Primary PCI...
...latelet Therapy...
...pirin 162-325 mg should be given before primary...
...aspirin should be continued indefin...
...l 600 mg (I-B) or ( B , I )7...
...60 mg (I-B) or (B, I)701
...or 180 mg (B, I)701...
...75 mg daily or ( B , I )701...
...10 mg daily or ( B , I )701...
...agrelor 90 mg bida ( B , I )701...
...ded maintenance dose of aspirin to...
...ble to use 81 mg of aspirin per day in prefer...
...bciximab ( A , IIa...
...s-dose tirofiban ( B , IIa )701...
...us eptifibatide ( B , IIa )701...
...nable to administer intravenous GP IIb/IIIa...
...y be reasonable to administer intracoronary abc...
...f a P2Y inhibitor beyond 1 year ma...
...should NOT be administered to pati...
...icoagulant Ther...
...additional boluses administered as neede...
...or without prior treatment with UFH. ( B ,...
In patients with STEMI undergoing PCI...
...arinux should NOT be used as the sole anticoagulan...
...tional boluses administered as needed...
...with or without prior treatment with UFH. (...
...ive Antithrombotic Therapy to Support...
...platelet thera...
...spiri...
...-325 mg load before procedure (B)701
...mg daily maintenance dose (indefinit...
...1 mg daily is the preferred maintenance dosea ( B...
... inhibitors...
...l: 600 mg as early as possible or at time of PCI o...
...mg as early as possible or at time of PCI or ( B...
...or: 180 mg as early as possible or at time of...
...aintenance Doses and Duration of Thera...
Clopidogrel: 75 mg daily or ( B , I...
...10 mg daily or ( B , I )...
...cagrelor: 90 mg bida ( B , I...
...ogrel: 75 mg daily or ( B , I...
...mg daily or ( B , I )701...
...or: 90 mg bida ( B , I )701...
...prasugrel, or ticagrelor a continued...
...Patients with STEMI with prior stro...
...VÂ GPÂ IIb/IIIa receptor antagonists in...
...iximab: 0.25-mg/kg IV bolus, then 0.125 mcg/kg/mi...
...n: (high-bolus dose): 25-mcg/kg IV bolus, then...
...atients with creatinine clearance (CrCl...
...ide: (double bolus): 180-mcg/kg IV bolus...
...patients with Cr...
...ients on hemodialysis ( B , IIa )701...
...catheterization laboratory administration of IV...
...y abciximab 0.25-mg/kg bolus ( B , IIb )701...
Anticoagulant ther...
UFH:
...P IIb/IIIa receptor antagonist planned: 50-70-U/...
...h no GP IIb/IIIa receptor antagonist planned: 7...
...udin: 0.75-mg/kg IV bolus, then 1....
...duce infusion to 1 mg/kg/h with estimated CrCl...
...red over UFH with GP IIb/IIIa receptor an...
...ondaparinux: not recommended as so...
...The recommended maintenance dose of...
...a Non–PCI-Capable Hospital...
...olytic Therapy When There Is An Anticipated Dela...
...ce of contraindications, fibrinolytic therapy...
...e of contraindications and when PCI is not avail...
...ytic therapy should NOT be administered...
...ble 4. Indications for Fibrinolytic Therap...
...hemic symptoms...
...ing ischemia 12-24 h after symptom onset an...
...T depression, except if true posterior (inferoba...
Table 5. Fibrinolytic Agents
...5. Fibrinolytic Agents Having trouble viewing t...
...ntraindications and Cautions for Fibrinolytic...
...junctive Antithrombotic Therapy With Fibrinolysis...
...latelet Therapy...
...5 mg loading dose) and clopidogrel (300 mg lo...
Aspirin should be continued indefinitely. ( A ,...
...l (75 mg daily) should be continued for ≥14 day...
...nd up to 1 year ( C , I...
...s reasonable to use aspirin 81 mg per day in...
...ticoagulant Thera...
...tients with STEMI undergoing reperfu...
...nded regimens include:...
...ministered as a weight-adjusted intravenou...
Enoxaparin administered according t...
...ux administered with initial intravenous do...
.... Adjunctive Antithrombotic Therapy to Support...
...ntiplatelet therapy
...spirin...
...oading dose ( A , I )701
...325 mg daily maintenance dose (indefinite)...
...aily is the preferred maintenance dose ( A ,...
...12 inhibitors...
...lopidogr...
...300 mg loading dose ( A , I )...
...( A , I )701...
...¤1 y) ( C , I...
...no loading dose, give 75 mg ( A , I )701...
...) ( A , I )701...
...¤1 y) ( C , I )7...
...gulant therapy...
UFH
...V bolus and infusion adjusted to obtai...
...oxaparin
If ag...
...ondaparinux...
...l dose 2.5 mg IV, then 2.5 mg subcutaneously d...
...Patients With STEMI to a PCI-Capable...
...ediate transfer to a PCI-capable hospi...
...er to a PCI-capable hospital for co...
...PCI-capable hospital for coronary a...
...gh individual circumstances will vary, clinical s...
...cations for Transfer for Angiography Afte...
...ansfer for cardiogenic shock or severe acute HF i...
...ent transfer for failed reperfusion or reocc...
...an invasive strategy in stable patients wit...
...gh individual circumstances will vary,...
...nvasive Management...
...ngiography in Patients Who Initially Were Man...
...enic shock or acute severe HF that develops after...
...ermediate- or high-risk findings on...
...al ischemia that is spontaneous or provoked...
...iography with intent to perform revascularizatio...
...oronary angiography is reasonable befo...
...idual circumstances will vary, clinical...
...ndications for Coronary Angiography in Pat...
...ardiogenic shock or acute severe HF that...
...or high-risk findings on pre-dischar...
Spontaneous or easily provoked myocardial is...
...usion or reocclusion after fibrinolytic thera...
...tients after successful fibrinolysis, before...
...lthough individual circumstances w...
...farct Artery in Patients Who Initially Were M...
...ardiogenic shock or acute severe HF or (B, I)701...
...- or high-risk findings on predischa...
...ardial ischemia that is spontaneous...
...s reasonable in patients with STEMI and evidence...
...PCIa of a significant stenosis in a paten...
...of a significant stenosis in a patent i...
...a totally occluded infarct artery >24 hours...
...individual circumstances will var...
...Indications for PCI of an Infarct Artery in Patie...
...ic shock or acute severe HF ( B , I )701...
...r high-risk findings on predischarge noninvasive...
...r easily provoked myocardial ischem...
...with evidence of failed reperfusion or reocclus...
...ents after successful fibrinolysis, i...
...tablea patients >24 h after successful fibrinol...
...totally occluded infarct artery >24 h after STEMI...
...ough individual circumstances will vary,...
...I of a Noninfarct Artery Before Hospital D...
...ndicated in a noninfarct artery at...
...I is reasonable in a noninfarct artery at a t...
...ithrombotic Therapy to Support Delayed PCI After...
...tiplatelet The...
...PCI, aspirin should be continued in...
...mg loading dose should be given before or...
...oading dose should be given before or at the tim...
...se of 75 mg daily should be given after PCI. ( C ,...
After PCI, it is reasonable to use 81...
...sugrel, in a 60 mg loading dose, is reasonabl...
...asugrel, in a 10 mg daily maintenance dose,...
...rasugrel should NOT be administered...
...nticoagulant Therapy...
...patients with STEMI undergoing PCI after recei...
For patients with STEMI undergoing PCI after re...
...ondaparinux should NOT be used as the sole antico...
...Adjunctive Antithrombotic Therapy to Support P...
...ntiplatelet the...
Aspirin
...ding dose given with fibrinolytic agent (before P...
81-325 mg daily maintenance dose a...
...ly is the preferred daily maintenance dose ( B ,...
...Y12Â inhibitors...
Loading Dose...
...o received a loading dose of clop...
...ients who have not received a loadi...
...s performed ≤24 h after fibrinolyt...
...performed >24 h after fibrinolytic the...
...is performed >24 h after treatmen...
...ients with prior stroke/TIA: prasugrel ( B , III...
...enance Doses and Duration of Therap...
...Continue therapy for ≥30 d and up to 1 y...
...pidogrel: 75 mg daily OR ( C ,...
...: 10 mg daily ( B , IIa )701...
...opidogrel: 75 mg daily or ( C , I...
...el: 10 mg daily ( B , IIa )70...
Anticoagulant therapy
...through PCI, administering additional IV boluses...
...noxaparin through PCI: No additional drug...
...aparinux as sole anticoagulant for PCI ( C...
...ecommended aACT with no planned GP II...
...ry Artery Bypass Graft Surgery (C...
...G in Patients With STEMI...
...s indicated in patients with STEMI and coron...
...recommended in patients with STEM...
...mechanical circulatory support is reason...
...mergency CABG within 6 hours of symptom onset m...
...Urgent CABG in Patients With STEMI in R...
...should not be withheld before urgent CABG...
...el or ticagrelor should be discontinued at...
...ing intravenous GP IIb/IIIa receptor antagon...
...ciximab should be discontinued at least 12 hours b...
...mp CABG within 24 hours of clopidogrel or ticag...
...G within 5 days of clopidogrel or ticagrelo...
Routine Medical Therapie...
...kers Oral beta blockers should be initi...
...should be continued during and after ho...
...ts with initial contraindications to the u...
...onable to administer intravenous bet...
...ngiotensin-Aldosterone System Inhibitors...
...-converting enzyme (ACE) inhibitor sho...
...eceptor blocker (ARB) should be given to patients...
...ldosterone antagonist should be given to patie...
...are reasonable for all patients with STEMI and...
...pid Manageme...
...h-intensity statin therapy should be initiated...
...e to obtain a fasting lipid profile in patien...
...ected Routine Medical TherapiesHavin...
...lications After STEM...
...ogenic Shock
...vascularization with either PCI or CABG is recomme...
...ce of contraindications, fibrinolytic...
...tra-aortic balloon pump (IABP) counter...
...LV assist devices for circulatory support ma...
...plantable Cardioverter-Defibrillator Therapy...
...mplantable cardioverter-defibrillator...
...rdia, AV Block, and Intraventricular Conduction...
...ing in STEMI
...ry pacing is indicated for symptomat...
Pericardi...
...irin is recommended for treatment of p...
...stration of acetaminophen, colchicine, or...
...icoids and nonsteroidal anti-inflammatory drugs...
...3. Selected Risk Factors for Bleed...
...omboembolic and Bleeding Complication...
...herapy with a vitamin K antagonist should be prov...
...f triple antithrombotic therapy with a vitamin...
...therapy with a vitamin K antagonist is rea...
...ulant therapy may be considered for patients with...
...argeting vitamin K antagonist thera...
...eriaHaving trouble viewing table? Expand...
...essment After STEMI...
...oninvasive Testing for Ischemia Before D...
...vasive testing for ischemia should...
...ve testing for ischemia might be considered b...
...ing for ischemia might be considered before disc...
...sessment of LV Fu...
...ricular ejection fraction (LVEF) should be me...
Assessment of Risk for Sudden Cardiac Death (S...
...initially reduced LVEF who are po...
...spitalization Plan Of C...
Posthospital systems of care designed to...
...e-based cardiac rehabilitation/secon...
...clear, detailed, and evidence-based plan of...
...nt and advice to stop smoking and to avo...