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
...of Myocardial Infarction (MI)...
...gional Systems of STEMI Care, Reperfusion...
...l communities should create and ma...
...a 12-lead electrocardiogram (ECG) by EMS...
...on therapy should be administered to a...
...he recommended method of reperfusion when it ca...
...pital for primary PCI is the recomm...
...ediate transfer to a PCI-capable hospital f...
...of contraindications, fibrinolytic therapy shoul...
...ytic therapy is indicated or chosen as the...
...on therapy is reasonable for patie...
...ion and Management of Patients With STEMI andÂ...
...c hypothermia should be started as...
...ediate angiography and PCI when in...
...d time windows are system goals. For any indiv...
...e 1. Improving Door-to-Balloon (D2B...
...e 1. Reperfusion Therapy for Patients with ST...
Reperfusion At a PCI-Capable H...
...I should be performed in patients wit...
...PCI should be performed in patients...
...PCI should be performed in patients w...
Primary PCI is reasonable in patients...
...d NOT be performed in a noninfarct artery...
...2. Primary PCI in STEM...
...emic symptoms...
...schemic symptoms...
...rdiogenic shock or acute severe HF...
...ngoing ischemia 12-24 h after symptom onset (...
...rct artery at the time of primary PCI in patients...
...piration Thrombectom...
...tion thrombectomy is reasonable fo...
...se of Stents in Primary...
...ent of a stent (bare-metal stent [BMS] or drug...
...a should be used in patients with high bleeding...
...be used in primary PCI for patients with ST...
...Balloon angioplasty without stent...
...tive Antithrombotic Therapy for Prima...
...ntiplatelet Therap...
...irin 162-325 mg should be given before...
...aspirin should be continued indefinite...
...rel 600 mg (I-B) or ( B , I )701...
...0 mg (I-B) or (B, I)701...
...r 180 mg (B, I)701...
...lopidogrel 75 mg daily or ( B...
...10 mg daily or ( B , I )701
...agrelor 90 mg bida ( B ,...
...The recommended maintenance dose of a...
...sonable to use 81 mg of aspirin per day in prefer...
abciximab ( A , I...
...olus-dose tirofiban ( B , I...
...-bolus eptifibatide ( B , IIa )70...
...easonable to administer intravenous G...
...be reasonable to administer intracoronary abcixim...
...ontinuation of a P2Y inhibitor beyond...
...sugrel should NOT be administered to pa...
...agulant Therapy...
...ditional boluses administered as ne...
...or without prior treatment with UFH....
...ith STEMI undergoing PCI who are at high risk of b...
...inux should NOT be used as the sole anticoagulan...
UFH, with additional boluses admini...
...n with or without prior treatment with UFH. (B)701...
...djunctive Antithrombotic Therapy to Suppor...
...latelet therapy...
...pirin
...g load before procedure (B...
...mg daily maintenance dose (indefinite)a ( A ,...
...ily is the preferred maintenance dosea ( B , IIa...
...Y12Â inhibit...
...opidogrel: 600 mg as early as possible or at time...
...asugrel: 60 mg as early as possible or...
...relor: 180 mg as early as possible or a...
...Doses and Duration of Therapy
...l: 75 mg daily or ( B , I )701...
...10 mg daily or ( B , I )701...
...icagrelor: 90 mg bida ( B , I )70...
...75 mg daily or ( B , I )701...
...el: 10 mg daily or ( B , I )701...
...icagrelor: 90 mg bida ( B ,...
...Clopidogrel, prasugrel, or ticagrelor a continu...
...ts with STEMI with prior stroke or TIA: prasu...
...IIa receptor antagonists in conjunction with UF...
...Abciximab: 0.25-mg/kg IV bolus, then 0.125...
...irofiban: (high-bolus dose): 25-mcg/kg I...
...ith creatinine clearance (CrCl)...
...ptifibatide: (double bolus): 180-mcg/kg IV...
...tients with CrCl...
...patients on hemodialysis ( B , II...
...atheterization laboratory administration of IV GP...
...racoronary abciximab 0.25-mg/kg bolus...
...oagulant therapy
...FH:...
...receptor antagonist planned: 50-70-U/kg...
With no GP IIb/IIIa receptor antagonist planned:...
...rudin: 0.75-mg/kg IV bolus, then 1.75 mg/k...
...sion to 1 mg/kg/h with estimated CrCl...
...d over UFH with GP IIb/IIIa receptor anta...
...x: not recommended as sole anticoagula...
...a The recommended maintenance dose of aspir...
...at a Non–PCI-Capable Hospital...
...tic Therapy When There Is An Anticipated D...
...bsence of contraindications, fibrinoly...
...nce of contraindications and when PCI is...
...therapy should NOT be administered to p...
...able 4. Indications for Fibrinolytic Thera...
Ischemic symptom...
...going ischemia 12-24 h after sympto...
...depression, except if true posterior (inferobasal)...
Table 5. Fibrinolytic Agents
...Fibrinolytic Agents Having trouble viewing...
...le 6. Contraindications and Cautions f...
...Antithrombotic Therapy With Fibrinolysis (T...
Antiplatelet Therap...
...spirin(162-325 mg loading dose) and clopi...
...should be continued indefinitely. ( A ,...
...(75 mg daily) should be continued for...
...nd up to 1 year ( C ,...
...ble to use aspirin 81 mg per day in preference to...
...agulant Therapy...
...ts with STEMI undergoing reperfusion with f...
...nded regimens include:...
UFH administered as a weight-adjusted intravenous...
...administered according to age, weigh...
...x administered with initial intravenou...
...djunctive Antithrombotic Therapy to Support...
...platelet therapy...
Aspirin
...325 mg loading dose ( A ,...
...1-325 mg daily maintenance dose (indefinite...
81 mg daily is the preferred maintenance do...
...12 inhibitors...
...pidogrel...
...y: 300 mg loading dose ( A , I )701
...d) ( A , I )701...
...‰¤1 y) ( C , I )701...
...: no loading dose, give 75 mg ( A , I )701...
...) ( A , I )701...
...y) ( C , I )701...
...nticoagulant ther...
...FH
...ight-based IV bolus and infusion adjusted t...
...noxapar...
...If age...
...ndaparinuxÂ
...dose 2.5 mg IV, then 2.5 mg subcutan...
...sfer of Patients With STEMI to a PCI-Capa...
...te transfer to a PCI-capable hospital for coron...
...ent transfer to a PCI-capable hosp...
...I-capable hospital for coronary angiog...
...gh individual circumstances will va...
...e 8. Indications for Transfer for Angiograp...
Immediate transfer for cardiogenic shock or severe...
...transfer for failed reperfusion or reocclu...
...t of an invasive strategy in stable patients wi...
...hough individual circumstances will va...
...Invasive Management...
...aphy in Patients Who Initially Were Managed Wit...
...k or acute severe HF that develops af...
...ediate- or high-risk findings on pre...
Myocardial ischemia that is spontaneous or prov...
...ngiography with intent to perform revas...
...nary angiography is reasonable before hospit...
a Although individual circumstances wi...
...ions for Coronary Angiography in Patients Who...
...shock or acute severe HF that develops...
...ermediate-or high-risk findings on pr...
...or easily provoked myocardial ischem...
...rfusion or reocclusion after fibrinolytic t...
...patients after successful fibrinolysi...
...lthough individual circumstances will vary, cl...
...I of an Infarct Artery in Patients Who Initially...
...c shock or acute severe HF or (B, I)701...
...- or high-risk findings on predischarge no...
...mia that is spontaneous or provoked by minimal...
Delayed PCI is reasonable in patients with STEM...
...a of a significant stenosis in a pa...
...layed PCI of a significant stenosis in a patent...
...d PCI of a totally occluded infarct ar...
...though individual circumstances will...
...le 10. Indications for PCI of an Infarct Arter...
...shock or acute severe HF ( B , I )701...
...diate-or high-risk findings on predischarge...
...s or easily provoked myocardial ischemia...
...with evidence of failed reperfusion or reoccl...
...a patients after successful fibrinolysis, ideall...
Stablea patients >24 h after successful fibrinoly...
...totally occluded infarct artery >24 h afte...
...ividual circumstances will vary, clinical st...
PCI of a Noninfarct Artery Before H...
...in a noninfarct artery at a time sep...
...sonable in a noninfarct artery at a time sepa...
...hrombotic Therapy to Support Delayed PCI After Fi...
...latelet Therapy...
...aspirin should be continued indefinit...
...ng dose should be given before or at t...
...mg loading dose should be given before or at the...
...dose of 75 mg daily should be given after PCI. ( C...
...CI, it is reasonable to use 81 mg of aspirin per d...
..., in a 60 mg loading dose, is reaso...
...10 mg daily maintenance dose, is reasonable after...
...asugrel should NOT be administered t...
...nticoagulant Ther...
...s with STEMI undergoing PCI after receiving f...
...patients with STEMI undergoing PCI afte...
...ould NOT be used as the sole anticoagula...
...Adjunctive Antithrombotic Therapy to...
...latelet therapy...
...spirin
...5 mg loading dose given with fibrin...
...y maintenance dose after PCI (indefinite)...
...the preferred daily maintenance dose...
...2Â inhibitor...
...ding Dose...
...o received a loading dose of clopidogrel wit...
...patients who have not received a loading dose...
If PCI is performed ≤24 h after fibrinolytic...
...CI is performed >24 h after fibrinolytic therap...
...CI is performed >24 h after treatment w...
...nts with prior stroke/TIA: prasugrel (...
...oses and Duration of Therapy
...Sa placed: Continue therapy for ≥30 d...
...ogrel: 75 mg daily OR ( C , I )701...
...rel: 10 mg daily ( B , IIa )...
...dogrel: 75 mg daily or ( C , I )7...
Prasugrel: 10 mg daily ( B ,...
...agulant therapy...
...inue UFH through PCI, administering additional...
...parin through PCI: No additional drug if las...
...arinux as sole anticoagulant for PCI...
...commended aACT with no planned GP IIb...
...Artery Bypass Graft Surgery (CABG)...
...in Patients With STEMI...
...nt CABG is indicated in patients with STEMI...
CABG is recommended in patients with S...
...echanical circulatory support is reasonable in...
...gency CABG within 6 hours of symptom onset may b...
...gent CABG in Patients With STEMI in Re...
Aspirin should not be withheld before urgent CABG....
...opidogrel or ticagrelor should be discon...
...hort-acting intravenous GP IIb/IIIa...
...mab should be discontinued at least...
...f-pump CABG within 24 hours of clopidogrel...
...ithin 5 days of clopidogrel or ticagrelor a...
...outine Medical Therapies (Table 12)
...Blockers Oral beta blockers should be i...
...kers should be continued during and after hospi...
...tients with initial contraindications to the use...
...easonable to administer intravenous beta...
...nin-Angiotensin-Aldosterone System...
...converting enzyme (ACE) inhibitor should be admini...
...nsin receptor blocker (ARB) should be given to pat...
...n aldosterone antagonist should be given to patie...
...tors are reasonable for all patients with...
...ipid Manageme...
...nsity statin therapy should be initiated or con...
...onable to obtain a fasting lipid profile in patie...
...able 12. Selected Routine Medical TherapiesHaving...
Complications After...
Cardiogenic Shoc...
...cularization with either PCI or CAB...
...nce of contraindications, fibrinol...
...se of intra-aortic balloon pump (IAB...
...ative LV assist devices for circulatory supp...
...e Cardioverter-Defibrillator Therapy Be...
...e cardioverter-defibrillator (ICD) therapy is indi...
...ardia, AV Block, and Intraventricular...
...g in STEMI
...is indicated for symptomatic bradya...
...ericarditi...
...mmended for treatment of pericarditis afte...
...of acetaminophen, colchicine, or nar...
...s and nonsteroidal anti-inflammatory drugs are...
...cted Risk Factors for Bleeding in Patients W...
...boembolic and Bleeding Complication...
...ant therapy with a vitamin K antagonist should be...
The duration of triple antithrombotic...
...coagulant therapy with a vitamin K...
...t therapy may be considered for patie...
...in K antagonist therapy to a lower inter...
...CriteriaHaving trouble viewing table? Expand...
...ssessment After STEMI...
...of Noninvasive Testing for Ischemia Before Disch...
...sive testing for ischemia should be performed befo...
...oninvasive testing for ischemia might...
...nvasive testing for ischemia might be...
...ment of LV Function
...ntricular ejection fraction (LVEF) should be...
Assessment of Risk for Sudden Cardiac Death...
...n initially reduced LVEF who are possible can...
...sthospitalization Plan Of...
...spital systems of care designed to prevent ho...
...se-based cardiac rehabilitation/secondary preventi...
A clear, detailed, and evidence-based plan of car...
...agement and advice to stop smoking and to avoid s...