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 Myocardia...

...Regional Syst...

...ities should create and maintain a...

...a 12-lead electrocardiogram (ECG) by E...

...therapy should be administered to all elig...

...mended method of reperfusion when it can be...

...pital for primary PCI is the recommended triage s...

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

...absence of contraindications, fibrinolytic th...

...n fibrinolytic therapy is indicated or chosen...

...apy is reasonable for patients with STE...

...Evaluation and M...

...tic hypothermia should be started as soon as po...

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

a The proposed time windows are system goals. For...


...ble 1. Improving Door-to-Balloon (D2B) Times...


...1. Reperfusion Therapy for Patients with STE...


...Reperfusion...

...should be performed in patients with STE...

...ry PCI should be performed in patients with STEMI...

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

...is reasonable in patients with STEMI if there is...

...I should NOT be performed in a non...


...Table 2. P...

...hemic symptom...

...emic symptoms...

...hock or acute severe HF irrespective of time d...

...e of ongoing ischemia 12-24 h after symptom ons...

...noninfarct artery at the time of p...

...Aspira...

...ion thrombectomy is reasonable for patients...

...Use of Stents in P...

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

...be used in patients with high blee...

...NOT be used in primary PCI for pat...

...alloon angioplasty without stent placement may be...

...Adj...

...Antiplatelet...

...-325 mg should be given before primary PCI. ( B...

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

...opidogrel 600 mg (I-B) or ( B , I )701

...60 mg (I-B) or (B, I)7...

...agrelor 180 mg (B, I)7...

...opidogrel 75 mg daily or ( B ,...

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

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

...d maintenance dose of aspirin to be used w...

...le to use 81 mg of aspirin per day in preference...

...ximab ( A , IIa )70...

...igh-bolus-dose tirofiban ( B , IIa )70...

...s eptifibatide ( B , IIa )701...

It may be reasonable to administer intrav...

It may be reasonable to administer intrac...

...uation of a P2Y inhibitor beyond 1 year...

...ld NOT be administered to patients wi...

...tional boluses administered as needed t...

...n with or without prior treatment with UFH...

...with STEMI undergoing PCI who are at high risk...

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

...tional boluses administered as needed to mainta...

...ivalirudin with or without prior treatmen...


...Table 3....

...Antiplatelet therapy...

...Aspir...

...load before procedure (B)701...

...25 mg daily maintenance dose (indefinite)a ( A ,...

...mg daily is the preferred maintenance dos...

...P2Y12 inhibitors...

...l: 600 mg as early as possible or at time...

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

...: 180 mg as early as possible or at...

...Maintenance Doses and D...

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

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

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

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

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

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

...lopidogrel, prasugrel, or ticagrelor a co...

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

...IV GP IIb/IIIa rece...

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

...fiban: (high-bolus dose): 25-mcg/kg IV bo...

In patients with creatinine clearance (CrC...

...Eptifibatide: (double bolus): 180-mcg/kg...

...patients with CrCl...

...in patients on hemodialysis ( B ,...

...Pre-catheterization laboratory adm...

...ntracoronary abciximab 0.25-mg/kg bolus...

...Anticoagu...

With GP IIb/IIIa receptor antagonist planned:...

...ith no GP IIb/IIIa receptor antagonist planne...

Bivalirudin: 0.75-mg/kg IV bolus, then 1.75 mg/...

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

...er UFH with GP IIb/IIIa receptor antagonist in...

...aparinux: not recommended as sole anticoagulan...

...The recommended maintenance dose of asp...


...Reperfusio...

...Fibrinolytic Therap...

...the absence of contraindications, fibrinolytic t...

...n the absence of contraindications and whe...

...tic therapy should NOT be administered to p...


...Table 4. Indi...

...chemic symptom...

...vidence of ongoing ischemia 12-24 h after...

..., except if true posterior (inferobasal) MI is sus...


Table 5. Fibrinolytic Agents 

...5. Fibrinolytic Agents  Fibrin...

...indications and Cautions for Fibrinolytic Ther...

...Adjunctive A...

...Antiplatele...

...62-325 mg loading dose) and clopidog...

...n should be continued indefinitely. ( A ,...

...rel (75 mg daily) should be contin...

...p to 1 year ( C , I )701...

...reasonable to use aspirin 81 mg per day in...

...Anticoagulan...

...ith STEMI undergoing reperfusion with fibrin...

Recommended regimens...

...tered as a weight-adjusted intravenous bolus...

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

...administered with initial intravenous do...


...Table 7. Adjun...

...Antiplatele...

Aspiri...

...oading dose ( A , I )701

...y maintenance dose (indefinite) ( A ,...

...daily is the preferred maintenance dose ( A , I )...

...P2Y12 i...

...Cl...

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

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

...1 y) ( C , I )7...

...loading dose, give 75 mg ( A , I )701...

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

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

...Anticoagulant...

...UFH...

Weight-based IV bolus and infusion adjusted to ob...

Enox...

...If age...

...Fondaparinux ...

...Initial dose 2.5 mg IV, then 2.5 mg subcut...

...Transfer of Patient...

...iate transfer to a PCI-capable hospita...

...ransfer to a PCI-capable hospital f...

...CI-capable hospital for coronary an...

...h individual circumstances will vary, clinical...


...Table 8. Indicatio...

...te transfer for cardiogenic shock or sever...

...r for failed reperfusion or reocclusio...

...part of an invasive strategy in sta...

...ugh individual circumstances will var...


...Delayed Invasive Ma...

...Coronary...

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

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

...dial ischemia that is spontaneous o...

Coronary angiography with intent to perform re...

...ary angiography is reasonable before hos...

...ividual circumstances will vary, clinical...


...Table...

...iogenic shock or acute severe HF that deve...

...termediate-or high-risk findings on p...

...taneous or easily provoked myocardial ischemia (...

...ed reperfusion or reocclusion after...

...nts after successful fibrinolysis, be...

...Although individual circumstances...

...PCI...

Cardiogenic shock or acute severe HF or...

...termediate- or high-risk findings o...

...l ischemia that is spontaneous or...

...layed PCI is reasonable in patients w...

Delayed PCIa of a significant stenosis in a pat...

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

...a totally occluded infarct artery >24 hours af...

...ugh individual circumstances will vary, clin...


...Table 10. Indication...

Cardiogenic shock or acute severe HF (...

...-or high-risk findings on predisch...

...ontaneous or easily provoked myocardi...

...th evidence of failed reperfusion or reocclusion...

...ients after successful fibrinolysis, idea...

Stablea patients >24 h after successfu...

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

...individual circumstances will vary,...

...PCI of a Noninf...

...d in a noninfarct artery at a time sep...

...asonable in a noninfarct artery at a time sepa...

...Adjunctive An...

...Antiplatelet...

After PCI, aspirin should be continued...

...0 mg loading dose should be given b...

...600 mg loading dose should be given before or...

...dose of 75 mg daily should be given...

...s reasonable to use 81 mg of aspirin per day in...

...el, in a 60 mg loading dose, is reasonable once th...

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

...uld NOT be administered to patient...

...Antico...

...s with STEMI undergoing PCI after r...

...ts with STEMI undergoing PCI after rece...

...rinux should NOT be used as the sole anticoagulan...


...Table 11...

...Antiplatelet therap...

...Aspirin...

...g loading dose given with fibrinolytic agent...

...25 mg daily maintenance dose after PCI (ind...

...ly is the preferred daily maintenanc...

...P2Y12 ...

...Loading D...

...atients who received a loading dose of clop...

...ho have not received a loading dose of clo...

...rmed ≤24 h after fibrinolytic therapy...

...ormed >24 h after fibrinolytic therapy: clop...

...formed >24 h after treatment with a f...

...ith prior stroke/TIA: prasugrel ( B , III (ha...

...Main...

...ontinue therapy for ≥30 d and up to 1 y wit...

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

Prasugrel: 10 mg daily ( B...

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

...rel: 10 mg daily ( B , IIa )...

...Anticoag...

...ue UFH through PCI, administering additional IV...

...tinue enoxaparin through PCI: No ad...

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

...ed aACT with no planned GP IIb/IIIa...


...Coronary Arter...

...CABG in Patients...

...indicated in patients with STEMI and coronary...

...nded in patients with STEMI at time of oper...

...mechanical circulatory support is...

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

...Timing of Urg...

...uld not be withheld before urgent CABG. (...

...icagrelor should be discontinued a...

...ng intravenous GP IIb/IIIa receptor antagonists (...

...d be discontinued at least 12 hours bef...

...CABG within 24 hours of clopidogrel or ticagrelo...

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


...Routine M...

Beta Blockers Oral beta blockers should b...

...rs should be continued during and after hospit...

...nts with initial contraindications to the use...

It is reasonable to administer intravenou...

...Renin-Angiotensin-Aldos...

...angiotensin-converting enzyme (ACE)...

...giotensin receptor blocker (ARB) s...

...n aldosterone antagonist should be give...

...are reasonable for all patients wi...

...Lipid Management...

...ensity statin therapy should be initiat...

...nable to obtain a fasting lipid profile in pat...

...ted Routine Medical Therapies...


...Comp...

...Cardiogenic S...

...revascularization with either PCI or CABG is recom...

...e absence of contraindications, fibrinolytic...

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

...ssist devices for circulatory support may...

Impla...

...ioverter-defibrillator (ICD) therapy is indic...

...Brady...

...Pacing in STEM...

...mporary pacing is indicated for sympto...

...Pericarditis

...n is recommended for treatment of peric...

...nistration of acetaminophen, colchicin...

...ticoids and nonsteroidal anti-inflammatory...


...e 13. Selected Risk Factors for Bleeding in Patien...

...Thromboembolic and...

...nt therapy with a vitamin K antagonist shoul...

...duration of triple antithrombotic...

...ant therapy with a vitamin K antagonist is re...

...coagulant therapy may be considered for...

...ting vitamin K antagonist therapy to a lower inter...

...sk Criteria CHADS2 Risk Criteria...


...Risk Assess...

...Use of Noninv...

...testing for ischemia should be pe...

...testing for ischemia might be consi...

...ing for ischemia might be considered bef...

...Assessment of...

...ventricular ejection fraction (LVEF) shou...

...Assessmen...

...ents with an initially reduced LVEF who are po...


...Posthospitali...

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

...based cardiac rehabilitation/secondary prevent...

...ailed, and evidence-based plan of care that...

Encouragement and advice to stop smoking and to a...