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

• Prehospital ECG to diagnose STEMI is used to activate the PCI team while the patient is en route to the hospital.
• Emergency physicians activate the PCI team.
• A single call to a central page operator activates the PCI team.
• Goal is set for the PCI team to arrive in the catheterization laboratory within 20 minutes after being paged.
• Timely data feedback and analysis are provided to members of the STEMI care team.

Figure 1. Reperfusion Therapy for Patients with STEMI

Reperfusion At a PCI-Capable Hospital

• Primary PCI should be performed in patients with STEMI and ischemic symptoms of <12 hours’ duration. (I-A)
• Primary PCI should be performed in patients with STEMI and ischemic symptoms of <12 hours’ duration who have contraindications to fibrinolytic therapy, irrespective of the time delay from FMC. (I-B)
• Primary PCI should be performed in patients with STEMI and cardiogenic shock or acute severe heart failure (HF), irrespective of time delay from MI onset. (I-B)
• Primary PCI is reasonable in patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia between 12 and 24 hours after symptom onset. (IIa-B)
• PCI should NOT be performed in a noninfarct artery at the time of primary PCI in patients with STEMI who are hemodynamically stable. (III-B: Harm)

Table 2. Primary PCI in STEMI

Aspiration Thrombectomy

• Manual aspiration thrombectomy is reasonable for patients undergoing primary PCI. (IIa-B)

Use of Stents in Primary PCI

• Placement of a stent (bare-metal stent [BMS] or drug-eluting stent [DES]) is useful in primary PCI for patients with STEMI. (I-A)
• BMS^a should be used in patients with high bleeding risk, inability to comply with 1 year of dual antiplatelet therapy (DAPT), or anticipated invasive or surgical procedures in the next year. (I-C)
• DES should NOT be used in primary PCI for patients with STEMI who are unable to tolerate or comply with a prolonged course of DAPT because of the increased risk of stent thrombosis with premature discontinuation of one or both agents. (III-B: Harm)

^a Balloon angioplasty without stent placement may be used in selected patients.

Adjunctive Antithrombotic Therapy for Primary PCI (Table 3)

Antiplatelet Therapy

• Aspirin 162-325 mg should be given before primary PCI. (I-B)
• After PCI, aspirin should be continued indefinitely. (I-A)
• A loading dose of a P2Y₁₂ receptor inhibitor should be given as early as possible or at the time of primary PCI to patients with STEMI.
  Options include:
  • Clopidogrel 600 mg (I-B) or
  • Prasugrel 60 mg (I-B) or
  • Ticagrelor 180 mg (I-B)
• P2Y₁₂ inhibitor therapy should be given for 1 year to patients with STEMI who receive a stent (BMS or DES) during primary PCI using the following maintenance doses:
  • Clopidogrel 75 mg daily (I-B) or
  • Prasugrel 10 mg daily (I-B) or
  • Ticagrelor 90 mg bida (I-B)

^a The recommended maintenance dose of aspirin to be used with ticagrelor is 81 mg daily.

• It is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses after primary PCI. (IIa-B)
• It is reasonable to begin treatment with an intravenous GP IIb/IIIa receptor antagonist such as abciximab (IIa-A), high-bolus-dose tirofiban (IIa-B), or double-bolus eptifibatide (IIa-B) at the time of primary PCI (with or without stenting or clopidogrel pretreatment) in selected patients with STEMI who are receiving unfractionated heparin (UFH).
• It may be reasonable to administer intravenous GP IIb/IIIa receptor antagonist in the precatheterization laboratory setting (eg, ambulance, emergency department) to patients with STEMI for whom primary PCI is intended. (IIb-B)
• It may be reasonable to administer intracoronary abciximab to patients with STEMI undergoing primary PCI. (IIb-B)
• Continuation of a P2Y12 inhibitor beyond 1 year may be considered in patients undergoing DES placement. (IIb-C)
• Prasugrel should NOT be administered to patients with a history of prior stroke or transient ischemic attack. (III-B: Harm)

Anticoagulant Therapy

• For patients with STEMI undergoing primary PCI, the following supportive anticoagulant regimens are recommended:
• UFH, with additional boluses administered as needed to maintain therapeutic activated clotting time (ACT) levels, taking into account whether a GP IIb/IIIa receptor antagonist has been administered (I-C) or
• Bivalirudin with or without prior treatment with UFH. (I-B)
• In patients with STEMI undergoing PCI who are at high risk of bleeding, it is reasonable to use bivalirudin monotherapy in preference to the combination of UFH and a GP IIb/IIIa receptor antagonist. (IIa-B)
• Fondaparinux should NOT be used as the sole anticoagulant to support primary PCI because of the risk of catheter thrombosis. (III-B: Harm)

Table 3. Adjunctive Antithrombotic Therapy to Support

Reperfusion at a Non–PCI-Capable Hospital

Fibrinolytic Therapy When There Is An Anticipated Delay To Performing Primary PCI Within 120 Minutes Of FMC (Table 4)

• In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of FMC. (I-A)
• In the absence of contraindications and when PCI is not available, fibrinolytic therapy is reasonable for patients with STEMI if there is clinical and/or ECG evidence of ongoing ischemia within 12-24 hours of symptom onset and a large area of myocardium at risk or hemodynamic instability. (IIa-C)
• Fibrinolytic therapy should NOT be administered to patients with ST depression except when a true posterior (inferobasal) MI is suspected or when associated with ST elevation in lead aVR. (III-B: Harm

Table 4. Indications for Fibrinolytic Therapy When There Is a

Table 5. Fibrinolytic Agents

Table 6. Contraindications and Cautions for Fibrinolytic Therapy in STEMIa

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Absolute contraindications

• Any prior intracranial hemorrhage (ICH)
• Known structural cerebral vascular lesion (eg, arteriovenous malformation)
• Known malignant intracranial neoplasm (primary or metastatic)
• Ischemic stroke within 3 mo
  • EXCEPT acute ischemic stroke within 4.5 h
• Suspected aortic dissection
• Active bleeding or bleeding diathesis (excluding menses)
• Significant closed-head or facial trauma within 3 mo
• Intracranial or intraspinal surgery within 2 mo
• Severe uncontrolled hypertension (unresponsive to emergency therapy)
• For streptokinase, prior treatment within the previous 6 mo

Relative contraindications

• History of chronic, severe, poorly controlled hypertension
• Significant hypertension on presentation (SBP >180 mm Hg or DBP >110 mm Hg)
• History of prior ischemic stroke >3 mo
• Dementia
• Known intracranial pathology not covered in absolute contraindications
• Traumatic or prolonged (>10 min) CPR
• Recent major surgery (<3 wk)
• Recent (within 2-4 wk) internal bleeding
• Noncompressible vascular punctures
• Pregnancy
• Active peptic ulcer
• Oral anticoagulant therapy

CPR, cardiopulmonary resuscitation, DBP, diastolic blood pressure; SBP, systolic blood pressure
^a Viewed as advisory for clinical decision making and may not be all-inclusive or definitive.

Adjunctive Antithrombotic Therapy With Fibrinolysis (Table 7)

Antiplatelet Therapy

• Aspirin (162-325 mg loading dose) and clopidogrel (300 mg loading dose for patients ≤75 years of age, 75 mg dose for patients >75 years of age) should be administered to patients with STEMI who receive fibrinolytic therapy. (I-A)
• Aspirin should be continued indefinitely (I-A), and clopidogrel (75 mg daily) should be continued for ≥14 days (I-A) and up to 1 year (I-C) in patients with STEMI who receive fibrinolytic therapy.
• It is reasonable to use aspirin 81 mg per day in preference to higher maintenance doses after fibrinolytic therapy. (IIa-B)

Anticoagulant Therapy

• Patients with STEMI undergoing reperfusion with fibrinolytic therapy should receive anticoagulant therapy for a minimum of 48 hours and preferably for the duration of the index hospitalization, up to 8 days or until revascularization if performed. (I-A)
  Recommended regimens include:
  • UFH administered as a weight-adjusted intravenous bolus and infusion to obtain an activated partial thromboplastin time (aPTT) of 1.5-2.0 times control, for 48 hours or until revascularization. (I-C)
    or
  • Enoxaparin administered according to age, weight, and CrCl, given as an intravenous bolus, followed in 15 minutes by subcutaneous injection for the duration of the index hospitalization, up to 8 days or until revascularization. (I-A) or
  • Fondaparinux administered with initial intravenous dose, followed in 24 hours by daily subcutaneous injections if the estimated CrCl is >30 mL/min, for the duration of the index hospitalization, up to 8 days or until revascularization. (I-B)

Table 7. Adjunctive Antithrombotic Therapy to Support Reperfusion With Fibrinolytic Therapy

Table 8. Indications for Transfer for Angiography After Fibrinolytic Therapy

Delayed Invasive Management

Coronary Angiography in Patients Who Initially Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion (Table 9)

• Cardiac catheterization and coronary angiography with intent to perform revascularization should be performed after STEMI in patients with any of the following:
• Cardiogenic shock or acute severe HF that develops after initial presentation. (I-B) or
• Intermediate- or high-risk findings on predischarge noninvasive ischemia testing. (I-B) or
• Myocardial ischemia that is spontaneous or provoked by minimal exertion during hospitalization. (I-C)
• Coronary angiography with intent to perform revascularization is reasonable for patients with evidence of failed reperfusion or reocclusion after fibrinolytic therapy. Angiography can be performed as soon as logistically feasible. (IIa-B)
• Coronary angiography is reasonable before hospital discharge in stable^a patients with STEMI after successful fibrinolytic therapy. Angiography can be performed as soon as logistically feasible, and ideally within 24 hours, but should not be performed within the first 2-3 hours after administration of fibrinolytic therapy. (IIa-B)

^a Although individual circumstances will vary, clinical stability is defined by the absence of low output, hypotension, persistent tachycardia, apparent shock, high-grade ventricular or symptomatic supraventricular tachyarrhythmias, and spontaneous recurrent ischemia.

Table 9. Indications for Coronary Angiography in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

Table 10. Indications for PCI of an Infarct Artery in Patients Who Were Managed With Fibrinolytic Therapy or Who Did Not Receive Reperfusion Therapy

PCI of a Noninfarct Artery Before Hospital Discharge

• PCI is indicated in a noninfarct artery at a time separate from primary PCI in patients who have spontaneous symptoms of myocardial ischemia. (I-C)
• PCI is reasonable in a noninfarct artery at a time separate from primary PCI in patients with intermediate- or high-risk findings on noninvasive testing. (IIa-B)

Adjunctive Antithrombotic Therapy to Support Delayed PCI After Fibrinolytic Therapy (Table 11)

Antiplatelet Therapy

• After PCI, aspirin should be continued indefinitely. (I-A)
• Clopidogrel should be provided as follows:
• A 300 mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI within 24 hours of receiving fibrinolytic therapy (I-C)
• A 600 mg loading dose should be given before or at the time of PCI to patients who did not receive a previous loading dose and who are undergoing PCI more than 24 hours after receiving fibrinolytic therapy (I-C) and
• A dose of 75 mg daily should be given after PCI. (I-C)
• After PCI, it is reasonable to use 81 mg of aspirin per day in preference to higher maintenance doses. (IIa-B)
• Prasugrel, in a 60 mg loading dose, is reasonable once the coronary anatomy is known in patients who did not receive a previous loading dose of clopidogrel at the time of administration of a fibrinolytic agent, but prasugrel should NOT be given sooner than 24 hours after administration of a fibrin-specific agent or 48 hours after administration of a non–fibrin-specific agent. (IIa-B)
• Prasugrel, in a 10 mg daily maintenance dose, is reasonable after PCI. (IIa-B)
• Prasugrel should NOT be administered to patients with a history of prior stroke or transient ischemic attack. (III-B: Harm)

Anticoagulant Therapy

• For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with intravenous UFH, additional boluses of intravenous UFH should be administered as needed to support the procedure, taking into account whether GP IIb/IIIa receptor antagonists have been administered. (I-C)
• For patients with STEMI undergoing PCI after receiving fibrinolytic therapy with enoxaparin, if the last subcutaneous dose was administered within the prior 8 hours, no additional enoxaparin should be given. If the last subcutaneous dose was administered between 8 and 12 hours earlier, enoxaparin 0.3 mg/kg IV should be given. (I-B)
• Fondaparinux should NOT be used as the sole anticoagulant to support PCI. An additional anticoagulant with anti-IIa activity should be administered because of the risk of catheter thrombosis. (III-C: Harm)

Table 11. Adjunctive Antithrombotic Therapy to Support PCI After Fibrinolytic Therapy

Routine Medical Therapies (Table 12)

Beta Blockers

• Oral beta blockers should be initiated in the first 24 hours in patients with STEMI who do not have any of the following:
• signs of HF
• evidence of a low output state
• increased risk for cardiogenic shock
• other contraindications to use of oral beta blockers:
  • PR interval >0.24 seconds
  • second- or third-degree heart block
  • active asthma or reactive airway disease). (I-B)

Note: Risk factors for cardiogenic shock (the greater the number of risk factors present, the higher the risk of developing cardiogenic shock) are age >70 years, SBP <120 mm Hg, sinus tachycardia >110 bpm or heart rate <60 bpm, and increased time since onset of symptoms of STEMI.

• Beta blockers should be continued during and after hospitalization for all patients with STEMI and with no contraindications to their use. (I-B)
• Patients with initial contraindications to the use of beta blockers in the first 24 hours after STEMI should be reevaluated to determine their subsequent eligibility. (I-C)
• It is reasonable to administer intravenous beta blockers at the time of presentation to patients with STEMI and no contraindications to their use who are hypertensive or have ongoing ischemia. (IIa-B)

Renin-Angiotensin-Aldosterone System Inhibitors

• An angiotensin-converting enzyme (ACE) inhibitor should be administered within the first 24 hours to all patients with STEMI with anterior location, HF, or ejection fraction (EF) ≤0.40, unless contraindicated. (I-A)
• An angiotensin receptor blocker (ARB) should be given to patients with STEMI who have indications for but are intolerant of ACE inhibitors. (I-B)
• An aldosterone antagonist should be given to patients with STEMI and no contraindications who are already receiving an ACE inhibitor and beta blocker and who have an EF ≤0.40 and either symptomatic HF or diabetes mellitus. (I-B)
• ACE inhibitors are reasonable for all patients with STEMI and no contraindications to their use. (IIa-A)

Lipid Management

• High-intensity statin therapy should be initiated or continued in all patients with STEMI and no contraindications to its use. (I-B)
• It is reasonable to obtain a fasting lipid profile in patients with STEMI, preferably within 24 hours of presentation. (IIa-C)

Table 12. Selected Routine Medical Therapies

Complications After STEMI

Cardiogenic Shock

• Emergency revascularization with either PCI or CABG is recommended in suitable patients with cardiogenic shock due to pump failure after STEMI irrespective of the time delay from MI onset. (I-B)
• In the absence of contraindications, fibrinolytic therapy should be administered to patients with STEMI and cardiogenic shock who are unsuitable candidates for either PCI or CABG. (I-B)
• The use of intra-aortic balloon pump (IABP) counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy. (IIa-B)
• Alternative LV assist devices for circulatory support may be considered in patients with refractory cardiogenic shock. (IIb-C)

Implantable Cardioverter-Defibrillator Therapy Before Discharge

• Implantable cardioverter-defibrillator (ICD) therapy is indicated before discharge in patients who develop sustained VT/VF more than 48 hours after STEMI, provided the arrhythmia is not due to transient or reversible ischemia, reinfarction, or metabolic abnormalities. (I-B)

Bradycardia, AV Block, and Intraventricular Conduction Defects

Pacing in STEMI

• Temporary pacing is indicated for symptomatic bradyarrhythmias unresponsive to medical treatment. (I-C)

Pericarditis

• Aspirin is recommended for treatment of pericarditis after STEMI. (I-B)
• Administration of acetaminophen, colchicine, or narcotic analgesics may be reasonable if aspirin, even in higher doses, is not effective. (IIb-C)
• Glucocorticoids and nonsteroidal anti-inflammatory drugs are potentially harmful for treatment of pericarditis after STEMI. (III-B: Harm)

Thromboembolic and Bleeding Complications

• Anticoagulant therapy with a vitamin K antagonist should be provided to patients with STEMI and atrial fibrillation (AF) with CHADS2 score^a ≥2, mechanical heart valves, venous thromboembolism, or hypercoagulable disorder. (I-C)

Note: These recommendations apply to patients who receive intracoronary stents during PCI for STEMI. Among individuals with STEMI who do not receive an intracoronary stent, the duration of DAPT beyond 14 days has not been studied adequately for patients who undergo balloon angioplasty alone, are treated with fibrinolysis alone, or do not receive reperfusion therapy. In this subset of patients with STEMI who do not receive an intracoronary stent, the threshold for initiation of oral anticoagulation for secondary prevention, either alone or in combination with aspirin, may be lower, especially if a shorter duration (ie,14 days) of DAPT is planned.

• The duration of triple antithrombotic therapy with a vitamin K antagonist, aspirin, and a P2Y₁₂ receptor inhibitor should be minimized to the extent possible to limit the risk of bleeding. (I-C)

Note: Individual circumstances will vary and depend on the indications for triple therapy and the type of stent placed during PCI. After this initial treatment period, consider therapy with a vitamin K antagonist plus a single antiplatelet agent. For patients treated with fibrinolysis, consider triple therapy for 14 days, followed by a vitamin K antagonist plus a single antiplatelet agent.

• Anticoagulant therapy with a vitamin K antagonist is reasonable for patients with STEMI and asymptomatic LV mural thrombi. (IIa-C)
• Anticoagulant therapy may be considered for patients with STEMI and anterior-apical akinesis or dyskinesis. (IIb-C)
• Targeting vitamin K antagonist therapy to a lower international normalized ratio (eg, 2.0-2.5) might be considered in patients with STEMI who are receiving DAPT. (IIb-C)

^a CHADS2 = (Congestive heart failure, Hypertension, Age >75 years, Diabetes mellitus, previous Stroke/transient ischemic attack [doubled risk weight]) score.

Table 13. Selected Risk Factors for Bleeding in Patients With ACS

• Advanced age (>75 y)
• Presentation with STEMI or NSTEMI (vs. UA)
• Female sex
• Severe renal dysfunction (CrCl <30 mL/min)
• HF or shock
• Elevated white blood cell count
• Diabetes
• Use of fibrinolytic therapy
• Body size
• Invasive strategy
• History of GI bleeding
• Inappropriate dosing of antithrombotic medications
• Anemia

Risk Assessment After STEMI

Use of Noninvasive Testing for Ischemia Before Discharge

• Noninvasive testing for ischemia should be performed before discharge to assess the presence and extent of inducible ischemia in patients with STEMI who have not had coronary angiography and do not have high-risk clinical features for which coronary angiography would be warranted. (I-B)
• Noninvasive testing for ischemia might be considered before discharge to evaluate the functional significance of a noninfarct artery stenosis previously identified at angiography. (IIb-C)
• Noninvasive testing for ischemia might be considered before discharge to guide the postdischarge exercise prescription. (IIb-C)

Assessment of LV Function

• Left ventricular ejection fraction (LVEF) should be measured in all patients with STEMI. (I-C)

Assessment of Risk for Sudden Cardiac Death (SCD)

• Patients with an initially reduced LVEF who are possible candidates for ICD therapy should undergo reevaluation of LVEF 40 or more days after discharge. (I-B)

Posthospitalization Plan Of Care

• Posthospital systems of care designed to prevent hospital readmissions should be used to facilitate the transition to effective, coordinated outpatient care for all patients with STEMI. (I-B)
• Exercise-based cardiac rehabilitation/secondary prevention programs are recommended for patients with STEMI. (I-B)
• A clear, detailed, and evidence-based plan of care that promotes medication adherence, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with interventions for secondary prevention should be provided to patients with STEMI. (I-C)
• Encouragement and advice to stop smoking and to avoid secondhand smoke should be provided to patients with STEMI. (I-A)