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
...reatmen...
...Myocardial Infarction (MI)...
...stems of STEMI Care, Reperfusion Therapy, and...
...es should create and maintain a reg...
...ormance of a 12-lead electrocardiogram (...
...apy should be administered to all eligible...
PCI is the recommended method of reperfusion when...
...le hospital for primary PCI is the recom...
...ediate transfer to a PCI-capable hospital fo...
...of contraindications, fibrinolytic thera...
...lytic therapy is indicated or chosen a...
...ion therapy is reasonable for patients with STE...
...aluation and Management of Patient...
...herapeutic hypothermia should be started as soon...
...graphy and PCI when indicated should be...
...sed time windows are system goals. For any indi...
...1. Improving Door-to-Balloon (D2B) TimesHaving...
...ure 1. Reperfusion Therapy for Patient...
...At a PCI-Capable Hospital...
...rimary PCI should be performed in...
...hould be performed in patients with STEMI and...
...imary PCI should be performed in patien...
...easonable in patients with STEMI if there is cl...
...should NOT be performed in a noninfarct artery...
...ble 2. Primary PCI in STE...
Ischemic symptoms...
...chemic symptoms
...iogenic shock or acute severe HF irrespective...
...vidence of ongoing ischemia 12-24 h af...
PCI of a noninfarct artery at the ti...
Aspiration Throm...
...ual aspiration thrombectomy is reasonable for pati...
...tents in Primary PCI...
...lacement of a stent (bare-metal stent [...
...be used in patients with high bleeding risk, i...
...d NOT be used in primary PCI for patients with S...
...Balloon angioplasty without stent p...
...nctive Antithrombotic Therapy for P...
...tiplatelet Therap...
...2-325 mg should be given before primary PCI. ( B...
After PCI, aspirin should be continued in...
...600 mg (I-B) or ( B , I )701...
...60 mg (I-B) or (B, I)701...
...relor 180 mg (B, I)701...
...dogrel 75 mg daily or ( B , I )701...
...0 mg daily or ( B , I )701...
...cagrelor 90 mg bida ( B ,...
...reasonable to use 81 mg of aspirin p...
...mab ( A , IIa )701...
...ose tirofiban ( B , IIa )70...
...uble-bolus eptifibatide ( B ,...
...t may be reasonable to administer intra...
...easonable to administer intracoronary abcixi...
...inuation of a P2Y inhibitor beyond 1 y...
Prasugrel should NOT be administered to pat...
...agulant Therapy...
...H, with additional boluses administered as...
...lirudin with or without prior treatment with U...
...nts with STEMI undergoing PCI who...
...arinux should NOT be used as the sole anticoagulan...
...additional boluses administered as n...
...irudin with or without prior treatm...
...e 3. Adjunctive Antithrombotic Therapy to Supp...
...atelet therapy
Aspiri...
...25 mg load before procedure...
...5 mg daily maintenance dose (indefini...
...ily is the preferred maintenance dosea ( B , IIa...
...2Y12Â inhibitors...
...00 mg as early as possible or at time...
...0 mg as early as possible or at time of PCI or...
...icagrelor: 180 mg as early as possibl...
...ce Doses and Duration of Therapy
Clopidogrel: 75 mg daily or ( B , I )701
...asugrel: 10 mg daily or ( B , I )701...
...90 mg bida ( B , I )701...
Clopidogrel: 75 mg daily or ( B...
...el: 10 mg daily or ( B ,...
...grelor: 90 mg bida ( B ,...
...lopidogrel, prasugrel, or ticagrel...
...atients with STEMI with prior stroke or TIA: p...
.../IIIa receptor antagonists in conjuncti...
...mab: 0.25-mg/kg IV bolus, then 0.125 mcg...
...-bolus dose): 25-mcg/kg IV bolus, then 0.15 mcg/kg...
In patients with creatinine clearance (Cr...
...(double bolus): 180-mcg/kg IV bolus, then 2 m...
...patients with CrCl...
...id in patients on hemodialysis ( B , IIa )701
...-catheterization laboratory administra...
...racoronary abciximab 0.25-mg/kg bolus ( B , I...
...nticoagulant therapy...
...FH:...
.../IIIa receptor antagonist planned: 50-70-U/kg...
...th no GP IIb/IIIa receptor antagonist p...
...valirudin: 0.75-mg/kg IV bolus, then 1.75 mg/kg...
...ce infusion to 1 mg/kg/h with estimated CrCl...
...over UFH with GP IIb/IIIa receptor antagonist in p...
...ux: not recommended as sole anticoagulant...
...a The recommended maintenance dose of...
...fusion at a Non–PCI-Capable Hospital...
...ibrinolytic Therapy When There Is An Anti...
...of contraindications, fibrinolytic th...
...ence of contraindications and when PCI is...
...herapy should NOT be administered to patients...
...ions for Fibrinolytic Therapy When There Is a...
...mic symptoms...
...of ongoing ischemia 12-24 h after symptom onset an...
...depression, except if true posterior (inferobas...
...lytic Agents Having trouble viewing table...
...Contraindications and Cautions for Fibrin...
...ntithrombotic Therapy With Fibrinolysis (Tabl...
...platelet Therapy...
...rin(162-325 mg loading dose) and clopidog...
...n should be continued indefinitely....
...ogrel (75 mg daily) should be continued for...
...d continued up to 1 year. ( C , I )70...
...is reasonable to use aspirin 81 mg per...
...agulant Therapy
...with STEMI undergoing reperfusion wi...
...ommended regimens include:...
...stered as a weight-adjusted intravenous bo...
...parin administered according to age, weight,...
...ndaparinux administered with initi...
...7. Adjunctive Antithrombotic Therapy to Support R...
...tiplatelet therapy
...pirin...
...mg loading dose ( A , I )701...
...-325 mg daily maintenance dose (indefinite) ( A ,...
...aily is the preferred maintenance dose ( A...
...inhibitors...
...lopidogr...
...e ≤75 y: 300 mg loading dose ( A...
(14 d) ( A , I )701
(≤1 y) ( C ,...
...o loading dose, give 75 mg ( A , I )701...
...) ( A , I )701...
...y) ( C , I )701
...coagulant therapy
UFH
...ight-based IV bolus and infusion adjust...
...noxapar...
...If age
...ondaparinu...
...al dose 2.5 mg IV, then 2.5 mg subcuta...
...er of Patients With STEMI to a PCI-Capab...
...transfer to a PCI-capable hospital for coronary...
...sfer to a PCI-capable hospital for coronary angi...
...nsfer to a PCI-capable hospital fo...
...lthough individual circumstances will...
...le 8. Indications for Transfer for Ang...
...transfer for cardiogenic shock or...
...ansfer for failed reperfusion or reocclu...
...invasive strategy in stable patients with a...
...Although individual circumstances...
...nvasive Management...
...aphy in Patients Who Initially Were Managed...
...shock or acute severe HF that develops after init...
...termediate- or high-risk findings on predi...
Myocardial ischemia that is spontane...
...angiography with intent to perform re...
...onary angiography is reasonable before...
...ividual circumstances will vary, clinical s...
...ions for Coronary Angiography in Patients Who...
...ock or acute severe HF that develops aft...
...ntermediate-or high-risk findings on pre-...
...ontaneous or easily provoked myocardial...
...usion or reocclusion after fibrinolytic...
...patients after successful fibrinolysis, before d...
...ugh individual circumstances will...
...an Infarct Artery in Patients Who Initially...
...shock or acute severe HF or (B, I)7...
...diate- or high-risk findings on predisch...
Myocardial ischemia that is spontane...
...is reasonable in patients with STEMI and ev...
...of a significant stenosis in a patent infarct art...
Delayed PCI of a significant stenosis in a paten...
...PCI of a totally occluded infarct ar...
...Although individual circumstances will vary, cli...
...10. Indications for PCI of an Infarct Ar...
...shock or acute severe HF ( B , I )701...
...or high-risk findings on predischarge noni...
...asily provoked myocardial ischemia...
Patients with evidence of failed reperfusion o...
Stablea patients after successful...
...tablea patients >24 h after successful...
...I of a totally occluded infarct artery...
...ugh individual circumstances will va...
...farct Artery Before Hospital Discharge...
...in a noninfarct artery at a time separate f...
...able in a noninfarct artery at a time separat...
...nctive Antithrombotic Therapy to Support Delay...
...tiplatelet Therap...
...I, aspirin should be continued indefinitely...
...300 mg loading dose should be given be...
...g loading dose should be given bef...
...of 75 mg daily should be given aft...
...reasonable to use 81 mg of aspirin per...
...grel, in a 60 mg loading dose, is rea...
...asugrel, in a 10 mg daily maintenance dose, i...
...el should NOT be administered to p...
...nticoagulant Therapy
...with STEMI undergoing PCI after receiving fibrin...
...tients with STEMI undergoing PCI af...
...uld NOT be used as the sole anticoagulant...
...ble 11. Adjunctive Antithrombotic Therapy to Supp...
...tiplatelet therapy...
...pirin...
162-325 mg loading dose given with...
81-325 mg daily maintenance dose after PCI...
...1 mg daily is the preferred daily maintena...
...Y12Â inhibitors...
...ading Doses...
...patients who received a loading dose of clo...
...who have not received a loading dose of...
...performed ≤24 h after fibrinolytic ther...
...s performed >24 h after fibrinolytic the...
...f PCI is performed >24 h after treatment wit...
...with prior stroke/TIA: prasugrel ( B , I...
...ntenance Doses and Duration of Therap...
...ced: Continue therapy for ≥30 d and up...
...75 mg daily OR ( C , I )701...
...asugrel: 10 mg daily ( B , I...
...lopidogrel: 75 mg daily or ( C ,...
...rel: 10 mg daily ( B , IIa )701...
...gulant therapy...
...nue UFH through PCI, administering additional IV b...
...noxaparin through PCI: No additio...
...sole anticoagulant for PCI ( C , III...
...commended aACT with no planned GP IIb/IIIa recep...
...onary Artery Bypass Graft Surg...
...atients With STEMI...
...indicated in patients with STEMI and coronary an...
...recommended in patients with STEMI at t...
...he use of mechanical circulatory support is rea...
...cy CABG within 6 hours of symptom onset may be con...
...rgent CABG in Patients With STEMI in Relation...
...in should not be withheld before urgent CABG....
...or ticagrelor should be discontinued at...
...ntravenous GP IIb/IIIa receptor antagonist...
...ciximab should be discontinued at leas...
...ff-pump CABG within 24 hours of clopidogrel or ti...
...within 5 days of clopidogrel or ticag...
...ne Medical Therapies (Table...
...Oral beta blockers should be initiated in the...
...ockers should be continued during an...
...initial contraindications to the use of...
...onable to administer intravenous be...
...nsin-Aldosterone System Inhibitors...
...iotensin-converting enzyme (ACE) in...
...n angiotensin receptor blocker (ARB)...
...terone antagonist should be given to...
...itors are reasonable for all patients wi...
...ipid Management...
...ty statin therapy should be initia...
...e to obtain a fasting lipid profile in patien...
...able 12. Selected Routine Medical Ther...
...tions After STEMI...
...ardiogenic Shock...
...ascularization with either PCI or C...
...ence of contraindications, fibrinolytic the...
...e of intra-aortic balloon pump (IABP) counterpuls...
...tive LV assist devices for circulatory support...
...rdioverter-Defibrillator Therapy Before D...
...ardioverter-defibrillator (ICD) the...
...ycardia, AV Block, and Intraventric...
Pacing in STE...
...orary pacing is indicated for symptomatic brad...
...ricarditis...
...in is recommended for treatment of pericarditis...
...inistration of acetaminophen, colchi...
...and nonsteroidal anti-inflammatory drugs...
...able 13. Selected Risk Factors for Bleed...
...embolic and Bleeding Complications...
...icoagulant therapy with a vitamin K antagonist...
The duration of triple antithrombotic the...
...lant therapy with a vitamin K antagonist...
...nt therapy may be considered for patients with...
...ting vitamin K antagonist therapy to a lower inte...
...sk CriteriaHaving trouble viewing table? Expand...
...sessment After STEM...
...of Noninvasive Testing for Ischemia Before...
...vasive testing for ischemia should be...
Noninvasive testing for ischemia mig...
...sting for ischemia might be considered b...
Assessment of LV Functio...
...t ventricular ejection fraction (LVEF)...
...isk for Sudden Cardiac Death (SCD)...
...tients with an initially reduced LVEF w...
...hospitalization Plan Of Care...
...systems of care designed to prevent hospit...
...ed cardiac rehabilitation/secondary p...
...clear, detailed, and evidence-based p...
...nd advice to stop smoking and to avoid secon...