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
...eatmen...
...nset of Myocardial Infarction (MI)
...ional Systems of STEMI Care, Reperfusion Therap...
...mmunities should create and maintain a...
...e of a 12-lead electrocardiogram (E...
...fusion therapy should be administered to all e...
...the recommended method of reperfusion when it ca...
EMS-capable hospital for primary PCI is th...
...te transfer to a PCI-capable hospital for prim...
...the absence of contraindications, f...
...c therapy is indicated or chosen as the primary re...
...eperfusion therapy is reasonable for patients wit...
...d Management of Patients With STEMI and Ou...
...c hypothermia should be started as soon...
...ography and PCI when indicated should...
...d time windows are system goals. For an...
Table 1. Improving Door-to-Balloon...
...eperfusion Therapy for Patients with STEMI...
...ion At a PCI-Capable Hospital...
Primary PCI should be performed in patients w...
...PCI should be performed in patien...
...hould be performed in patients with...
Primary PCI is reasonable in patie...
...NOT be performed in a noninfarct artery a...
Table 2. Primary PCI i...
...emic symptoms...
Ischemic sympt...
...rdiogenic shock or acute severe HF ir...
...oing ischemia 12-24 h after symptom onset ( B...
...farct artery at the time of primary P...
...ation Thrombectom...
...on thrombectomy is reasonable for patients un...
...tents in Primary PCI...
...cement of a stent (bare-metal stent [BMS] or dr...
...be used in patients with high bleedin...
...should NOT be used in primary PCI for pa...
...on angioplasty without stent placement may be use...
...Antithrombotic Therapy for Primary PCI (T...
...atelet Therapy...
...2-325 mg should be given before primary PC...
..., aspirin should be continued indefinite...
Clopidogrel 600 mg (I-B) or ( B...
...60 mg (I-B) or (B, I)701...
...grelor 180 mg (B, I)701...
...75 mg daily or ( B , I )701...
...0 mg daily or ( B , I )701...
...lor 90 mg bida ( B , I )701...
...able to use 81 mg of aspirin per day in prefere...
abciximab ( A , IIa )7...
...us-dose tirofiban ( B , IIa )701...
...bolus eptifibatide ( B , IIa )701...
...easonable to administer intravenous GP IIb/II...
...asonable to administer intracoronary abcixima...
...of a P2Y inhibitor beyond 1 year may be considered...
...l should NOT be administered to patients with...
...coagulant Therapy...
...h additional boluses administered as needed to ma...
...in with or without prior treatment...
...patients with STEMI undergoing PCI who...
...ndaparinux should NOT be used as the sole anti...
..., with additional boluses administer...
...th or without prior treatment with UF...
...3. Adjunctive Antithrombotic Therapy to Sup...
...platelet therapy...
Aspirin
...25 mg load before procedure (B)701...
...g daily maintenance dose (indefinite)a ( A ,...
...daily is the preferred maintenance dosea (...
...12Â inhibitors
...pidogrel: 600 mg as early as possible or at...
...ugrel: 60 mg as early as possible or at...
...relor: 180 mg as early as possible or at...
...Doses and Duration of Therapy
...grel: 75 mg daily or ( B , I )70...
...: 10 mg daily or ( B , I )70...
Ticagrelor: 90 mg bida ( B ,...
Clopidogrel: 75 mg daily or ( B...
Prasugrel: 10 mg daily or ( B ,...
...lor: 90 mg bida ( B , I )701...
..., prasugrel, or ticagrelor a continued beyond 1 y...
...ients with STEMI with prior stroke or TIA...
...receptor antagonists in conjunction with...
...ab: 0.25-mg/kg IV bolus, then 0.125 m...
...gh-bolus dose): 25-mcg/kg IV bolus, then 0.1...
...ts with creatinine clearance (CrCl)...
...e: (double bolus): 180-mcg/kg IV bolu...
...ents with CrCl...
...oid in patients on hemodialysis ( B ,...
Pre-catheterization laboratory administration of...
...acoronary abciximab 0.25-mg/kg bolus ( B...
...ticoagulant therapy...
UFH...
...P IIb/IIIa receptor antagonist plan...
...th no GP IIb/IIIa receptor antagonist...
...: 0.75-mg/kg IV bolus, then 1.75 mg/kg/...
...ion to 1 mg/kg/h with estimated CrCl...
...over UFH with GP IIb/IIIa receptor...
...not recommended as sole anticoagulant f...
...he recommended maintenance dose of aspirin...
...on at a Non–PCI-Capable Hospita...
...tic Therapy When There Is An Anticipate...
...n the absence of contraindications,...
...absence of contraindications and when PCI is not...
...rinolytic therapy should NOT be adminis...
...dications for Fibrinolytic Therapy When...
Ischemic sympto...
...ongoing ischemia 12-24 h after symptom onse...
...depression, except if true posterior (inf...
...e 5. Fibrinolytic Agents Having trouble v...
...e 6. Contraindications and Cautions for Fibrin...
...ithrombotic Therapy With Fibrinolysis (Table 7)...
Antiplatelet Therap...
...mg loading dose) and clopidogrel (300...
...should be continued indefinitely. ( A , I...
...lopidogrel (75 mg daily) should be continued for â...
...continued up to 1 year. ( C , I )701...
...sonable to use aspirin 81 mg per day in preference...
...nticoagulant Therapy...
...with STEMI undergoing reperfusion with...
Recommended regimens inc...
...administered as a weight-adjusted intravenous bolu...
...n administered according to age, weight, an...
...nux administered with initial intra...
.... Adjunctive Antithrombotic Therapy to Support R...
...atelet therapy...
...spiri...
...325 mg loading dose ( A , I )701
81-325 mg daily maintenance dose (indefinite)...
...daily is the preferred maintenance dose ( A , I )...
...2 inhibitor...
Clopidogre...
...75 y: 300 mg loading dose ( A , I )701...
...( A , I )701...
...≤1 y) ( C , I )701
...ge >75 y: no loading dose, give 75 mg ( A , I )7...
...) ( A , I )701...
(≤1 y) ( C , I...
...coagulant therapy...
UF...
...based IV bolus and infusion adjusted to obt...
Enoxaparin
...If age...
...ndaparinuxÂ
...dose 2.5 mg IV, then 2.5 mg subcutaneously dai...
...ents With STEMI to a PCI-Capable Hos...
...mediate transfer to a PCI-capable...
...ransfer to a PCI-capable hospital fo...
...fer to a PCI-capable hospital for coronary angiogr...
...ividual circumstances will vary, clinical s...
.... Indications for Transfer for Angiography Aft...
...sfer for cardiogenic shock or severe acute HF...
...er for failed reperfusion or reocclu...
...art of an invasive strategy in stable patients w...
...though individual circumstances will vary, clin...
...nvasive Management...
...y Angiography in Patients Who Initially Were...
...ock or acute severe HF that develops afte...
...ermediate- or high-risk findings o...
...ocardial ischemia that is spontaneous or provoked...
...ography with intent to perform revascularizatio...
...ography is reasonable before hospital disc...
...dividual circumstances will vary, clinical st...
...le 9. Indications for Coronary Angiography in...
...c shock or acute severe HF that develops after...
...high-risk findings on pre-discharge noninvasive is...
...ntaneous or easily provoked myocard...
Failed reperfusion or reocclusion after...
...ea patients after successful fibrinolysis,...
...ough individual circumstances will vary, clinica...
...rct Artery in Patients Who Initially W...
...ogenic shock or acute severe HF or (B, I...
...te- or high-risk findings on predischarge n...
Myocardial ischemia that is spontaneous or...
...is reasonable in patients with STEMI...
...PCIa of a significant stenosis in a patent...
...layed PCI of a significant stenosis i...
...yed PCI of a totally occluded infarct...
...ndividual circumstances will vary, clinical...
...e 10. Indications for PCI of an Infar...
...enic shock or acute severe HF ( B , I )701...
...or high-risk findings on predischarge noninvasiv...
...taneous or easily provoked myocard...
...evidence of failed reperfusion or reocc...
...patients after successful fibrinolysis, ideally...
...ents >24 h after successful fibrinolysi...
...layed PCI of a totally occluded infarct artery >...
...ough individual circumstances will vary, clinica...
...Noninfarct Artery Before Hospital Discharge...
...I is indicated in a noninfarct artery...
...easonable in a noninfarct artery at a time sepa...
...thrombotic Therapy to Support Delayed PC...
Antiplatelet Therapy
...spirin should be continued indefinite...
...loading dose should be given before or at the...
A 600 mg loading dose should be give...
...f 75 mg daily should be given after P...
...I, it is reasonable to use 81 mg of aspirin...
Prasugrel, in a 60 mg loading dose, is reason...
...rasugrel, in a 10 mg daily maintenance dose, is...
Prasugrel should NOT be administered...
...nticoagulant Thera...
...h STEMI undergoing PCI after receiving f...
...nts with STEMI undergoing PCI after receiv...
...should NOT be used as the sole anticoag...
...11. Adjunctive Antithrombotic Therapy to Su...
Antiplatelet thera...
...spirin
...mg loading dose given with fibrinolytic...
...g daily maintenance dose after PCI (indefi...
...ily is the preferred daily maintena...
...2Y12Â inhibi...
...oading Dos...
...who received a loading dose of clopidogrel ...
...r patients who have not received a loadin...
...is performed ≤24 h after fibrinolytic...
...rformed >24 h after fibrinolytic therapy: clopidog...
...is performed >24 h after treatment with a...
...with prior stroke/TIA: prasugrel ( B , III...
...tenance Doses and Duration of Therapy...
...Continue therapy for ≥30 d and up to 1 y...
...pidogrel: 75 mg daily OR ( C ,...
...0 mg daily ( B , IIa )701...
...lopidogrel: 75 mg daily or ( C ,...
...el: 10 mg daily ( B , IIa...
Anticoagulant therap...
...H through PCI, administering additional IV bolus...
...e enoxaparin through PCI: No additional drug...
...arinux as sole anticoagulant for PCI ( C , I...
...mmended aACT with no planned GP IIb...
...tery Bypass Graft Surgery (CABG)...
...in Patients With...
...rgent CABG is indicated in patients with ST...
...s recommended in patients with STEMI at...
...mechanical circulatory support is reasonable in p...
...mergency CABG within 6 hours of symp...
...Urgent CABG in Patients With STEMI in Relation to...
...d not be withheld before urgent CABG. ( C ,...
...grel or ticagrelor should be discontinued at...
...hort-acting intravenous GP IIb/IIIa re...
...should be discontinued at least 12...
...pump CABG within 24 hours of clopidogre...
...nt CABG within 5 days of clopidogrel or...
...ine Medical Therapies (Table 12)...
...Oral beta blockers should be initiated i...
...s should be continued during and after h...
...nts with initial contraindications to...
...reasonable to administer intravenous...
...enin-Angiotensin-Aldosterone System Inhi...
...n angiotensin-converting enzyme (ACE) inhibito...
...giotensin receptor blocker (ARB) s...
...terone antagonist should be given to patients with...
...CE inhibitors are reasonable for all patients wit...
...Management...
...tatin therapy should be initiated or con...
...reasonable to obtain a fasting lipi...
...ted Routine Medical TherapiesHaving trouble...
...ications After STE...
...diogenic Shock...
...rgency revascularization with either PCI...
...bsence of contraindications, fibrinolytic...
...ra-aortic balloon pump (IABP) counte...
...LV assist devices for circulatory support ma...
...ioverter-Defibrillator Therapy Before D...
...antable cardioverter-defibrillator (ICD...
...ycardia, AV Block, and Intraventricula...
...cing in ST...
...pacing is indicated for symptomat...
...carditis...
...rin is recommended for treatment of pericarditi...
...f acetaminophen, colchicine, or nar...
...coids and nonsteroidal anti-inflammatory drug...
...ted Risk Factors for Bleeding in Pa...
...omboembolic and Bleeding Complications...
...ulant therapy with a vitamin K antagonist should...
...duration of triple antithrombotic therapy...
...coagulant therapy with a vitamin K antagonist is r...
...lant therapy may be considered for patie...
...amin K antagonist therapy to a low...
...iteriaHaving trouble viewing table? Expa...
...sk Assessment After STEMI...
...sive Testing for Ischemia Before Discharge...
...nvasive testing for ischemia should...
...ive testing for ischemia might be cons...
...sting for ischemia might be considered...
...nt of LV Function...
...tricular ejection fraction (LVEF)...
...sessment of Risk for Sudden Cardiac De...
...nts with an initially reduced LVEF who are poss...
...italization Plan Of Car...
...thospital systems of care designed to prevent...
...-based cardiac rehabilitation/second...
...iled, and evidence-based plan of care t...
...and advice to stop smoking and to avoid secon...