ACC/AHA Guidelines for the

Management of Patients with

ST-Elevation Myocardial Infarction

Management Before STEMI

ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

Identification of Patients at Risk of STEMI

The presence and status of control of major
risk factors for CHD should be evaluated
approximately every 3 to 5 years.

10-year risk of developing symptomatic CHD

should be calculated for all patients with 2
major risk factors to assess the need for
primary prevention strategies.

Identification of Patients at Risk of STEMI

Patients with established CHD or a CHD risk
equivalent (diabetes mellitus, chronic kidney
disease, > 20% 10-year Framingham risk)
should be identified for secondary prevention.

Onset of STEMI
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

Prehospital Chest Pain Evaluation

and Treatment

Prehospital EMS providers should administer 162 to 325 mg of

aspirin (chewed) to chest pain patients suspected of having STEMI
unless contraindicated or already taken by the patient. Although
some trials have used enteric-coated aspirin for initial dosing, more
rapid buccal absorption occurs with nonenteric-coated
formulations.

Options for Transport of Patients With

STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.

Not PCI
capable
Onset of
symptoms of
STEMI

EMS
Dispatch

EMS on-scene
Encourage 12-lead ECGs.
Consider prehospital fibrinolytic if
capable and EMS-to-needle within
30 min.

GOALS

5
min.
Patient

8
min.
EMS

Dispatch
1 min.

InterHospital
Transfer

EMS
Triage
Plan

PCI
capable

EMS Transport
Prehospital fibrinolysis
EMS transport
EMS-to-needle
EMS-to-balloon within 90 min.
within 30 min.
Patient self-transport
Hospital door-to-balloon
within 90 min.

Golden Hour = first 60 min.

Total ischemic time: within 120 min.

Options for Transport of Patients With STEMI and

Initial Reperfusion Treatment

Patients receiving fibrinolysis should be risk-stratified to identify need

for further revascularization with percutaneous coronary intervention
(PCI) or coronary artery bypass graft surgery (CABG).

All patients should receive late hospital care and secondary

prevention of STEMI.
Fibrinolysis
Not
PCI Capable

Noninvasive Risk
Stratification
Rescue Ischemia
driven

PCI Capable

Late
Hospital Care
and Secondary
Prevention

PCI or CABG
Primary PCI

Initial Recognition and

Management in the
Emergency Department
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

ED Evaluation of
Patients With STEMI
Brief Physical Examination in the ED
1. Airway, Breathing, Circulation (ABC)
2. Vital signs, general observation
3. Presence or absence of jugular venous distension
4. Pulmonary auscultation for rales
5. Cardiac auscultation for murmurs and gallops
6. Presence or absence of stroke
7. Presence or absence of pulses
8. Presence or absence of systemic hypoperfusion (cool, clammy,
pale, ashen)

10

ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Life-Threatening
Aortic dissection

Tension pneumothorax

Pulmonary embolus

Boerhaave syndrome

Perforating ulcer

(esophageal rupture with

mediastinitis)

11

ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Cardiovascular and
Nonischemic
Pericarditis
Atypical angina
Early repolarization
Wolff-Parkinson-White
syndrome
Deeply inverted T-waves
suggestive of a central
nervous system lesion
or apical hypertrophic
cardiomyopathy

LV hypertrophy with strain

Brugada syndrome
Myocarditis
Hyperkalemia
Bundle-branch blocks
Vasospastic angina
Hypertrophic
cardiomyopathy

12

ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux
(GERD) and spasm

Cervical disc or neuropathic

pain

Chest-wall pain

Biliary or pancreatic pain

Pleurisy

Somatization and
psychogenic pain disorder

Peptic ulcer disease

Panic attack

13

Electrocardiogram
If the initial ECG is not diagnostic of STEMI, serial
ECGs or continuous ST-segment monitoring should
be performed in the patient who remains
symptomatic or if there is high clinical suspicion for
STEMI.

14

Electrocardiogram
Show 12-lead ECG results to emergency physician
within 10 minutes of ED arrival in all patients with
chest discomfort (or anginal equivalent) or other
symptoms of STEMI.
In patients with inferior STEMI, ECG leads should
also be obtained to screen for right ventricular
infarction.

15

Laboratory Examinations
Laboratory examinations should be performed as part of the
management of STEMI patients, but should not delay the
implementation of reperfusion therapy.
Serum biomarkers for cardiac damage
Complete blood count (CBC) with platelets
International normalized ratio (INR)
Activated partial thromboplastin time (aPTT)
Electrolytes and magnesium
Blood urea nitrogen (BUN)
Creatinine
Glucose
Complete lipid profile
16

Biomarkers of Cardiac Damage

Cardiac-specific troponins should be used as the
optimum biomarkers for the evaluation of patients
with STEMI who have coexistent skeletal muscle
injury.
For patients with ST elevation on the 12-lead ECG
and symptoms of STEMI, reperfusion therapy
should be initiated as soon as possible and is not
contingent on a biomarker assay.

17

Imaging
Patients with STEMI should have a portable chest
X-ray, but this should not delay implementation of
reperfusion therapy (unless a potential
contraindication is suspected, such as aortic
dissection).
Imaging studies such as a high quality portable chest
X-ray, transthoracic and/or transesophageal
echocardiography, and a contrast chest CT scan or
an MRI scan should be used for differentiating STEMI
from aortic dissection in patients for whom this
distinction is initially unclear.
18

Oxygen

Supplemental oxygen should be administered to

patients with arterial oxygen desaturation (SaO2
< 90%).
It is reasonable to administer supplemental
oxygen to all patients with uncomplicated STEMI
during the first 6 hours.

19

Nitroglycerin
Patients with ongoing ischemic discomfort should
receive sublingual NTG (0.4 mg) every 5 minutes for a
total of 3 doses, after which an assessment should be
made about the need for intravenous NTG.

Intravenous NTG is indicated for relief of ongoing

ischemic discomfort that responds to nitrate therapy,
control of hypertension, or management of pulmonary
congestion.

20

Nitroglycerin
Nitrates should not be administered to patients with:
systolic pressure < 90 mm Hg or to 30 mm
Hg below baseline
severe bradycardia (< 50 bpm)
tachycardia (> 100 bpm) or
suspected RV infarction.
Nitrates should not be administered to patients who
have received a phosphodiesterase inhibitor for
erectile dysfunction within the last 24 hours (48
hours for tadalafil).

21

Analgesia

Morphine sulfate (2 to 4 mg intravenously with

increments of 2 to 8 mg intravenously repeated at
5 to 15 minute intervals) is the analgesic of choice
for management of pain associated with STEMI.

22

Aspirin
Aspirin should be chewed by patients who have
not taken aspirin before presentation with STEMI.
The initial dose should be 162 mg (Level of
Evidence: A) to 325 mg (Level of Evidence: C)

Although some trials have used enteric-coated aspirin for

initial dosing, more rapid buccal absorption occurs with
nonenteric-coated formulations.

23

Beta-Blockers
Oral beta-blocker therapy should be administered
promptly to those patients without a contraindication,
irrespective of concomitant fibrinolytic therapy or
performance of primary PCI.

It is reasonable to administer intravenous betablockers promptly to STEMI patients without

contraindications, especially if a tachyarrhythmia or
hypertension is present.

24

Reperfusion

Given the current literature, it is not possible to say

definitively that a particular reperfusion approach is
superior for all pts, in all clinical settings, at all times of
day

The main point is that some type of reperfusion therapy

should be selected for all appropriate pts with suspected
STEMI
The appropriate & timely use of some reperfusion
therapy is likely more important than the choice of
therapy
25

Reperfusion
The medical system goal is to facilitate rapid recognition
and treatment of patients with STEMI such that door-toneedle (or medical contactto-needle) time for initiation
of fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical contacttoballoon) time for PCI can be kept within 90 minutes.

26

Reperfusion
Patient

Transport

Inhospital

Reperfusion

Goals
D-N 30 min
5 min

< 30 min

D-B 90 min

Prehospital
ECG
MI protocol
Critical pathway
Bolus lytics
Quality
Greater use of
improvement Dedicated
9-1-1
PCI team
program
Prehospital Rx

Media campaign
Patient education

Methods of
Speeding
Time to
Reperfusion

27

Treatment Delayed is Treatment Denied

Symptom
Recognition

Call to
Medical System

PreHospital

ED

Cath Lab

Increasing Loss of Myocytes

Delay in Initiation of Reperfusion Therapy

28

Contraindications and Cautions

for Fibrinolysis in STEMI
Any prior intracranial hemorrhage
Absolute
Contraindications Known structural cerebral vascular lesion
(e.g., arteriovenous malformation)
Known malignant intracranial neoplasm
(primary or metastatic)
Ischemic stroke within 3 months EXCEPT
acute ischemic stroke within 3 hours
NOTE: Age restriction for fibrinolysis has been removed
compared with prior guidelines.

29

Contraindications and Cautions

for Fibrinolysis in STEMI
Suspected aortic dissection
Absolute
Contraindications
Active bleeding or bleeding diathesis
(excluding menses)
Significant closed-head or facial trauma
within 3 months

30

Contraindications and Cautions

for Fibrinolysis in STEMI
Relative
History of chronic, severe, poorly controlled
Contraindications hypertension
Severe uncontrolled hypertension on
presentation (SBP > 180 mm Hg or DBP >
110 mm Hg)
History of prior ischemic stroke greater than
3 months, dementia, or known intracranial
pathology not covered in contraindications
Traumatic or prolonged (> 10 minutes) CPR
or major surgery (< 3 weeks)

31

Contraindications and Cautions

for Fibrinolysis in STEMI
Relative
Recent (< 2 to 4 weeks) internal bleeding
Contraindications Noncompressible vascular punctures
For streptokinase/anistreplase: prior
exposure (> 5 days ago) or prior allergic
reaction to these agents
Pregnancy
Active peptic ulcer
Current use of anticoagulants: the higher the
INR, the higher the risk of bleeding

32

Reperfusion Options for STEMI Patients

Step One: Assess Time and Risk.

Time Since
Symptom
Onset

Risk of STEMI

Risk of
Fibrinolysis

Time Required
for Transport to
a Skilled PCI
Lab

33

Reperfusion Options for STEMI Patients

Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive
strategy, there is no preference for either strategy.
Fibrinolysis generally preferred
Early presentation ( 3 hours from symptom
onset and delay to invasive strategy)
Invasive strategy not an option
Cath lab occupied or not available
Vascular access difficulties
No access to skilled PCI lab
Delay to invasive strategy
Prolonged transport
Door-to-balloon more than 90 minutes
> 1 hour vs fibrinolysis (fibrin-specific agent) now

34

Reperfusion Options for STEMI Patients

Step 2: Select Reperfusion Treatment.
If presentation is < 3 hours and there is no delay to an invasive strategy,
there is no preference for either strategy.
Invasive strategy generally preferred
Skilled PCI lab available with surgical backup
Door-to-balloon < 90 minutes
High Risk from STEMI
Cardiogenic shock, Killip class 3
Contraindications to fibrinolysis, including
increased risk of bleeding and ICH
Late presentation
> 3 hours from symptom onset
Diagnosis of STEMI is in doubt
35

Fibrinolysis

In the absence of contraindications, fibrinolytic

therapy should be administered to STEMI
patients with symptom onset within the prior 12
hours.
In the absence of contraindications, fibrinolytic
therapy should be administered to STEMI
patients with symptom onset within the prior 12
hours and new or presumably new left bundle
branch block (LBBB).

36

Fibrinolysis
In the absence of contraindications, it is
reasonable to administer fibrinolytic therapy to
STEMI patients with symptom onset within the
prior 12 hours and 12-lead ECG findings
consistent with a true posterior MI.
In the absence of contraindications, it is
reasonable to administer fibrinolytic therapy to
patients with symptoms of STEMI beginning in
the prior 12 to 24 hours who have continuing
ischemic symptoms and ST elevation > 0.1 mV
in 2 contiguous precordial leads or 2 adjacent
limb leads.
37

Fibrinolysis
Fibrinolytic therapy should not be administered to
asymptomatic patients whose initial symptoms of
STEMI began more than 24 hours earlier.
Fibrinolytic therapy should not be administered to
patients whose 12-lead ECG shows only STsegment depression, except if a true posterior MI
is suspected.

38

Evolution of PCI for STEMI

39

Primary PCI for STEMI:

General Considerations
Patient with STEMI (including posterior MI) or MI
with new or presumably new LBBB
PCI of infarct artery within 12 hours of symptom
onset
Balloon inflation within 90 minutes of presentation
Skilled personnel available (individual performs > 75
procedures per year)
Appropriate lab environment (lab performs > 200
PCIs/year of which at least 36 are primary PCI for
STEMI)
Cardiac surgical backup available
40

Primary PCI for STEMI:

Specific Considerations
Medical contactto-balloon or door-to-balloon
should be within 90 minutes.

PCI preferred if > 3 hours from symptom onset.

Primary PCI should be performed in patients with

severe congestive heart failure (CHF) and/or
pulmonary edema (Killip class 3) and onset of
symptoms within 12 hours.

41

Primary PCI for STEMI:

Specific Considerations
Primary PCI should be performed in patients less
than 75 years old with ST elevation or LBBB who
develop shock within 36 hours of MI and are
suitable for revascularization that can be
performed within 18 hours of shock.

42

Primary PCI for STEMI:

Specific Considerations
Primary PCI is reasonable in selected patients 75
years or older with ST elevation or LBBB who develop
shock within 36 hours of MI and are suitable for
revascularization that can be performed within 18
hours of shock.

43

Primary PCI for STEMI:

Specific Considerations
It is reasonable to perform primary PCI for
patients with onset of symptoms within the prior
12 to 24 hours and 1 or more of the following:
a. Severe CHF
b. Hemodynamic or electrical instability
c. Persistent ischemic symptoms.

44

Rescue PCI
Rescue PCI should be performed in patients less
than 75 years old with ST elevation or LBBB who
develop shock within 36 hours of MI and are
suitable for revascularization that can be
performed within 18 hours of shock.
Rescue PCI should be performed in patients with
severe CHF and/or pulmonary edema (Killip class
3) and onset of symptoms within 12 hours.

45

Rescue PCI
Rescue PCI is reasonable for selected patients 75
years or older with ST elevation or LBBB or who
develop shock within 36 hours of MI and are suitable
for revascularization that can be performed within 18
hours of shock.
It is reasonable to perform rescue PCI for patients
with one or more of the following:
a. Hemodynamic or electrical instability
b. Persistent ischemic symptoms.

46

PCI for Cardiogenic Shock

Primary PCI is recommended for patients less than
75 years with ST elevation or LBBB or who develop
shock within 36 hours of MI and are suitable for
revascularization that can be performed within 18
hours of shock.
Primary PCI is reasonable for selected patients
75 years or older with ST elevation or LBBB or
who develop shock within 36 hours of MI and
are suitable for revascularization that can be
performed within 18 hours of shock.

47

PCI for Cardiogenic Shock

Cardiogenic Shock
Early Shock, Diagnosed on
Hospital Presentation

Delayed Onset Shock

Echocardiogram to Rule Out
Mechanical Defects

Fibrinolytic therapy if all of the

following are present:
1. Greater than 90 minutes to PCI
2. Less than 3 hours post STEMI
onset
3. No contraindications
Arrange prompt transfer to invasive
procedure-capable center

Arrange rapid transfer to invasive

procedure-capable center

IABP
Cardiac Catheterization and Coronary
Angiography

1-2 vessel CAD

Moderate 3-vessel CAD

PCI IRA

PCI IRA

Staged Multivessel
PCI

Severe 3-vessel CAD

Left main CAD

Immediate CABG

Staged CABG

Cannot be
performed

48

PCI After Fibrinolysis

In patients whose anatomy is suitable, PCI should be
performed for the following:
Objective evidence of recurrent MI
Moderate or severe spontaneous/provocable
myocardial ischemia during recovery from STEMI
Cardiogenic shock or hemodynamic instability.

49

PCI After Fibrinolysis

It is reasonable to perform routine PCI in patients
with left ventricular ejection fraction (LVEF) 0.40,
CHF, or serious ventricular arrhythmias.
It is reasonable to perform PCI when there is
documented clinical heart failure during the acute
episode, even though subsequent evaluation
shows preserved LV function (LVEF > 0.40).
Routine PCI might be considered as part of
an invasive strategy after fibrinolytic therapy.

50

Assessment of Reperfusion
It is reasonable to monitor the pattern of ST elevation,
cardiac rhythm and clinical symptoms over the 60 to 180
minutes after initiation of fibrinolytic therapy.
Noninvasive findings suggestive of reperfusion include:
Relief of symptoms
Maintenance and restoration of hemodynamic and/or
electrical instability
Reduction of 50% of the initial ST-segment elevation
pattern on follow-up ECG 60 to 90 minutes after
initiation of therapy.

51

Ancillary Therapy to Reperfusion

Unfractionated heparin (UFH) should be given
intravenously in:
Patients undergoing PCI or surgical
revascularization
After alteplase, reteplase, tenecteplase
After streptokinase, anistreplase, urokinase in
patients at high risk for systemic emboli.

52

Ancillary Therapy to Reperfusion

Platelet counts should be monitored daily in patients

taking UFH.

Low molecular-weight heparin (LMWH) might be considered an

acceptable alternative to UFH in patients less than 75 years
who are receiving fibrinolytic therapy in the absence of
significant renal dysfunction.
Enoxaparin used with tenecteplase is the most
comprehensively studied.

53

Aspirin

A daily dose of aspirin (initial dose of 162 to

325 mg orally; maintenance dose of 75 to 162
mg) should be given indefinitely after STEMI to
all patients without a true aspirin allergy.

54

Thienopyridines
In patients for whom PCI is planned, clopidogrel
should be started and continued:
1 month after bare-metal stent
3 months after sirolimus-eluting stent
6 months after paclitaxel-eluting stent
Up to 12 months in absence of high risk for
bleeding.

55

Thienopyridines
In patients taking clopidogrel in whom CABG is
planned, the drug should be withheld for at
least 5 days, and preferably for 7 days, unless
the urgency for revascularization outweighs the
risk of excessive bleeding.

56

Thienopyridines
Clopidogrel is probably indicated in patients
receiving fibrinolytic therapy who are unable
to take aspirin because of hypersensitivity or
gastrointestinal intolerance.

57

Glycoprotein IIb/IIIa Inhibitors

It is reasonable to start treatment with
abciximab as early as possible before primary
PCI (with or without stenting) in patients with
STEMI.
Treatment with tirofiban or eptifibatide may be
considered before primary PCI (with or
without stenting) in patients with STEMI.

58

Other Pharmacological Measures

Inhibition of
the renin
-angiotensin
-aldosterone
system

Angiotensin converting enzyme (ACE)

inhibitors
Angiotensin receptor blockers (ARB)
Aldosterone blockers
Glucose control
Magnesium
Calcium channel blockers

59

ACE/ARB: Within 24 Hours

An ACE inhibitor should be administered orally
within the first 24 hours of STEMI to the following
patients without hypotension or known class of
contraindications:
Anterior infarction
Pulmonary congestion
LVEF < 0.40
An ARB should be given to ACE-intolerant patients
with either clinical or radiological signs of HF or LVEF
< 0.40.

60

ACE/ARB: Within 24 Hours

An ACE inhibitor administered orally can be useful
within the first 24 hours of STEMI to the following
patients without hypotension or known class
contraindications:
Anterior infarction
Pulmonary congestion
LVEF < 0.40.
An intravenous ACE inhibitor should not be given to
patients within the first 24 hours of STEMI because
of the risk of hypotension (possible exception:
refractory hypotension).
61

Strict Glucose Control During STEMI

An insulin infusion to normalize blood glucose
is recommended for patients and complicated
courses.
It is reasonable to administer an insulin
infusion to normalize blood glucose even in
patients with an uncomplicated course.

62

Hospital Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

63

Sample Admitting Orders for the

Patient With STEMI
1. Condition: Serious
2. Normal Saline or D5W intravenous to keep vein open
3. Vital signs: Heart rate, blood pressure, respiratory rate
4. Monitor: Continuous ECG monitoring for arrhythmia/STsegment deviation
5. Diet: NCEP ATP III Therapeutic Lifestyle Changes, low
sodium diet

64

Sample Admitting Orders for the

Patient With STEMI
6. Activity: Bed rest with bedside commode, light
activity when stable
7. Oxygen: 2 L/min when stable for 6 hrs, reassess
need (i.e., O2 sat < 90%). Consider discontinuing if
O2 saturation is > 90%.
8. Medications: NTG, ASA, beta-blocker, ACE, ARB,
pain meds, anxiolytics, daily stool softener
9. Laboratory tests: cardiac biomarkers, CBC
w/platelets, INR, aPTT, electrolytes, Mg2+, BUN,
creatinine, glucose, serum lipids
65

Emergency Management of Complicated STEMI

Clinical signs: Shock, hypoperfusion, congestive heart failure, acute pulmonary edema
Most likely major underlying disturbance?

First line of action

Second line of action
Third line of action

Administer
Furosemide IV 0.5 to 1.0 mg/kg
Morphine IV 2 to 4 mg
Oxygen/intubation as needed
Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP
greater than 100 mm Hg
Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to
100 mm Hg and signs/symptoms of shock present
Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70
to 100 mm Hg and no signs/symptoms of shock

Check Blood Pressure

Systolic BP
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline

Low Output Cardiogenic Shock

Hypovolemia

Acute Pulmonary Edema

Administer
Fluids
Blood transfusions
Cause-specific
interventions
Consider vasopressors

Arrhythmia

Bradycardia

Check Blood Pressure

Tachycardia

See Section 7.7

in the ACC/AHA Guidelines for
Patients With ST-Elevation
Myocardial Infarction

Systolic BP
Greater than 100 mm Hg

Systolic BP
70 to 100 mm Hg
NO signs/symptoms
of shock

Systolic BP
70 to 100 mm Hg
Signs/symptoms
of shock

Systolic BP
less than 70 mm Hg
Signs/symptoms of shock

Nitroglycerin
10 to 20 mcg/min IV

Dobutamine
2 to 20
mcg/kg per
minute IV

Dopamine
5 to 15
mcg/kg per
minute IV

Norepinephrine
0.5 to 30 mcg/min IV

ACE Inhibitors
Short-acting agent such as
captopril (1 to 6.25 mg)
Further diagnostic/therapeutic considerations (should be considered in
nonhypovolemic shock)
Diagnostic
Therapeutic
Pulmonary artery catheter
Intra-aortic balloon pump
Echocardiography
Reperfusion/revascularization
Angiography for MI/ischemia
Additional diagnostic studies

Circulation 2000;102(suppl I):I-172-I-216.

66

Arrhythmias During Acute Phase of STEMI:

Electrical Instability
Arrhythmia

Treatment

VPBs

K+ , Mg++, beta blocker

VT

Antiarrhythmics, DC shock

AIVR
compromise

Observe unless hemodynamic

NPJT

Search for cause (e.g., dig toxicity)

67

Arrhythmias During Acute Phase of STEMI:

Pump Failure / Excess Sympathetic Tone
Arrhythmia

Treatment

Sinus Tach

Treat cause; beta blocker

Afib / Flutter

Treat cause; slow ventricular rate; DC shock

PSVT
Vagal maneuvers; beta blocker,
verapamil / diltiazem; DC shock

68

Arrhythmias During Acute Phase of STEMI:

Bradyarrhythmias
Arrhythmia

Treatment

Sinus Brady

Treat if hemodynamic compromise;

atropine / pacing

Junctional

Treat if hemodynamic compromise;

atropine / pacing

69

Arrhythmias During Acute Phase of STEMI:

AV Conduction Disturbances
Escape Rhythm

Proximal
His Bundle
< 120 ms
45 - 60

Distal
Distal
> 120 ms
Often < 30

Duration of AVB

2 - 3 days

Transient

Mortality

Low

High (CHF, VT)

Rx

Observe

PM (ICD)
70

Recommendations for Treatment of

Atrioventricular and Intraventricular Conduction
Disturbances During STEMI
INTRAVENTRICULAR
CONDUCTION
Normal
ACTION CLASS
Normal
Observe
I
A
III
TC
III
TV
III
Old or New
Observe
I
Fascicular block A
III
(LAFB or LPFB) TC
IIb
TV
III
Old bundle
Observe
I
A
III
branch block
TC
IIb
TV
III
New bundle
Observe
III
A
III
branch block
TC
I
TV
IIb
Fascicular
Observe
III
block + RBBB
A
III
TC
I
TV
IIb
Alternating
Observe
III
left and right
A
III
bundle branch
TC
IIb
block
TV
I

Atrioventricular Conduction
First degree AV block
Mobitz I second degree AV block
ANTERIOR MI
NON-ANTERIOR
ANTERIOR MI
NON-ANTERIOR
ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS
Observe
I
Observe
I
Observe
IIb
Observe
IIa
A
III
A
III
A*
III
A
III
TC
IIb
TC
IIb
TC
I
TC
I
TV
III
TV
III
TV
III
TV
III
Observe
IIb
Observe
IIb
Observe
IIb
Observe
IIb
A
III
A
III
A*
III
A
III
TC
I
TC
IIa
TC
I
TC
I
TV
III
TV
III
TV
III
TV
III
Observe
III
Observe
III
Observe
III
Observe
III
A
III
A
III
A*
III
A
III
TC
I
TC
I
TC
I
TC
I
TV
IIb
TV
IIb
TV
IIb
TV
IIb
Observe
III
Observe
III
Observe
III
Observe
III
A
III
A
III
A*
III
A
III
TC
I
TC
I
TC
I
TC
I
TV
IIa
TV
IIa
TV
IIa
TV
IIa
Observe
III
Observe
III
Observe
III
Observe
III
A
III
A
III
A*
III
A
III
TC
I
TC
I
TC
I
TC
I
TV
IIa
TV
IIa
TV
IIa
TV
IIa
Observe
III
Observe
III
Observe
III
Observe
III
A
III
A
III
A*
III
A
III
TC
IIb
TC
IIb
TC
IIb
TC
IIb
TV
I
TV
I
TV
I
TV
I

Mobitz II second degree AV block

ANTERIOR MI
NON-ANTERIOR
ACTION CLASS ACTION CLASS
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIa
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIb
Observe
III
Observe
III
A
III
A
III
TC
I
TC
I
TV
IIa
TV
IIa
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I
Observe
III
Observe
III
A
III
A
III
TC
IIb
TC
IIb
TV
I
TV
I

71

ICD Implantation After STEMI

One Month After STEMI;

No Spontaneous VT or VF 48 hours post-STEMI

EF < 0.30

EF > 0.40

EF 0.31 - 0.40

Additional Marker of
Electrical Instability?
Yes

EPS

No

No ICD.
Medical Rx

NEJM 349:
1836,2003

72

Algorithm for Management of Recurrent

Ischemia/Infarction After STEMI
Recurrent ischemic-type discomfort at rest after STEMI

Obtain 12-lead ECG

Escalation of medical therapy (nitrates, beta

blockers)
Anticoagulation if not already given
Consider IABP for hemodynamic instability,
poor LV function, or a large area of
myocardium at risk
Correct secondary causes of ischemia

ST-segment elevation?

YES

NO

Is patient
a candidate for
revascularization
revascularization?
?

Is
Is ischemia
ischemia
controlled
controlled by
by escalation
escalation
of
of medical
medical therapy?
therapy?
YES
YES

YES

NO

Can
Can
catheterization
catheterization
be
be performed
performed promptly?*
promptly?
promptly?*

YES
YES

Coronary
Coronary
angiography
angiography

Revascularization
Revascularization with
with PCI
PCI
and/or
and/or CABG
CABG as
as dictated
dictated by
by
anatomy
anatomy

NO
NO

Consider
Consider
(re) administration
(re)
of
administration
fibrinolytic therapy
of

NO
NO

Refer
Refer for
for
nonurgent
nonurgent
catheterization
catheterization

Refer
Refer for
for urgent
urgent
catheterization
catheterization (consider
(consider
IABP)
IABP)

Modified from Braunwald. Heart Disease: A Textbook

of Cardiovascular Medicine. 6th ed. Philadelphia, PA:
WB Saunders Co. Ltd. 2001:1195.

Consider (re) administration

of fibrinolytic therapy

73

Evidence-Based Approach to Need for

Catheterization and Revascularization After STEMI
STEMI
Primary Invasive Strategy

Fibrinolytic Therapy
Cath
Performed

No Cath
Performed

EF greater
than 0.40

Revascularization as
Indicated

No High -Risk
Features

No Reperfusion Therapy

EF less
than 0.40

High-Risk
Features

EF less
than 0.40

Catheterization and
Revascularization as
Indicated

EF greater
than 0.40
High-Risk
Features

No High -Risk
Features

Functional
Evaluation
ECG Interpretable
Able to Exercise

ECG Uninterpretable
Unable to Exercise

Able to Exercise

Pharmacological Stress
Submaximal
Symptom-Limited
Symptom-Limited
Adenosine
Exercise Test
Exercise Test
or Dipyridamole
Before Discharge Before or After Discharge Nuclear Scan

Catheterization and
Revascularization as
Indicated

Clinically Significant
Ischemia*
Ischemia

Dobutamine
Echo

No Clinically Significant
Ischemia*
Ischemia

Exercise
Echo

Exercise
Nuclear

Medical
Therapy

74

Long-Term Antithrombotic Therapy at

Hospital Discharge After STEMI
STEMI Patient at Discharge
No Stent Implanted

No ASA allergy

ASA Allergy

No Indications
for Anticoagulation

Indications
for Anticoagulation

No Indications
for Anticoagulation

Preferred:
ASA 75 to 162 mg
Class I; LOE: A

ASA 75 to 162 mg
Warfarin
(INR 2.0 to 3.0)
Class I; LOE B

Preferred:
Clopidogrel 75 mg
Class I; LOE: C

Alternative:
ASA 75 to 162 mg
Warfarin
(INR 2.0 to 3.0)
Class: IIa; LOE: B

OR
Warfarin
(INR 2.5 to 3.5)
Class I; LOE: B

Indications
for Anticoagulation

Warfarin
INR (2.5 to 3.5)
Class I; LOE: B

Alternative:
Warfarin
INR (2.5 to 3.5)
Class I; LOE: B

OR
Warfarin
(INR 2.5 to 3.5)
Class IIa; LOE: B

75

Long-Term Antithrombotic Therapy at

Hospital Discharge After STEMI
STEMI Patient at Discharge
Stent Implanted

No ASA Allergy

ASA Allergy

No Indications
for
Anticoagulation

Indications
for Anticoagulation

ASA 75 to 162 mg
Clopidogrel 75 mg
Class: I; LOE: B

ASA 75 to 162 mg
Clopidogrel 75 mg
Warfarin
(INR 2.0 to 3.0)
Class: IIb; LOE: C

No Indications
for
Anticoagulation

Indications
for
Anticoagulation

Clopidogrel 75 mg
Class I; LOE: B

Clopidogrel 75 mg
Warfarin
(INR 2.0 to 3.0)
Class I; LOE: C

76

Long-Term Management
ACC/AHA Guidelines for the
Management of Patients with
ST-Elevation Myocardial Infarction

77

Secondary Prevention and Long Term Management

Goals
Smoking
Goal:
Complete
Cessation

Recommendations
Assess tobacco use.
Strongly encourage patient and family to
stop smoking and to avoid secondhand
smoke.
Provide counseling, pharmacological
therapy (including nicotine replacement and
bupropion), and formal smoking cessation
programs as appropriate.

78

Secondary Prevention and Long Term Management

Goals
Blood pressure
control:
Goal: < 140/90
mm Hg or
<130/80 mm Hg
if chronic kidney
disease or
diabetes

Recommendations
If blood pressure is 120/80 mm Hg or greater:
Initiate lifestyle modification (weight control, physical
activity, alcohol moderation, moderate sodium restriction, and
emphasis on fruits, vegetables, and low-fat dairy products) in
all patients.
If blood pressure is 140/90 mm Hg or greater or 130/80
mm Hg or greater for individuals with chronic kidney
disease or diabetes:
Add blood pressure-reducing medications, emphasizing the
use of beta-blockers and inhibitors of the renin-angiotensinaldosterone system.

79

Secondary Prevention and Long Term Management

Goals
Physical activity:
Minimum goal:
30 minutes 3 to 4
days per week;
Optimal daily

Recommendations
Assess risk, preferably with exercise test, to guide
prescription.
Encourage minimum of 30 to 60 minutes of activity,
preferably daily but at least 3 or 4 times weekly (walking,
jogging, cycling, or other aerobic activity) supplemented by
an increase in daily lifestyle activities (e.g., walking breaks
at work, gardening, household work).
Cardiac rehabilitation programs are recommended for
patients with STEMI.

80

Secondary Prevention and Long Term Management

Goals
Lipid
management:
(TG less than
200 mg/dL)
Primary goal:
LDL-C << than
100 mg/dL

Recommendations
Start dietary therapy in all patients (< 7% of total calories as
saturated fat and < 200 mg/d cholesterol). Promote physical
activity and weight management. Encourage increased
consumption of omega-3 fatty acids.
Assess fasting lipid profile in all patients, preferably within
24 hours of STEMI. Add drug therapy according to the
following guide:
LDL-C < 100 mg/dL (baseline or on treatment):
Statins should be used to lower LDL-C.
LDL-C 100 mg/dL (baseline or on
treatment):
Intensify LDL-Clowering therapy with drug treatment,
giving preference to statins.

81

Secondary Prevention and Long Term Management

Goals
Lipid
management:
(TG 200 mg/dL
or greater)
Primary goal:
NonHDL-C <<
130 mg/dL

Recommendations
If TGs are 150 mg/dL or HDL-C is < 40 mg/dL:
Emphasize weight management and physical
activity. Advise smoking cessation.
If TG is 200 to 499 mg/dL:
After LDL-Clowering therapy, consider adding
fibrate or niacin.
If TG is 500 mg/dL:
Consider fibrate or niacin before LDL-Clowering
therapy.
Consider omega-3 fatty acids as adjunct for high
TG.

82

Secondary Prevention and Long Term Management

Goals
Weight
management:
Goal:
BMI 18.5 to 24.9
kg/m2
Waist
circumference:
Women: < 35 in.
Men: < 40 in.

Recommendations
Calculate BMI and measure waist circumference
as part of evaluation. Monitor response of BMI
and waist circumference to therapy.
Start weight management and physical activity as
appropriate. Desirable BMI range is 18.5 to 24.9
kg/m2.
If waist circumference is 35 inches in women or
40 inches in men, initiate lifestyle changes and
treatment strategies for metabolic syndrome.

83

Secondary Prevention and Long Term Management

Goals
Diabetes
management:
Goal:
HbA1c < 7%

Recommendations
Appropriate hypoglycemic therapy to
achieve near-normal fasting plasma
glucose, as indicated by HbA1c.
Treatment of other risk factors (e.g.,
physical activity, weight management,
blood pressure, and cholesterol
management).

84

Secondary Prevention and Long Term Management

Goals

Recommendations

Antiplatelet
In the absence of contraindications, start aspirin
agents/
75 to 162 mg/d and continue indefinitely.
anticoagulants

If aspirin is contraindicated, consider clopidogrel

75 mg/day or warfarin.
Manage warfarin to INR 2.5 to 3.5 in postSTEMI patients when clinically indicated or for
those not able to take aspirin or clopidogrel.

85

Secondary Prevention and Long Term Management

Goals
ReninAngiotensinAldosterone
System
Blockers

Recommendations
ACE inhibitors in all patients indefinitely; start early in
stable, high-risk patients (ant. MI, previous MI, Killip
class 2 [S3 gallop, rales, radiographic CHF], LVEF <
0.40).
Angiotensin receptor blockers in patients who are
intolerant of ACE inhibitors and with either clinical or
radiological signs of heart failure or LVEF < 0.40.
Aldosterone blockade in patients without significant renal
dysfunction or hyperkalemia who are already receiving
therapeutic doses of an ACE inhibitor, have LVEF 0.40,
and have either diabetes or heart failure.

86

Secondary Prevention and Long Term Management

Goals
BetaBlockers

Recommendations
Start in all patients. Continue indefinitely.
Observe usual contraindications.

87

Summary of Pharmacologic Rx: Ischemia

1st
24 h

During
Hosp

Hosp DC +
Long Term

Aspirin

162-325 mg
chewed

75-162
mg/d p.o.

75-162
mg/d p.o.

Fibrinolytic

tPA,TNK,
rPA, SK

UFH

60U/kg (4000)
12 U/kg/h (1000)
aPTT 1.5 - 2 x C

aPTT
1.5 - 2 x C

Beta-blocker

Oral daily

Oral daily

JACC 2004;44: 671

Circulation 2004;110: 588

Oral daily

88

Summary of Pharmacologic Rx: LVD, Sec. Prev.,

1st
24 h
ACEI

Anterior MI,
Pulm Cong., EF < 40

ARB
Aldo
Blocker

Statin

JACC 2004;44:671
Circ 2004;110:588

ACEI intol.,
HF, EF < 40

During Hosp

Oral
Daily
No renal dysf,
K+ < 5.0 mEq/L
On ACEI,
HF or DM

Hosp DC +
Long Term
Oral
Daily
Indefinitely
Same as
during
Hosp.

Start w/o lipid Indefinitely,

profile
LDL << 100

89

Hormone Therapy

Hormone therapy with estrogen plus progestin

should not be given de novo to postmenopausal
women after STEMI for secondary prevention of
coronary events.

90

Hormone Therapy
Postmenopausal women who are already taking
estrogen plus progestin at the time of STEMI should
not continue hormone therapy.
However, women who are beyond 1 to 2 years after
initiation of hormone therapy who wish to continue
such therapy for another compelling indication
should weigh the risks and benefits.

91

Antioxidants

Antioxidant vitamins such as vitamin E and/or

vitamin C supplements should not be prescribed to
patients recovering from STEMI to prevent
cardiovascular disease.

92

Psychosocial Impact of STEMI

The psychosocial status of the patient should be evaluated,

including inquiries regarding symptoms of depression, anxiety,
or sleep disorders and the social support environment.

Treatment with cognitive-behavioral therapy and selective

serotonin reuptake inhibitors can be useful for STEMI patients
with depression that occurs in the year after hospital discharge.

93

Cardiac Rehabilitation
Cardiac rehabilitation/secondary prevention
programs, when available, are recommended
for patients with STEMI, particularly those
with multiple modifiable risk factors and/or
those moderate- to high-risk patients in whom
supervised exercise training is warranted.

94