ACC/AHA Guidelines For The Management of Patients With ST-Elevation Myocardial Infarction

ACC/AHA Guidelines for the
Management of Patients with

ST-Elevation Myocardial Infarction
1
Management Before STEMI

2
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.
3
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.
4
Onset of STEMI

5
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 non–enteric-coated
formulations.
6
Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.
Not PCI
capable
Onset of EMS EMS on-scene EMS Inter-

symptoms of Dispatch • Encourage 12-lead ECGs. Triage Hospital
STEMI • Consider prehospital fibrinolytic if Plan Transfer
capable and EMS-to-needle within
30 min.
PCI
capable
GOALS
5 8
min. EMS Transport
min.
Patient EMS Prehospital fibrinolysis EMS transport
EMS-to-needle EMS-to-balloon within 90 min.
within 30 min. Patient self-transport
Dispatch Hospital door-to-balloon
1 min. within 90 min.
Golden Hour = first 60 min. Total ischemic time: within 120 min.
7
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.
Noninvasive Risk
Fibrinolysis
Stratification
Not Late
Rescue Ischemia Hospital Care
PCI Capable driven and Secondary
PCI Capable Prevention
PCI or CABG
Primary PCI
8
Initial Recognition and
Management in the
Emergency Department

9
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 LV hypertrophy with

Atypical angina strain
Early repolarization Brugada syndrome
Wolff-Parkinson-White
syndrome Myocarditis
Deeply inverted T-waves Hyperkalemia
suggestive of a central Bundle-branch blocks
nervous system lesion
or apical hypertrophic Vasospastic angina
cardiomyopathy Hypertrophic
cardiomyopathy
12
ED Evaluation of
Patients With STEMI
Differential Diagnosis of STEMI: Other Noncardiac
Gastroesophageal reflux Cervical disc or neuropathic

(GERD) and spasm pain
Chest-wall pain Biliary or pancreatic pain
Pleurisy Somatization and
Peptic ulcer disease psychogenic pain disorder
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
non–enteric-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 beta-

blockers 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-to-
needle (or medical contact–to-needle) time for initiation
of fibrinolytic therapy can be achieved within 30
minutes or that door-to-balloon (or medical contact–to-
balloon) 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
Methods of
Speeding
Media campaign Prehospital Time to
Patient education ECG Reperfusion
MI protocol
Critical pathway
Quality Bolus lytics
Greater use of
9-1-1 improvement Dedicated
Prehospital Rx program PCI team
27
Treatment Delayed is Treatment Denied
Symptom Call to PreHospital ED Cath Lab

Recognition Medical System
Increasing Loss of Myocytes
Delay in Initiation of Reperfusion Therapy
28
Contraindications and Cautions
for Fibrinolysis in STEMI
Absolute • Any prior intracranial hemorrhage

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
Absolute • Suspected aortic dissection

Contraindications
• Active bleeding or bleeding diathesis
(excluding menses)
• Significant closed-head or facial trauma
within 3 months
30
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
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 Risk of STEMI Risk of Time Required

Symptom Fibrinolysis for Transport to
Onset a Skilled PCI
Lab
33
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
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 ST-
segment 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
Specific Considerations
Medical contact–to-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 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 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
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
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
47
PCI for Cardiogenic Shock
Cardiogenic Shock
Early Shock, Diagnosed on Delayed Onset Shock

Hospital Presentation Echocardiogram to Rule Out
Mechanical Defects
Fibrinolytic therapy if all of the
following are present:
Arrange rapid transfer to invasive
1. Greater than 90 minutes to PCI IABP procedure-capable center
2. Less than 3 hours post STEMI
onset
3. No contraindications
Cardiac Catheterization and Coronary
Arrange prompt transfer to invasive
procedure-capable center
Angiography
1-2 vessel CAD Moderate 3-vessel CAD Severe 3-vessel CAD Left main CAD
PCI IRA PCI IRA Immediate CABG
Cannot be
Staged Multivessel Staged CABG performed
PCI
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 Angiotensin converting enzyme (ACE)

the renin
inhibitors
-angiotensin
-aldosterone Angiotensin receptor blockers (ARB)
system
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

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/ST-
segment 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?
Hypovolemia Low Output - Arrhythmia

Acute Pulmonary Edema
Cardiogenic Shock
Administer
First line of action
Administer Bradycardia Tachycardia

• Furosemide IV 0.5 to 1.0 mg/kg
• Morphine IV 2 to 4 mg • Fluids
• Oxygen/intubation as needed • Blood transfusions
• Nitroglycerin SL, then 10 to 20 mcg/min IV if SBP • Cause-specific Check Blood Pressure
greater than 100 mm Hg interventions See Section 7.7
• Dopamine 5 to 15 mcg/kg per minute IV if SBP 70 to Consider vasopressors in the ACC/AHA Guidelines for
100 mm Hg and signs/symptoms of shock present Patients With ST-Elevation
• Dobutamine 2 to 20 mcg/kg per minute IV if SBP 70 Myocardial Infarction
to 100 mm Hg and no signs/symptoms of shock
Check Blood Pressure Systolic BP Systolic BP Systolic BP

Second line of action
Systolic BP
Greater than 100 mm Hg 70 to 100 mm Hg 70 to 100 mm Hg less than 70 mm Hg
NO signs/symptoms Signs/symptoms Signs/symptoms of shock
Systolic BP
of shock of shock
Greater than 100 mm Hg
and not less than 30 mm Hg
below baseline Nitroglycerin Dobutamine Dopamine Norepinephrine
10 to 20 mcg/min IV 2 to 20 5 to 15 0.5 to 30 mcg/min IV
mcg/kg per mcg/kg per
ACE Inhibitors minute IV minute IV
Short-acting agent such as
captopril (1 to 6.25 mg)
Third line of action
Further diagnostic/therapeutic considerations (should be considered in

nonhypovolemic shock)
Circulation 2000;102(suppl I):I-172-I-216.
Diagnostic Therapeutic
♥ Pulmonary artery catheter ♥ Intra-aortic balloon pump
♥ Echocardiography ♥ Reperfusion/revascularization
♥ Angiography for MI/ischemia
♥ Additional diagnostic studies
66
Arrhythmias During Acute Phase of STEMI:
Electrical Instability
Arrhythmia Treatment
VPBs K+ , Mg++ , beta blocker
VT Antiarrhythmics, DC shock
AIVR Observe unless hemodynamic

compromise
NPJT Search for cause (e.g., dig toxicity)
67
Pump Failure / Excess Sympathetic Tone
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
Bradyarrhythmias
Sinus Brady Treat if hemodynamic compromise;
atropine / pacing
Junctional Treat if hemodynamic compromise;

atropine / pacing
69
AV Conduction Disturbances
Proximal Distal
Escape Rhythm His Bundle Distal
< 120 ms > 120 ms
45 - 60 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
Atrioventricular Conduction
INTRAVENTRICULAR First degree AV block Mobitz I second degree AV block Mobitz II second degree AV block
CONDUCTION Normal ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR ANTERIOR MI NON-ANTERIOR
Normal ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS ACTION CLASS
Observe I Observe I Observe I Observe IIb Observe IIa Observe III Observe III
A III A III A III A* III A III A III A III
TC III TC IIb TC IIb TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIa
Old or New Observe I Observe IIb Observe IIb Observe IIb Observe IIb Observe III Observe III
Fascicular block A III A III A III A* III A III A III A III
(LAFB or LPFB) TC IIb TC I TC IIa TC I TC I TC I TC I
TV III TV III TV III TV III TV III TV IIa TV IIb
Old bundle Observe I Observe III Observe III Observe III Observe III Observe III Observe III
branch block A III A III A III A* III A III A III A III
TC IIb TC I TC I TC I TC I TC I TC I
TV III TV IIb TV IIb TV IIb TV IIb TV IIa TV IIa
New bundle Observe III Observe III Observe III Observe III Observe III Observe III Observe III
branch block A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIb
TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Fascicular Observe III Observe III Observe III Observe III Observe III Observe III Observe III
block + RBBB A III A III A III A* III A III A III A III
TC I TC I TC I TC I TC I TC IIb TC IIb
TV IIb TV IIa TV IIa TV IIa TV IIa TV I TV I
Alternating Observe III Observe III Observe III Observe III Observe III Observe III Observe III
left and right A III A III A III A* III A III A III A III
bundle branch TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb TC IIb
block TV I TV I TV I TV I TV I 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 0.31 - 0.40 EF > 0.40
Additional Marker of
Electrical Instability?
Yes No
No ICD.
+ EPS - Medical Rx
NEJM 349:
1836,2003
72
Algorithm for Management of Recurrent
Ischemia/Infarction After STEMI
Recurrent ischemic-type discomfort at rest after STEMI • Escalation of medical therapy (nitrates, beta
-
blockers)
• Anticoagulation if not already given
• Consider IABP for hemodynamic instability,
Obtain 12-lead ECG poor LV function, or a large area of
myocardium at risk
• Correct secondary causes of ischemia
YES ST-segment elevation? NO
Is patient Is
Is ischemia
ischemia
a candidate for controlled
controlled by
by escalation
escalation
revascularization
revascularization?
? of
of medical
medical therapy?
therapy?
YES
YES NO
NO
YES NO
Refer
Refer for
for Refer
Refer for
for urgent
urgent
Can
Can nonurgent
nonurgent catheterization
catheterization (consider
(consider
catheterization
catheterization Consider
Consider
(re) administration
(re)
catheterization
catheterization IABP)
IABP)
be
be performed
performed promptly?
promptly?*
promptly?* of
administration
fibrinolytic therapy
of
YES
YES
NO
NO Modified from Braunwald. Heart Disease: A Textbook
of Cardiovascular Medicine. 6th ed. Philadelphia, PA:
WB Saunders Co. Ltd. 2001:1195.
Coronary
Coronary
angiography
angiography Consider (re) administration
of fibrinolytic therapy
Revascularization
Revascularization with
with PCI
PCI
and/or
and/or CABG
CABG as
as dictated
dictated by
by
anatomy
anatomy
73
Evidence-Based Approach to Need for
Catheterization and Revascularization After STEMI
STEMI
Primary Invasive Strategy Fibrinolytic Therapy No Reperfusion Therapy
Cath No Cath EF less EF greater

Performed Performed than 0.40 than 0.40
EF greater EF less High-Risk No High -Risk

than 0.40 than 0.40 Features † Features †
Catheterization and
Revascularization as
No High -Risk High-Risk Indicated
Features † Features †
Functional
Indicated
Evaluation
ECG Interpretable ECG Uninterpretable
Able to Exercise Unable to Exercise Able to Exercise
Pharmacological Stress
Submaximal Symptom-Limited
Symptom-Limited Adenosine
Exercise Test Exercise Test Dobutamine Exercise Exercise
or Dipyridamole
Before Discharge Before or After Discharge Nuclear Scan Echo Echo Nuclear
Catheterization and
Clinically Significant No Clinically Significant Medical
Ischemia*
Ischemia Ischemia*
Ischemia Therapy
Indicated
74
Long-Term Antithrombotic Therapy at
Hospital Discharge After STEMI
STEMI Patient at Discharge
No Stent Implanted
No ASA allergy ASA Allergy
No Indications Indications No Indications Indications

for Anticoagulation for Anticoagulation for Anticoagulation for Anticoagulation
Preferred: ASA 75 to 162 mg Preferred:

ASA 75 to 162 mg Warfarin Clopidogrel 75 mg Warfarin
Class I; LOE: A (INR 2.0 to 3.0) Class I; LOE: C INR (2.5 to 3.5)
Class I; LOE B Class I; LOE: B
Alternative: Alternative:
OR Warfarin
ASA 75 to 162 mg
Warfarin INR (2.5 to 3.5)
Warfarin Class I; LOE: B
(INR 2.0 to 3.0)
(INR 2.5 to 3.5)
Class: IIa; LOE: B
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 Indications No Indications Indications

for for Anticoagulation for for
Anticoagulation Anticoagulation Anticoagulation
ASA 75 to 162 mg ASA 75 to 162 mg

Clopidogrel 75 mg
Clopidogrel 75 mg Clopidogrel 75 mg Clopidogrel 75 mg Warfarin
Class: I; LOE: B Warfarin Class I; LOE: B (INR 2.0 to 3.0)
(INR 2.0 to 3.0)
Class I; LOE: C
Class: IIb; LOE: C
76
Long-Term Management

77
Secondary Prevention and Long Term Management
Goals Recommendations
Smoking • Assess tobacco use.

Goal:
Complete • Strongly encourage patient and family to
Cessation stop smoking and to avoid secondhand
smoke.
• Provide counseling, pharmacological

therapy (including nicotine replacement and
bupropion), and formal smoking cessation
programs as appropriate.
78
If blood pressure is 120/80 mm Hg or greater:
Blood pressure
control:
• Initiate lifestyle modification (weight control, physical
Goal: < 140/90
activity, alcohol moderation, moderate sodium restriction, and
mm Hg or
emphasis on fruits, vegetables, and low-fat dairy products) in
<130/80 mm Hg
all patients.
if chronic kidney
disease or
If blood pressure is 140/90 mm Hg or greater or 130/80
diabetes
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-angiotensin-
aldosterone system.
79
Physical activity: • Assess risk, preferably with exercise test, to guide

Minimum goal: prescription.
30 minutes 3 to 4
days per week;
Optimal daily • 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
• Start dietary therapy in all patients (< 7% of total calories as
Lipid
saturated fat and < 200 mg/d cholesterol). Promote physical
management:
activity and weight management. Encourage increased
(TG less than
consumption of omega-3 fatty acids.
200 mg/dL)
Primary goal:
• Assess fasting lipid profile in all patients, preferably within
LDL-C << than
24 hours of STEMI. Add drug therapy according to the
100 mg/dL
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-C–lowering therapy with drug treatment,
giving preference to statins.
81
Lipid If TGs are ≥ 150 mg/dL or HDL-C is < 40 mg/dL:
management: Emphasize weight management and physical
(TG 200 mg/dL activity. Advise smoking cessation.
or greater)
Primary goal: If TG is 200 to 499 mg/dL:
Non–HDL-C << After LDL-C–lowering therapy, consider adding
130 mg/dL fibrate or niacin.
If TG is ≥ 500 mg/dL:
Consider fibrate or niacin before LDL-C–lowering
therapy.
Consider omega-3 fatty acids as adjunct for high
TG.
82
Weight
management: Calculate BMI and measure waist circumference
Goal: as part of evaluation. Monitor response of BMI
BMI 18.5 to 24.9 and waist circumference to therapy.
kg/m2
Start weight management and physical activity as
Waist appropriate. Desirable BMI range is 18.5 to 24.9
circumference: kg/m2.
Women: < 35 in.
Men: < 40 in. If waist circumference is ≥ 35 inches in women or
≥ 40 inches in men, initiate lifestyle changes and
treatment strategies for metabolic syndrome.
83
Diabetes Appropriate hypoglycemic therapy to
management: achieve near-normal fasting plasma
Goal: glucose, as indicated by HbA1c.
HbA1c < 7%
Treatment of other risk factors (e.g.,
physical activity, weight management,
blood pressure, and cholesterol
management).
84
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 post-
STEMI patients when clinically indicated or for
those not able to take aspirin or clopidogrel.
85
Renin- ACE inhibitors in all patients indefinitely; start early in

Angiotensin- stable, high-risk patients (ant. MI, previous MI, Killip
Aldosterone class ≥ 2 [S3 gallop, rales, radiographic CHF], LVEF <
System 0.40).
Blockers
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
Beta- Start in all patients. Continue indefinitely.

Blockers Observe usual contraindications.
87
Summary of Pharmacologic Rx: Ischemia
1st During Hosp DC +

24 h Hosp Long Term
Aspirin 162-325 mg 75-162 75-162 mg/d
chewed mg/d p.o. p.o.
Fibrinolytic tPA,TNK,
rPA, SK
60U/kg (4000) aPTT
UFH 12 U/kg/h (1000) 1.5 - 2 x C
aPTT 1.5 - 2 x C
Beta-blocker Oral daily Oral daily Oral daily
JACC 2004;44: 671

Circulation 2004;110: 588 88
Summary of Pharmacologic Rx: LVD, Sec. Prev.,
1st During Hosp Hosp DC +
24 h Long Term
ACEI Anterior MI, Oral
Pulm Cong., EF < 40 Oral Daily
ARB ACEI intol., Daily Indefinitely
HF, EF < 40
Aldo No renal dysf, Same as
Blocker K+ < 5.0 mEq/L during
On ACEI, Hosp.
HF or DM
Statin Start w/o lipid Indefinitely,
profile LDL << 100
JACC 2004;44:671
Circ 2004;110:588 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

ACC/AHA Guidelines For The Management of Patients With ST-Elevation Myocardial Infarction

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ACC/AHA Guidelines For The Management of Patients With ST-Elevation Myocardial Infarction

Uploaded by

Copyright:

Available Formats

ACC/AHA Guidelines for the

Management of Patients with